• Blog >
  • Freiberg’s Infraction
RSS Feed

Freiberg’s Infraction

Freiberg’s Infraction is a condition that affects the lesser metatarsal heads. The most common affected location is the second metatarsal followed by the 3rd 4th then 5th. This condition is also known as AVN (avascular necrosis). Freiberg’s Infraction causes a loss of blood supply to the metatarsal head. The condition occurs at the metaphysis of the bone where the nutrient artery of the bone supplies the distal metatarsal. This results in a collapse of the metatarsal head. The condition is more common in females and usually occurs between ages 10-18 and can occur in adulthood.


Smillie’s classification (1967)

Stage 1: Subtle fracture line through the epiphysis.
Radiographic changes at this stage may be subtle.

Stage 2: Central depression of the articular surface.

Stage 3: Central depression leads to medial and lateral projections at the margins. Plantar hinge remains intact.

Stage 4: Central portion frees from the intact plantar hinge, forming a loose body. Fractures of the medial and lateral projections are present.

Stage 5: Flattening of the metatarsal head with secondary degenerative changes.

Contributing Factors:

Freiberg disease in adolescents is thought to be due to growth disturbances of the epiphysis or apophysis.

  • Vascular insult- an injury of the blood supply to the metatarsal head
  • Traumatic insult- a single acute injury or multiple repetitive injuries


  • Local pain and Tenderness that usually increases with activity
  • Stiffness
  • Limping

Differential Diagnoses


Non Surgical:

  • Stiff Soled shoe or Post Op Shoe
  • Non weight-bearing cast
  • Short leg walking cast or CAM boot
  • Rest /Activity modification
  • Steroid injection

Shoe Modifications:

  • Metatarsal pads
  • Rigid shanks
  • Rocker bottom

Surgical Treatment:

  • Simple debridement


  • Dorsal closing wedge osteotomies- reorients the plantar intact cartilage to articulate with the proximal phalanx.
  • Shortening osteotomies- metatarsal overloading of the is reduced


  • Total joint arthroplasty- Utilizing an implant