Trauma & Sports

Freiberg's Disease: Forefoot Pain in Adolescents

Forefoot pain when walking in a teenage girl: Freiberg's disease is a metatarsal osteonecrosis typical of ages 12-18.

Updated: September 2026·Medically reviewed by Dr. Daniele Priano

Quick Answers

Does Freiberg's disease heal on its own?
Deformity and joint degeneration can remain, even after treatment. Care depends on stage, pain and function; offloading and footwear may ease symptoms but do not guarantee restoration of the metatarsal head.
Is surgery needed?
Not always. Persistent pain and limitation, disease stage and response to appropriate non-operative care guide the decision. Surgery is not limited solely to exceptionally rare advanced cases; the indication and procedure are individual.
See all 4 questions →

Freiberg's disease stands apart among the osteochondroses and deserves special attention: it is among the few that, if not recognized and managed in time, can lead to long-term consequences in the form of arthritis.

It affects the head of the 2nd or 3rd metatarsal (the long bones of the forefoot) and typically presents in female adolescents aged 12 to 18 — with a 3:1 female-to-male ratio thought to be related to biomechanical factors and footwear choices. The main symptom is forefoot pain that appears while walking, running, or wearing narrow shoes or heels.

The mechanism is not fully understood: mechanical and vascular factors may contribute to metatarsal head damage, with possible flattening and deformity. X-rays show flattening or fragmentation of the metatarsal head — an image that in early stages may appear normal (in which case MRI is more sensitive).

Treatment depends on stage and symptoms. Early disease may be managed with activity modification, footwear and targeted offloading. Persistent pain, functional limitation or substantial joint damage may lead to consideration of individual surgical options. Treatment cannot guarantee prevention of all arthritic change.

Assessment and treatment

When to seek evaluation

  • Forefoot pain during walking or sports
  • Pain localized under the second or third metatarsal head
  • Dorsal forefoot swelling
  • Limited dorsiflexion of the toes
  • Pain worsening with heels or narrow shoes

What is evaluated

  • Palpation of the metatarsal heads
  • Metatarsophalangeal joint mobility
  • Foot X-ray (flattening/fragmentation of the metatarsal head)
  • MRI in early cases (X-ray may be normal initially)
  • Forefoot biomechanical assessment

Treatment options

  • Reduce pain-provoking loads and select footwear or supports to offload the forefoot when appropriate
  • Observation, immobilisation, orthoses and physiotherapy are selected according to stage, symptoms and function
  • Targeted imaging when needed to define the involved metatarsal head and lesion stage
  • Surgery only in selected cases with persistent symptoms or advanced disease; procedure choice depends on joint morphology

Frequently Asked Questions

Does Freiberg's disease heal on its own?▼
Deformity and joint degeneration can remain, even after treatment. Care depends on stage, pain and function; offloading and footwear may ease symptoms but do not guarantee restoration of the metatarsal head.
Is surgery needed?▼
Not always. Persistent pain and limitation, disease stage and response to appropriate non-operative care guide the decision. Surgery is not limited solely to exceptionally rare advanced cases; the indication and procedure are individual.
Why does it affect girls more?▼
The reason for the female predominance (3:1) is unclear. Biomechanical factors (longer second metatarsal), footwear (heels, pointed shoes) and hormonal factors are hypothesized. Early recognition is important because it is among the few osteochondroses with a possible risk of arthritic evolution.
What does it look like on an X-ray?▼
X-rays show flattening, sclerosis or fragmentation of the affected metatarsal head. Early X-rays may be normal; MRI is more sensitive at that stage and shows early bone marrow oedema.

Other Juvenile Osteochondroses

Osteochondroses are a family of growth-related conditions. Learn about the others:

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Osgood-Schlatter(Knee)
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Sever(Heel)
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Sinding-Larsen(Kneecap)
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Köhler(Foot)
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Iselin(Outer foot)
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Panner(Elbow)
Complete guide to juvenile osteochondroses →

Important Notice: The information on this page is for educational and informational purposes only and does not constitute medical advice. Each clinical case is unique: the appropriate treatment is determined during the specialist consultation, based on a thorough clinical examination and, where necessary, diagnostic imaging. For any doubts or concerns, please consult a specialist.