Second Metatarsal Osteochondrosis

Aka: Second Metatarsal Osteochondrosis, Freiberg's Disease, Avascular Necrosis of the Metatarsal Head

1. See Also
   1. Osteochondrosis
2. Epidemiology
   1. Affects teens
   2. Girls predominate by a factor of 3-4
   3. Most associated with ballet and dance
3. Pathophysiology
   1. Unknown etiology, but presumed due to microtrauma, decreased vascular supply or systemic conditions
   2. Disordered ossification of the Metatarsal head (most often the second Metatarsal)
      1. Avascular necrosis (or aseptic necrosis) of the seccond Metatarsal head (other toes may be involved)
4. Risk Factors
   1. Trauma
   2. Repetitive stress
   3. Improper shoes
   4. Decreased blood supply to the affected area
5. Symptoms
   1. Pain and swelling localized to the affected metarsal head
   2. Typically unilateral (90% of cases)
   3. Worse with weight bearing or walking
6. Signs
   1. Metatarsal-phalangeal joint (MTP) inflammation
      1. Tenderness and swelling over the involved Metatarsal head
      2. Restricted Range of motion
   2. Metatarsal head palpably enlarged
7. Imaging
   1. Weight-Bearing Foot XRay
      1. XRay Findings may lag symptom onset by 3-6 weeks
      2. Sclerosis and flattening of the involved articular surface of the Metatarsal head
      3. Widening and irregularity of Metatarsal head
      4. Flattening and collapse of MTP joint with cystic changes
      5. Loose bodies sometimes present
   2. MRI
      1. Consider when serial XRays fail to make the diagnosis
8. Management
   1. NSAIDs
   2. Warm soaks
   3. Local Corticosteroid Injection
   4. Well padded shoes
   5. Stiff soled shoe or walking boot
   6. Anterior Metatarsal bar or pad
      1. Shifts pressure from Metatarsal head
   7. Surgery indications
      1. Loose bodies
      2. Significantly deformed Metatarsal head
9. References
   1. Achar (2019) Am Fam Physician 99(10): 610-8 [PubMed]
   2. Atanda (2011) Am Fam Physician 83(3): 285-91 [PubMed]
   3. Carmont (2009) Foot Ankle Int 30(2): 167-76 [PubMed]