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Health condition · Clinically reviewed

Freiberg’s infraction, osteonecrosis of the 2nd metatarsal head — from offloading to joint-sparing dorsal wedge osteotomy.

Osteonecrosis of a lesser metatarsal head — most commonly the second — classically in adolescent girls. Modern stratified care: offloading and orthoses early; dorsal wedge osteotomy or interposition arthroplasty for advanced disease.

Jump to treatment See red-flag forefoot pain
A radiographer guides a patient onto the bed of an advanced 3 Tesla MRI scanner in a London imaging suite

Why trust this guide

  • 01

    Clinically reviewed

    Written by our editorial team and reviewed by a registered UK clinician before publication.

  • 02

    Sourced from guidance

    Every claim is checked against BOFAS, NICE MSK guidance or peer-reviewed sources you can see at the end.

  • 03

    Current for 2026

    Reflects current UK practice on offloading, Smillie staging and joint-sparing dorsal wedge osteotomy.

Key facts

Freiberg’s infraction at a glance.

The essentials, in plain English — what Freiberg’s infraction is, why it usually affects the second metatarsal in adolescent girls, and how modern joint-sparing surgery has changed the picture.

  • Definition

    Freiberg’s infraction is an osteonecrosis of a lesser metatarsal head — a segmental loss of blood supply with collapse of the articular surface.

  • Which metatarsal

    The second metatarsal head is most commonly affected, followed by the third — reflecting the mechanical load pattern of the forefoot.

  • Who it affects

    Classically adolescent girls and young women — one of the few osteonecroses with a clear female predominance.

  • Smillie classification

    Smillie stages I–V describe the sequence from subchondral fracture through collapse to late secondary arthritis of the MTP joint.

  • Imaging of choice

    Weight-bearing X-ray is the starting point; MRI is the investigation of choice for early disease before X-ray changes appear.

  • Modern surgery

    Joint-sparing dorsal wedge osteotomy has largely displaced older excisional procedures for advanced but salvageable disease.

Why this guide matters

Offload first, operate later.

Most Freiberg’s can be managed conservatively for years — this guide sets out the stratified approach from insoles through to joint-sparing surgery.

  • Insoles do most of the work

    A well-fitted metatarsal dome insole and rocker sole shift load away from the affected head — the single biggest early lever.

  • Stage before you operate

    Smillie staging on X-ray and MRI decides who needs debridement, who needs a dorsal wedge osteotomy, and who needs arthroplasty.

  • Joint-sparing surgery when it fits

    A dorsal wedge osteotomy preserves the natural joint by rotating healthy plantar cartilage into the weight-bearing surface.

How the diagnosis is made

From forefoot pain to a clear plan.

The steps a UK GP, podiatrist and foot and ankle surgeon will normally follow, in order — so you know what to expect and why.

  1. 01

    Recognising

    Symptom and activity history

    Ball-of-foot pain in an adolescent girl or young woman, often with insidious onset and worse on push-off — the classic story.

  2. 02

    Recognising

    Palpation of the metatarsal head

    Focal tenderness over the second (or third) metatarsal head, sometimes with a palpable dorsal prominence.

  3. 03

    Recognising

    Weight-bearing X-ray

    The first-line image — looking for flattening, sclerosis or collapse of the metatarsal head, with joint-space changes in later stages.

  4. 04

    Confirming

    MRI foot for early disease

    MRI is the investigation of choice for early Freiberg’s — bone marrow oedema appears well before any change on plain film.

  5. 05

    Confirming

    Assess coexisting forefoot pathology

    Look for associated metatarsalgia, plantar plate insufficiency or hallux pathology that may modify the treatment plan.

  6. 06

    Confirming

    Assign a Smillie stage

    Staging from I (subchondral fracture) to V (arthritic collapse) guides whether conservative care or surgery is appropriate.

  7. 07

    Managing

    Foot and ankle surgery consultation

    Refer for surgical opinion in advanced or refractory disease — for debridement, dorsal wedge osteotomy or interposition arthroplasty.

Typical timeline: 2–6 weeks from first appointment to a settled plan.

Symptoms

What Freiberg’s infraction actually feels like.

The pattern is more telling than any single symptom — ball-of-foot pain, focal tenderness under the second metatarsal head and pain on push-off in an active young person.

  • Ball-of-foot pain

    A dull, activity-related ache under the forefoot — the dominant symptom in early Freiberg’s.

  • Pain under metatarsal head

    Focal, pinpoint pain directly under the affected metatarsal head — most often the second.

  • Local swelling

    Diffuse swelling and warmth around the affected MTP joint, especially after longer periods on the feet.

  • MTP joint stiffness

    Reduced range of movement at the MTP joint — with a mechanical block as loose bodies and collapse develop.

  • Pain on push-off

    Pain during the toe-off phase of gait — running, walking uphill or wearing heels reliably flare symptoms.

  • Adolescent age at onset

    Symptoms typically begin in the second decade — often in an active adolescent girl.

  • Recurrent symptoms

    A relapsing, remitting course over months — many patients settle for years before flaring again.

  • Red flag

    Acute severe collapse of the metatarsal head with visible deformity — arrange urgent foot and ankle surgical review.

Treatment

How Freiberg’s infraction is treated in the UK.

A stratified approach — offloading and orthoses first, then debridement or dorsal wedge osteotomy for advanced but salvageable disease, and interposition arthroplasty for arthritic collapse.

  • Metatarsal dome insole

    A dome-shaped insole redistributes load proximal to the affected metatarsal head — often the first and most useful intervention.

  • Stiff-soled shoe or rocker sole

    A rigid rocker sole reduces MTP joint bending forces and offloads the diseased head during gait.

  • Boot immobilisation for acute flare

    A short spell in a walking boot for a painful acute flare — settles bone marrow oedema and gives the head a chance to rest.

  • NSAIDs

    Short courses of NSAIDs for symptomatic relief during flares — used alongside offloading, not as a standalone strategy.

  • Physiotherapy

    Calf stretching, intrinsic foot strengthening and gait re-education to reduce forefoot overload.

  • Debridement of loose bodies

    Arthroscopic or open debridement of intra-articular loose bodies for mechanical symptoms in earlier stages.

  • Dorsal wedge osteotomy (joint-sparing)

    The modern operation of choice for advanced but salvageable disease — rotates healthy plantar cartilage into the joint surface.

  • Interposition arthroplasty

    Reserved for genuinely advanced disease with arthritic collapse — replaces the destroyed joint surface with a soft-tissue spacer.

What this guide is based on

The sources behind every claim on this page.

UK national guidance and specialist society standards, current at the time of last review.

Key references

Guidelines and standards we relied on.

A quiet reminder

This guide is for information, not medical advice.

Your GP, podiatrist or foot and ankle team knows your history and can tell you which parts apply to you. If in doubt, get seen.

  • British Orthopaedic Foot and Ankle Society (BOFAS). Patient information and clinical standards.

  • NICE. Musculoskeletal guidance relevant to forefoot pain.

  • Royal College of Podiatry. Guidance on forefoot pain and metatarsalgia.

  • Smillie IS. Freiberg’s infraction — original classification (stages I–V).

Red flags

When forefoot pain needs more than an insole.

Most Freiberg’s is manageable non-operatively. These are the situations where escalation to surgical review is appropriate.

  • Collapse of the metatarsal head

    Rapid, painful collapse of the articular surface with visible deformity — needs urgent surgical review.

  • Loose intra-articular body

    Mechanical locking or catching of the MTP joint suggests a loose osteochondral fragment amenable to debridement.

  • Advanced arthritis of the MTP

    Late Smillie stages with joint-space loss and osteophytes may need interposition arthroplasty rather than joint-sparing surgery.

  • Post-op transfer metatarsalgia

    New pain under an adjacent metatarsal head after osteotomy — reflects altered load-sharing across the forefoot.

  • Post-operative infection

    Increasing pain, redness, swelling or fever days after surgery — same-day surgical team review.

  • Nerve injury

    New numbness, tingling or burning in the toes after surgery — could reflect digital or intermetatarsal nerve injury.

  • Failed conservative therapy

    Persistent disabling pain after several months of offloading and orthoses — time to consider surgical opinion.

  • Recurrent symptoms

    Repeated flares over years despite good conservative care — reassess staging and consider joint-sparing surgery.

  • Bilateral disease

    Both feet affected — reconsider the diagnosis, exclude systemic causes and plan surgery with care to avoid simultaneous immobilisation.

Living with it

A chronic condition, but a very manageable one.

Four things that make the biggest difference day to day — offloading, footwear, load management and patient review.

A quiet reminder

Consistency beats intensity, every time.

Small, steady changes — kept up for months — do more than a heroic week that does not last.

  1. 01 Offload

    Insoles do most of the work

    Metatarsal dome insoles and stiff-soled shoes offload the affected head — the single biggest day-to-day lever.

  2. 02 Footwear

    Choose your shoes with care

    Rocker-sole shoes and generous toe boxes reduce MTP loading — avoid heels and thin-soled fashion shoes during flares.

  3. 03 Load

    Manage high-impact activity

    Running, dancing and prolonged standing reliably flare symptoms — modify volume, do not necessarily stop.

  4. 04 Reviews

    Reassess with imaging over years

    Freiberg’s is a chronic condition — periodic clinical and imaging review guides when to escalate to surgery.

Frequently asked

Everything we get asked about Freiberg’s infraction.

Quick answers on staging, MRI, insoles, dorsal wedge osteotomy and when to seek help.

  • What is Freiberg’s infraction?

    Freiberg’s infraction is an osteonecrosis of a lesser metatarsal head — most commonly the second — where a segment of bone loses its blood supply, collapses and, over time, may lead to secondary arthritis of the MTP joint.

  • Why does it usually affect the second metatarsal in adolescent girls?

    The second metatarsal is the longest and most rigidly fixed of the lesser rays, so it takes the highest peak load during push-off. Combined with the vascular and hormonal changes of adolescence, this creates the classic pattern of second-metatarsal disease in adolescent girls and young women.

  • Do I always need surgery?

    No. Most cases are managed non-operatively with a metatarsal dome insole, stiff-soled or rocker-sole shoes and short spells of NSAIDs or boot immobilisation for flares. Surgery is reserved for advanced disease or symptoms that do not settle with a proper trial of offloading.

  • What is a dorsal wedge osteotomy?

    A dorsal wedge osteotomy is a joint-sparing operation for advanced Freiberg’s. A wedge of bone is removed from the top of the metatarsal head and the head is rotated so that healthy plantar cartilage becomes the new weight-bearing surface — preserving the natural joint.

  • Why is MRI preferred over X-ray in early disease?

    X-ray changes take weeks to months to appear. MRI shows the bone marrow oedema of early osteonecrosis before any collapse is visible on plain film — so if the story is right and X-rays are normal, MRI is the correct next step.

  • What is the red flag I should not ignore?

    A sudden increase in pain with visible deformity of the ball of the foot may reflect acute collapse of the metatarsal head, and mechanical locking suggests a loose intra-articular body — both need urgent foot and ankle surgical review.

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