Expert Patient Guide · London & North London

Freiberg’s Disease (Freiberg’s Infraction)

A comprehensive patient guide by Mr Matthew Welck, Consultant Orthopaedic Foot & Ankle Surgeon, Royal National Orthopaedic Hospital (RNOH) Stanmore and UCL — London, UK.

At a Glance: Freiberg’s Disease

Condition	Osteonecrosis (loss of blood supply) of a lesser metatarsal head, causing collapse of the joint surface and arthritis of the metatarsophalangeal (MTP) joint.
Also Known As	Freiberg’s infraction, Köhler’s second disease, metatarsal head avascular necrosis.
Who Gets It	Around five times more common in females. Onset is typically age 11–17, though many present later in adult life.
Joint Affected	Second metatarsal in ~68% of cases, third in 27%, fourth in 3%. About 10% are affected on both feet.
Cause	Multifactorial — repetitive loading and microtrauma plus a vulnerable blood supply.
Diagnosis	Weight-bearing X-ray, MRI, weight-bearing CT (WBCT).
Staging	Smillie classification, stages I–V.
Non-Surgical Care	Activity modification, stiff-soled shoes, offloading insoles, walking boot, physiotherapy, anti-inflammatories.
Joint-Preserving Surgery	Dorsal closing-wedge (Gauthier) osteotomy, Weil osteotomy, debridement and microfracture, osteochondral graft, interposition arthroplasty.
Joint-Sacrificing Surgery	Hemiarthroplasty or resection arthroplasty — reserved for late-stage and salvage cases.
Evidence Base	A 2020 systematic review graded every surgical option grade C — individualised specialist assessment is essential.
Specialist	Mr Matthew Welck — Consultant Foot & Ankle Surgeon, RNOH Stanmore & UCL, London. matthewwelck.com

What Is Freiberg’s Disease?

Freiberg’s disease — also called Freiberg’s infraction — is a condition in which the blood supply to the head of one of the long bones of the forefoot (a metatarsal) is disrupted. The bone beneath the joint surface weakens, and over time the rounded head of the metatarsal flattens and collapses.

First described in 1914, it makes the metatarsophalangeal (MTP) joint — the ball-of-the-foot joint at the base of the toe — painful, stiff, swollen and eventually arthritic. Many patients settle with non-surgical care, and where surgery is needed there is a wide menu of options, several of which preserve your own joint.

Understanding the Stages (Smillie Classification)
Freiberg’s disease is graded I to V. Early on there is a fissure beneath an intact joint surface; later the bone underneath is absorbed, the surface sinks and cracks, and finally the joint is flattened and arthritic. The stage drives the choice of operation — early stages usually suit joint-preserving surgery, while late stages may need the joint surface reshaped or replaced.

How Common Is It?

Freiberg’s disease is uncommon — which is why high-quality research is scarce and why treatment should be directed by a specialist.

Sex: roughly five times more common in females than in males.
Age: typically begins between 11 and 17 years, though many present for the first time in adult life, once arthritis has developed.
Which toe: the second metatarsal is affected in around 68% of cases, the third in 27% and the fourth in 3%.
Both feet: approximately 10% of patients are affected bilaterally.

What Causes It?

The cause is multifactorial. The two accepted explanations — repetitive trauma and interruption of the blood supply to the metatarsal head — are thought to act together.

Repetitive loading and microtrauma: the second metatarsal is usually the longest and most rigid of the lesser rays, so it takes disproportionate load with every step.
Vascular vulnerability: the metatarsal head has a precarious blood supply; interruption leads to ischaemia and osteonecrosis.
Foot shape and mechanics: a long second metatarsal, a short or hypermobile first ray, or a bunion (hallux valgus) all increase pressure under the second MTP joint.
Systemic factors: steroid use, connective tissue disorders and clotting abnormalities may contribute in selected patients.

What Are the Symptoms?

Pain in the ball of the foot (metatarsalgia), typically localised to the second toe joint and worse on walking, running or standing.
A feeling of “walking on a pebble” or that the joint is catching or grinding.
Swelling and warmth over the affected joint, worse in high heels or on hard floors.
Stiffness and loss of upward movement of the toe, making push-off and stairs uncomfortable.
In later stages, a visibly widened, thickened or deviated toe, and callus under the joint.

A note on adolescents: persistent forefoot pain in a teenager — particularly a dancer, gymnast or runner — should never be dismissed as growing pains. Early diagnosis widens the treatment options considerably.

What Investigations Might You Need?

Weight-bearing X-rays: the first-line test. Often normal in early disease; later they show flattening of the metatarsal head, joint space narrowing, loose fragments and bone spurs.
MRI scan: the most sensitive test for early disease, detecting osteonecrosis before any change appears on X-ray.
Weight-bearing CT (WBCT): a modern, low-dose 3D scan taken while standing, showing the true extent of collapse under load. Mr Welck is a UK pioneer of WBCT and it is part of his standard practice at the RNOH.
Ultrasound: used to exclude other causes of forefoot pain such as Morton’s neuroma or plantar plate injury.

Why Getting the Diagnosis Right Matters
Morton’s neuroma, plantar plate tears, metatarsal stress fractures and inflammatory arthritis can all mimic Freiberg’s disease, and treating the wrong diagnosis wastes months. A dedicated foot and ankle specialist with rapid access to MRI and weight-bearing CT can separate them quickly.

Non-Surgical Treatment Options

Most patients start here and many never need an operation, particularly when the disease is caught early. The aim is to offload the affected metatarsal head and let the bone recover.

Activity modification — a temporary reduction in running, jumping, dancing and other high-impact loading.
Stiff-soled or rocker-bottom footwear to limit bending through the painful joint.
Custom insoles with a metatarsal dome or bar to redistribute pressure away from the affected metatarsal head.
A period in a walking boot in more acute cases.
Anti-inflammatory medication, oral or topical.
Physiotherapy to maintain toe movement and calf flexibility.
Ultrasound-guided steroid injection in carefully selected patients.

Surgical Options for Freiberg’s Disease

Surgery is considered when pain persists despite good non-surgical care. Operations fall into two groups: those that preserve your own joint, and those that sacrifice or replace the joint surface. The right choice depends on your age, activity, the Smillie stage and how much of the surface is damaged.

Joint Debridement and Microfracture

Through a small open approach, loose fragments, inflamed lining and bone spurs are removed and fine holes made in the damaged surface to stimulate a healing cartilage layer. Long-term series report substantial gains in pain and function. Best suited to earlier disease, where the head has kept most of its shape.

Dorsal Closing-Wedge Osteotomy (Gauthier Osteotomy)

The most established joint-preserving operation. A wedge of bone is removed from the top of the metatarsal head, rotating healthy cartilage from the underside up to replace the collapsed area, held with fine screws or absorbable pins. Published series report large improvements in pain and function, and restoration of the rounded shape of the head.

Weil Osteotomy and Metatarsal Shortening

The metatarsal neck is cut and the head slid backwards, shortening the bone slightly and offloading the joint. It can be combined with a closing wedge to address both length and the damaged surface, and has been reported to help at all stages.

Osteochondral Autograft or Allograft

For late-stage disease with a large defect, a plug of healthy bone and cartilage — from the patient (autograft) or a donor (allograft) — is transplanted into the damaged part of the head. Midterm results report high function scores beyond five years, with imaging confirming the graft has healed in.

Interposition Arthroplasty

The damaged surface is removed and a spacer of soft tissue — commonly the extensor digitorum brevis tendon or a tendon graft — is interposed into the joint. This maintains toe length and movement without an implant, and is useful where too little healthy cartilage remains.

Hemiarthroplasty and Resection (Excision) Arthroplasty

Reserved for late-stage and salvage situations. A small implant may replace the joint — or the damaged head can be excised. Excision reliably relieves pain but may shorten the toe and reduce push-off power, so it is used selectively.

What Does the Evidence Actually Say?
A 2020 systematic review in Foot and Ankle Surgery (the journal of the European Foot and Ankle Society) examined 50 studies covering every surgical option for Freiberg’s disease. All of them — osteotomy, debridement and microfracture, grafting, interposition arthroplasty, hemiarthroplasty and resection arthroplasty — carry only a grade C recommendation, meaning the evidence comes from small case series rather than randomised trials. This does not mean the operations do not work — individual series report excellent results. It means no single procedure has been proven superior, so surgical experience, accurate staging and an individualised plan matter more here than in almost any other forefoot condition.

Why Choose Mr Welck?

Mr Matthew Welck is a Consultant Orthopaedic Foot & Ankle Surgeon at the Royal National Orthopaedic Hospital (RNOH) Stanmore — the UK’s leading orthopaedic hospital — and Honorary Associate Clinical Professor at UCL. He practises across London and North London.

His practice is dedicated exclusively to foot and ankle surgery. Alongside forefoot reconstruction, his specialist interests include complex ankle reconstruction, total ankle replacement, joint-preserving surgery and sports injuries — including Achilles tendon tears and Achilles ruptures. He has authored over 50 peer-reviewed publications, completed double fellowship training including international experience, and is a pioneer of weight-bearing CT and 3D-printed patient-specific instrumentation.

Patients are seen across North and Central London with rapid access to MRI, weight-bearing CT and multidisciplinary care. Every option is discussed and an individualised plan agreed together.

About the Author
Mr Matthew Welck BSc (Hons) MBBS MRCS MD(Res) FRCS (Tr & Orth)
Consultant Orthopaedic Foot & Ankle Surgeon, RNOH Stanmore. Honorary Associate Clinical Professor, UCL. BOFAS Education Committee; Director of the Stanmore Foot & Ankle Course.

Over 50 peer-reviewed publications; h-index 22, 1,700+ citations. EFAS Best Publication Award, David Marsh Prize, Watson-Jones Prize. Subspecialty interests: total ankle replacement, foot and ankle sports injuries including Achilles rupture, cavovarus and flatfoot reconstruction, and complex forefoot surgery.

GMC registered specialist. This guide is written for patients and does not replace individual medical advice.

Frequently Asked Questions

What is Freiberg’s disease in simple terms?

Freiberg’s disease is a loss of blood supply to the head of one of the long bones in the forefoot, most often the second metatarsal. The bone beneath the joint surface weakens and collapses, causing pain, swelling and stiffness in the ball of the foot.

Will Freiberg’s disease get better on its own?

In early disease, offloading the joint with a stiff-soled shoe, a metatarsal-dome insole and reduced impact can settle symptoms, and some patients need nothing further. Once the metatarsal head has collapsed the shape change is permanent, and surgery is more likely to be needed if pain persists.

Which operation is best for Freiberg’s disease?

There is no single best operation. A 2020 systematic review found that all available procedures rest on relatively weak evidence and none has been proven superior. The right choice depends on your age, activity, the stage of disease and the shape of the joint — which is why individualised specialist assessment matters.

Can the joint be preserved?

Often, yes. In earlier stages, debridement with microfracture, a dorsal closing-wedge (Gauthier) osteotomy or an osteochondral graft can preserve your own joint. Joint-sacrificing options are generally reserved for late-stage or salvage cases.

How long is the recovery after surgery?

This depends on the procedure, but as a guide expect around 6 weeks in a stiff-soled post-operative shoe or boot, comfortable walking by 3 months, and 6–12 months for the joint to settle fully and for return to impact sport.

Can I still run or dance afterwards?

Many patients return to sport and dance, particularly after joint-preserving surgery in earlier-stage disease. Return to high-impact activity is individualised and staged over several months.

Is Freiberg’s disease the same as a Morton’s neuroma?

No. A Morton’s neuroma is a thickened, irritated nerve between the toes causing burning pain and numbness; Freiberg’s disease is a bone and joint problem. They can feel similar, which is why imaging and expert examination matter.

Can I be treated on the NHS?

Yes. Mr Welck treats NHS patients at the Royal National Orthopaedic Hospital (RNOH) Stanmore, and private patients across London and North London.

Where can I see Mr Matthew Welck for Freiberg’s disease in London?

Mr Welck consults across North and Central London. NHS patients are seen at the RNOH Stanmore. Private appointments can be booked on 07547 395270 or by emailing secretary@matthewwelck.com.

Book a Consultation

If you are struggling with persistent pain in the ball of your foot, specialist assessment can make a real difference to your outcome. Early review gives you the widest range of options — including the joint-preserving procedures that become harder to offer once the joint has collapsed.

Book a Private or NHS Consultation
Mr Matthew Welck — Consultant Orthopaedic Foot & Ankle Surgeon, London & North London

Email: secretary@matthewwelck.com
Call: 07547 395 270
Website: matthewwelck.com

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Key reference: Alhadhoud MA, Alsiri NF, Daniels TR, Glazebrook MA. Surgical interventions of Freiberg’s disease: a systematic review. Foot and Ankle Surgery 2021;27(6):606–614.

This page is for information only. It does not replace personalised medical advice. Always consult a qualified specialist for diagnosis and treatment.

Written by: Matthew Welck | Consultant Orthopaedic Foot & Ankle Surgeon London — last updated 9 July 2026