Your teenage daughter has started favouring one foot after netball training or a long day in school shoes. The sore spot is not the heel and not the arch. It sits right under the ball of the foot, near the base of the second toe, and it flares with running, jumping, and pushing off in a pair of heels for a family dinner. The forefoot may look a little puffy over the top, and the joint feels stiff when she bends the toe up. If this pattern has been building over weeks in an active adolescent, Freiberg’s disease is one of the conditions a podiatrist will want to rule in or out.
Freiberg’s disease, also called Freiberg’s infraction, is a temporary loss of blood supply to the head of a metatarsal bone, most often the second, sometimes the third. The affected bone softens, and the joint surface can flatten under the repeated load of walking, running, and jumping while the skeleton is still maturing. It belongs to the osteochondrosis family, the group of conditions that affect growing bone and cartilage, and it is the one that most often affects teenage girls. Accurate diagnosis matters because the early stage responds well to offloading, whereas a metatarsal head that is allowed to collapse under continued load can develop lasting joint change that is far harder to address later.
Symptoms of Freiberg’s Disease
The pain of Freiberg’s disease centres on a single joint in the ball of the foot, usually the second, and builds gradually rather than starting with one dramatic injury. The pattern below is what points a clinician toward the metatarsal head rather than the surrounding soft tissue.
- Pain under the ball of the foot at one metatarsal joint: the tenderness localises to the second (sometimes third) metatarsophalangeal joint, the knuckle at the base of the toe, rather than spreading across the whole forefoot.
- Pain that worsens with running, jumping, and heels: anything that loads and bends the forefoot at push-off reproduces or aggravates the ache. Wearing heels or thin-soled shoes tends to flare it.
- Swelling and warmth over the top of the joint: the forefoot can look and feel a little puffy over the affected metatarsal head, particularly after activity.
- Stiffness and reduced movement of the toe: bending the toe up and down feels tight or blocked, and this restriction often persists between flares as the joint surface changes.
- A limp or a shift onto the outer foot: to keep weight off the sore joint, an adolescent may walk on the outer edge of the foot or shorten their stride.
- Pain reproduced by pressing the metatarsal head: squeezing the joint or loading it directly recreates the patient’s pain, which helps separate it from a nerve or soft-tissue source nearby.
- Grinding or catching in longstanding cases: where the joint surface has flattened, some patients describe a gritty or catching sensation when the toe moves, a sign that degenerative change has set in.
From what we see in clinic, the most useful early clue is a single tender, stiff, slightly swollen joint in the ball of the foot of an active teenager, worse with impact and heels. Forefoot pain that stays fixed to one metatarsal joint and does not settle with rest deserves assessment rather than repeated changes of insole.
Causes of Freiberg’s Disease
The metatarsal head takes a large share of forefoot load every time the foot pushes off, and in a still-growing skeleton its blood supply is relatively fragile. Freiberg’s disease develops where repeated load outpaces what that developing bone can tolerate.
What Causes Freiberg’s Disease?
- Repetitive load on a growing metatarsal head: running, jumping, and pivoting sports drive force through the ball of the foot during a phase when the metatarsal head is still maturing, and repeated stress is thought to disrupt its blood supply.
- Disruption of blood supply to the bone: the softening and flattening that define the condition follow a temporary loss of circulation to the metatarsal head, similar in principle to the other osteochondroses, even though the exact trigger is not fully understood.
- A longer second metatarsal: where the second metatarsal is longer than the first, it carries more of the forefoot load at push-off, which concentrates stress on the joint most commonly affected.
- Footwear that loads the forefoot: high heels and stiff, narrow shoes push more weight onto the ball of the foot and hold the toes in a bent position, adding to the load the metatarsal head must absorb.
- A single higher-energy forefoot injury: less commonly, a heavy landing or a stubbing force to the forefoot can precede symptoms, though the more typical story is a gradual build-up rather than one event.
Who Carries a Higher Baseline Risk?
- Adolescents, most often girls, typically between the ages of 11 and 17.
- Dancers, netballers, footballers, gymnasts, and runners, whose sports load the forefoot repeatedly.
- Teenagers who spend long periods in high heels or thin-soled, narrow shoes.
- Young people with a longer second metatarsal or a forefoot shape that concentrates load on the second joint.
- Those who have recently increased training volume, particularly on hard surfaces.
Conditions Commonly Mistaken for Freiberg’s Disease
Pain in the ball of the foot has several possible sources, and Freiberg’s disease shares its territory with nerve, ligament, and stress-related problems. A focused assessment, usually including an X-ray of the forefoot, helps tell them apart.
Metatarsalgia
Metatarsalgia is a general term for pain under the ball of the foot rather than a single diagnosis, and Freiberg’s disease is one of its specific causes. The distinction that matters is whether the pain is spread across several metatarsal heads, which points to general forefoot overload, or fixed to one stiff, swollen joint with changes visible on X-ray, which points to Freiberg’s disease. Treating it as generic metatarsalgia risks missing the bone change underneath.
Morton’s neuroma
Morton’s neuroma is a thickening of a nerve between the metatarsal heads, most often between the third and fourth toes. It produces burning, tingling, or numbness that radiates into the toes and is often reproduced by squeezing the forefoot from side to side. Freiberg’s disease centres on the bone and joint itself, with tenderness and stiffness at a single metatarsal head rather than a shooting nerve pain into the toes.
Second toe plantar plate injury
A plantar plate injury affects the ligament under the base of the toe that stabilises the joint, and it also causes pain and swelling under the second metatarsophalangeal joint, which makes it a close mimic. The differentiators are the way the toe sits and moves. Plantar plate problems often let the toe drift or lift out of line, whereas Freiberg’s disease shows the flattening of the metatarsal head on imaging that a ligament injury does not.
Metatarsal stress fracture
A stress fracture of the metatarsal shaft can produce forefoot pain that worsens with impact and eases with rest, much like Freiberg’s disease. The differentiators are the site and the imaging pattern. Stress-fracture tenderness sits along the shaft of the bone rather than at the joint, and the two conditions show different changes on X-ray and MRI. Where the picture is unclear, imaging settles it.
Treating and Preventing Freiberg’s Disease
The aim of treatment is to take load off the affected metatarsal head so the softened bone is protected while the joint settles, control the pain and swelling of a flare, and correct any footwear or foot-shape factor that concentrated stress on that joint in the first place. Care is conservative first, and the earlier a case is caught, the more the offloading approach can do before joint change becomes established. How far treatment needs to go depends on the stage of the condition and how much the metatarsal head has flattened.
Conservative treatment
These measures are usually combined, and offloading the joint is the foundation of all of them.
- Activity modification and relative rest: stepping back from running, jumping, and pivoting sports during a flare takes the repetitive load off the metatarsal head. Low-impact activity such as swimming or cycling keeps a teenager moving while the joint settles, and load is rebuilt gradually as symptoms allow.
- Metatarsal offloading padding: a metatarsal dome or pad placed just behind the sore joint lifts and spreads forefoot load away from the affected head. It is one of the quickest ways to ease pain during walking and is often the first thing trialled in clinic.
- Custom foot orthoses: a device built with a metatarsal bar or dome redistributes pressure off the affected metatarsal head over the longer term and accounts for the individual’s forefoot shape and a longer second metatarsal where that is a factor. This is the mainstay for reducing recurrent flares once the acute pain has eased.
- Stiff-soled and rocker-soled footwear: a shoe with a rigid sole, or a rocker profile, limits how much the forefoot joint has to bend at push-off, which directly offloads the sore metatarsal head. Moving out of heels and thin, flexible shoes is part of the same principle.
- Protected weight-bearing in an acute flare: for a painful flare with a marked limp, a short period in a stiff-soled shoe or a walking boot offloads the joint more firmly and often produces the quickest settling before the padding and orthotic plan takes over.
- Pain and swelling control: ice after activity and a short course of anti-inflammatory or pain-relief medication, on medical advice, can help through the early weeks of a flare.
When conservative care isn’t enough
Where forefoot pain persists despite consistent offloading, or where imaging shows a metatarsal head that has flattened or collapsed with established joint change, an orthopaedic opinion is appropriate. Imaging, usually starting with an X-ray and sometimes an MRI in the earlier stages before changes are visible on plain film, is used to stage the condition and guide that decision. Surgery, when it is considered, is led by an orthopaedic surgeon, and the procedure chosen depends on the stage, ranging from clearing out the damaged joint surface through to reshaping or realigning the bone. Most adolescents caught early do not reach this stage, which is why prompt assessment and disciplined offloading matter.
Have Your Freiberg’s Disease Managed at Straits Podiatry
Freiberg’s disease rewards early, accurate diagnosis. The forefoot pain of an active teenager is easy to pass off as growing pains or a footwear niggle, and the offloading that protects the joint works best before the metatarsal head has flattened. An assessment at Straits Podiatry combines a focused history, examination of the affected metatarsophalangeal joint, a biomechanical and gait analysis of how the forefoot is loading, and a footwear review, with referral for imaging where the clinical picture calls for it.
Where Freiberg’s disease is confirmed, our podiatrists can help with the offloading side of care through metatarsal padding, custom foot orthoses with a metatarsal bar, and footwear guidance, and can coordinate an orthopaedic referral for advanced or collapsed joints. Our physiotherapy service, the rehabilitation arm of Straits Podiatry, can support the return to sport once the joint has settled. To have your child’s forefoot pain assessed, book a consultation for an assessment at any of our three Singapore clinics.
Frequently Asked Questions About Freiberg’s Disease
Will my teenager grow out of Freiberg’s disease?
Not in the way a younger child grows out of some other osteochondroses. Unlike Kohler’s disease, where the navicular reliably reforms on its own, Freiberg’s disease affects a joint surface that can flatten permanently if the softened metatarsal head is loaded through an active phase. Caught early and offloaded well, many adolescents settle to comfortable, active feet. The aim of treatment is to protect the joint while it is vulnerable so that it is far less likely to develop the stiffness and degenerative change that a collapsed metatarsal head can leave behind.
Does Freiberg’s disease need surgery?
Most cases do not, particularly when the condition is recognised early and the joint is offloaded with padding, orthoses, and footwear changes. Surgery is considered where pain persists despite consistent conservative care, or where imaging shows a metatarsal head that has flattened or collapsed with established joint change. When surgery is needed, it is led by an orthopaedic surgeon, and the procedure depends on the stage of the condition. A podiatrist’s role is to manage the offloading and to arrange that referral at the right point.
Can my child keep playing sport with Freiberg’s disease?
Within limits, and guided by pain. During a flare, running, jumping, and pivoting sports load the exact joint that needs protecting, so stepping back from them while keeping up low-impact activity such as swimming or cycling is usually the right balance. As pain and swelling settle with offloading, sport is rebuilt gradually rather than resumed all at once. Pushing through forefoot pain during the active phase is what risks letting the metatarsal head flatten further, so tolerance rather than the training calendar should set the pace.
How is Freiberg’s disease diagnosed?
Diagnosis starts with the clinical picture, a single tender, stiff, often swollen joint in the ball of the foot of an active adolescent, worse with impact and heels. An X-ray of the forefoot usually confirms it by showing flattening, widening, or fragmentation of the affected metatarsal head. In the earliest stage, before changes are visible on a plain X-ray, an MRI can pick up the loss of blood supply sooner. Imaging also stages how advanced the joint change is, which guides whether offloading alone is enough or an orthopaedic opinion is needed.
Do orthotics help Freiberg’s disease?
Yes, offloading the affected joint is the mainstay of conservative care, and custom foot orthoses are central to it. A device built with a metatarsal bar or dome shifts pressure off the sore metatarsal head at every step and can be shaped to account for a longer second metatarsal or a forefoot pattern that concentrated the load. Orthoses are usually combined with a stiff-soled or rocker-soled shoe and a move away from heels, so that the joint is bending and loading less at push-off. The earlier this offloading starts, the more it can protect the joint.
Are high heels linked to Freiberg’s disease?
High heels do not cause the condition on their own, but they add to the load on the ball of the foot and hold the toes bent, which concentrates stress on the metatarsal heads. Because Freiberg’s disease most often affects teenage girls, and heel wear tends to rise in that group, footwear is a factor worth addressing. Moving out of heels and thin, narrow shoes into supportive, stiffer-soled footwear is part of both settling a flare and reducing the chance of recurrence, alongside padding and orthoses.