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Freiberg's infraction

Discussion in 'Foot Surgery' started by donpod, Mar 3, 2011.

  1. donpod

    donpod Welcome New Poster

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    I have a middle aged business woman who presented with left forefoot pain about the 2nd and 3rd metatarsal. Pain started in October last year, after visiting the pedicurist and describes having a vigorous foot massage. Pain and swelling has persisted since. She reports pain not as bad with higher heeled footwear. MRI showed Freiberg's infraction of the 2nd and 3rd. Apart from the massage there is no history of repeated trauma except for her footwear style.
    Can anyone give me direction as to whether conservative management with moonboot, padding, orthotics, have better outcome than surgical. If surgical what is the preferred method of care? Also is there potentially a medical reason for an idiopathic Freiberg's
  2. drsarbes

    drsarbes Well-Known Member

    Hi Don

    Not an easy question to answer.

    Frieberg's are variable as far as amount of joint destruction and secondary decreased ROM and secondary bone formation. Some of these are quite remarkable on x-ray with considerable flattening of the head and base as well as no visible joint space or ROM. Others may be rather limited in joint destruction with pain only during acute flareups if any. I have had several over the years that I was able to take serial x-rays and follow the joint changes over time.

    "usually" the pain is from the lack of dorsiflexion at push off. It's interesting that your patient feels better with heels. Normally you want to off load the 2nd and 3rd metaheads and decrease the amount of DF neede for Push off, i.e., rocker bottom sole with perhaps a metatarsal pad if the rock or roller bottom does not afford relief.
    Usually the stiffer the sole and the lower the heel the better.

    Surgical debridement, metahead resection, minihead resection or replacement when all else fails.

    Good luck


    BTW - if there were a "medical reason" it wouldn't be idiopathic. Most attribute it to osteonecrosis of the avascular variety.
  3. Rob Christman

    Rob Christman Welcome New Poster

    Freiberg's disease is another name for epiphyseal osteonecrosis, a disease that occurs during childhood. The presentation in an adult typically is deformity of the metatarsal head with secondary osteoarthritis. Is that what is seen on radiographs? If the plain films were negative and the MRI abnormal, differential diagnosis may include stress fracture and joint disease. Could you provide more information regarding the radiographic findings (images would be great) and the MR report of findings?
  4. Ian Drakard

    Ian Drakard Active Member

    Just thinking why the patient would be better with heels- normally better with lower heel as Steve said. Is she a habitual heel wearer- is there a noticeable degree of ankle equinus? Worth doing a lunge test?

    If there is then the restricted rom in a flatter shoe may produce more pathological loading than the heels. Major calf stretches if this is the case.
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