Freiberg infraction: osteochondrosis of the metatarsal heads (typically the 2nd metatarsal head) characterized pathologically by subchondral bone collapse, osteonecrosis, and cartilaginous fissures

Freiberg infraction is more common in women and most commonly manifests during adolescence (aged 10-18 years). Bilateral presentation in 10% of cases. Cause unknown and probably multi-factorial. High-heeled shoes have been implicated as a causative factor

Patients may present with pain and limited motion, although symptoms may not begin until degenerative arthrosis has developed.

Freiberg infraction is typically diagnosed clinically and confirmed with plain films. Bone scans and magnetic resonance imaging (MRI) may be useful early in the disease process before radiograph changes are evident.

Plain X-ray features include

  • Early changes of cystic lesions and flattening of the affected metatarsal head with widening of the metatarsophalangeal joint
  • Late changes with sclerosis and flattening of the bone, increased cortical thickening, and osteochondral fragments

History of the Freiberg infraction

1913Albert Freiberg presented a paper to the Southern Surgical and Gynecological Association. He reported the cases of six young women presenting with a painful limp and discomfort localized to the second metatarsal, the first patient presenting in 1903. [1914; 26: 171-174]

During the past ten years I have encountered six cases of infraction of the distal end of the second metatarsal bone. The patient was a girl aged sixteen years. She had been suffering from pain in the ball of the foot for about six months. The patient was quite sure that the condition dated from and was due to a game of tennis in which she “stubbed her foot

Freiberg 1913

Freiberg employed the term ‘infraction’ as the diagnosis (archaic term for fracture without displacement implying trauma as the cause)

I felt justified in the diagnosis of infraction of the distal end of the second metatarsal, a condition which I have thus far failed to find described in the literature.

Freiberg 1914
Friberg infraction 1914
Case I, Fig 1; Girl aged sixteen years; Tennis injury of six months before; Infraction of second metatarsal with small loose body. Case 1903; lecture 1913; published 1914

1915Alban Köhler described in his book ‘Grenzen des Normalen und Anfänge des Pathologischen im Röntgenbilde‘:

Am 2. Metatarso phalangeal-Gelenk kommt eine äusserst eigenartige Erkrankung vor, die, soviel Verfasser weiss, in ihrer Eigenart in der Literatur bisher nirgends gewürdigt worden ist. Es handelt sich um eine Abflachung oder Abplattung der Gelenkfläche des Köpfchens des betreffenden Metatarsus, die manchmal gelockert bez. etwas abgehoben zu sein scheint; jedenfalls sieht man mitunter, bei den anscheinend frischeren Fällen, einen infraktions- oder frakturartigen 1-2mm breiten, durchlässigen Zwischenraum (…)

Äusserst merkwürdig ist, dass die ganze distale Hälfte des befallenen Metatarsus distalwärts gleichmässig an Umfang zunimmt.

Köhler, 1915

At the 2nd metatarso-phalangeal joint, a most peculiar disease may arise, which, to the knowledge of the author, has not been honoured in literature so far. It is a flattening, or squashing of the articular surface of the head of the affected metatarsal, which is sometimes loosened, or apparently somewhat lifted; in any case one may see in the fresher cases, an infraction- or fracture-like intermediary space of 1-2mm (…)

Particularly notable is that the entire distal half of the affected metatarsal broadens uniformly.

Köhler, 1915

1920Köhler described cases in greater detail at the 11th congress of the German Roentgen Ray Society and published his findings in 1923

The joint-space is not only broadened, but the broadening is strikingly irregular, so that the fibular half of the space is often double that of the tibial half (…) The head of the metatarsal is undoubtedly shortened, not in toto but in its distal third, as if the cap had been driven in.

About 1 patient in 10 gave a history of trauma. We need not dwell further on this point. Certainly trauma alone cannot be the cause.

Köhler, 1920
Köhler original description 1915

1926 – Numerous other cases were reported between 1915 and 1924. Köhler called out Freiberg for an ‘incomplete‘ description of ‘metatarsal infraction‘ lacking mention of the widening of the joint line; thickening of the shaft of the metatarsal and obliteration of the neck. Freiberg responded in 1926 acknowledging trauma unlikely to be the sole cause and the additional features as suggested by Köhler…

The interpretation of this change in the second metatarsal, occurring within a period of eight months, is a difficult matter without more evidence than is at command. My excuse for making this report without a definite expression of opinion is that I hope it may lead to further study of similar cases and perhaps bring us to an explanation of the condition implied in the caption of this paper.

This expression implies flat it is my belief that the case which I am here reporting represents a very early stage of the so-called “infraction of the second metatarsal bone.” It also implies that I am ready to acknowledge – that simple trauma is not a satisfying explanation of the clinical and roentgenographic phenomena which have been described in this connection and by various authors. The matters of priority of publication and of the attachment of an eponymic title to the condition seem to me of little importance.

Freiberg riposte to Köhler 1926

1967Ian Scott Smillie (1907-1992) described the most widely used classification of Freiberg’s infraction

It is possible by timely surgical intervention to interrupt the pathological process of Freiberg’s infraction and restore the conformation of the metatarsal head. For the purposes of treatment, the natural history of the disease can be conveniently divided into five stages

Smillie 1967
Smillie’s classification of Freiberg infraction
Smillie’s classification of Freiberg infraction. Smillie IS, 1967
  • Stage 1: Fissure in epiphysis with sclerosis between cancellous surfaces.
  • Stage 2: Absorption of cancellous tissue on the proximal side with sinking of the articular cartilage dorsally.
  • Stage 3: Further absorption and sinking of the articular surface with bony projections medially and laterally. There is exostosis on the dorsal proximal metatarsal head.
  • Stage 4: Articular surface has sunk so far that restoration of normal anatomy has passed. Fractures of the medial and lateral projections may occur
  • Stage 5: Arthrosis with flattening and deformity of the metatarsal head. The plantar aspect is the only area where cartilage retains its original contour. The shaft of metatarsal is thickened and dense

Associated Persons

Alternative names
  • Freiberg disease, Freiberg infraction, Freiberg’s infraction
  • Köhler disease II
  • Freiberg-Köhler syndrome


Infraction, not infarction. Freiberg believed the aetiology most likely was trauma possibly due to the excessive length of the second metatarsal with overload and subsequent articular collapse


Original articles

Review articles



the names behind the name

BA MA (Oxon) MBChB (Edin) FACEM FFSEM. Emergency physician, Sir Charles Gairdner Hospital.  Passion for rugby; medical history; medical education; and asynchronous learning #FOAMed evangelist. Co-founder and CTO of Life in the Fast lane | Eponyms | Books | Twitter |

Resident medical officer in emergency medicine MB ChB (Uni. Dundee)  MRCS Ed. Avid traveller, yoga teacher, polylinguist with a passion for discovering cultures.

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