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.

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
Freiberg original description (case 1903, lecture 1913, published 1914)
Freiberg case 1903; lecture 1913; and 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…

Associated Persons

Alternative names
  • Freiberg disease, Freiberg 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

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

Emergency physician MA (Oxon) MBChB (Edin) FACEM FFSEM with a 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 |

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