Freiberg’s disease, first described by Alfred H. Freiberg in 1914, is a perplexing and painful condition characterized by infraction, or osteochondrosis, of the metatarsal head. Most commonly affecting the second metatarsal, and occasionally the third, it represents a vascular insult leading to avascular necrosis, subchondral bone collapse, and subsequent joint deformity. This condition primarily afflicts adolescents during their growth spurt, with a notable predilection for active young women. The journey of treating Freiberg’s disease is not a linear path but a nuanced labyrinth, where the chosen route is dictated by the stage of the disease, the severity of symptoms, the patient’s age, and their functional demands. A successful treatment strategy evolves from a foundation of conservative management, progressing to surgical intervention only when necessary, with the ultimate goals of alleviating pain, restoring function, and preventing long-term joint degeneration.

The cornerstone of initial management for Freiberg’s disease, particularly in its early stages (I and II according to the Smillie classification), is a comprehensive conservative approach. The primary objective here is to offload the affected metatarsal head, thereby reducing the mechanical stress that exacerbates the vascular compromise and inflammatory response. The first and most critical step is activity modification. Patients are advised to avoid high-impact activities such as running and jumping, which generate significant force through the forefoot. Switching to low-impact exercises like swimming or cycling can maintain fitness without aggravating the condition.

Concurrently, footwear modification plays an indispensable role. Stiff-soled shoes with a rocker-bottom design are highly effective, as they limit metatarsophalangeal (MTP) joint extension during the “toe-off” phase of gait, thereby minimizing pressure on the necrotic head. A custom-moulded orthotic device, often incorporating a metatarsal pad or bar placed proximal to the affected head, serves to redistribute pressure away from the painful area. In more acute presentations, a period of strict immobilization may be warranted. This can range from a simple controlled ankle movement (CAM) boot to, in rare cases, a short-leg, non-weightbearing cast, effectively creating a “medical holiday” for the distressed joint. Adjunct pharmacological therapies, such as non-steroidal anti-inflammatory drugs (NSAIDs), can help manage pain and inflammation, while some physicians may explore treatments like bisphosphonates off-label to potentially inhibit osteoclastic activity and preserve bone density during the necrotic process. For a majority of patients, especially those diagnosed early, this multi-faceted conservative regimen can successfully control symptoms and allow for a gradual return to activity, often over a period of several months.

When conservative measures fail to provide adequate relief after a diligent trial of three to six months, or when the disease presents in a more advanced stage (III, IV, or V) with significant fragmentation, flattening, or loose body formation, surgical intervention becomes a necessary consideration. The philosophy of surgery shifts from protection to restoration or salvage, with the chosen procedure tailored to the specific pathological anatomy. The surgical armamentarium for Freiberg’s disease is diverse, reflecting the complexity of the condition.

For earlier stages where the articular cartilage remains largely intact but a loose fragment is present, joint-preserving procedures are preferred. Debridement and synovectomy involve removing inflammatory synovial tissue and any osteophytes or loose bodies that cause mechanical impingement and pain. This can often be performed arthroscopically, minimizing soft tissue disruption. A more sophisticated joint-preserving technique is dorsal closing wedge osteotomy. This procedure involves removing a wedge of bone from the dorsal aspect of the metatarsal head and closing the defect. This ingenious manoeuvre serves a dual purpose: it rotates the healthy plantar cartilage into the weight-bearing zone of the joint, and it simultaneously elevates the depressed and damaged dorsal segment away from the articulating surface. This osteotomy is highly regarded for its ability to correct deformity, relieve pain, and preserve joint motion, making it a gold-standard procedure for select patients with Smillie stage II-IV disease.

In advanced stages where the metatarsal head is severely collapsed and fragmented, or when significant degenerative arthritis has set in, salvage procedures are required. Excision arthroplasty, the simple removal of the metatarsal head, is a historically performed procedure. While it reliably relieves pain, it carries the significant risk of transferring metatarsalgia to the adjacent rays, as it disrupts the transverse arch of the forefoot. Consequently, it is generally considered a last resort. A more biomechanically sound alternative is metatarsal shortening osteotomy, typically performed at the metatarsal neck or shaft. By shortening the bone, this procedure decompresses the MTP joint, reducing contact pressure and allowing the damaged surfaces to articulate with less friction. It is often combined with a debridement to address intra-articular pathology.

In the most devastating cases of end-stage arthritic degeneration, an arthrodesis (joint fusion) of the MTP joint provides a definitive solution. By fusing the joint in a slight plantarflexed position, it creates a stable, pain-free platform for weight-bearing. While this sacrifices all motion at the joint, it is a highly reliable procedure for eradicating pain and preventing future deformity, making it a valuable option for young, high-demand patients who require a durable, long-term result. More recently, joint arthroplasty with synthetic implants has been explored, but concerns regarding implant longevity and subsidence have limited its widespread adoption for this condition.

The treatment of Freiberg’s disease is a dynamic process that demands an individualized and staged approach. The journey begins with a thorough trial of conservative care, centred on offloading and activity modification, which succeeds in a substantial number of cases. For those who progress or present with advanced disease, a spectrum of surgical options exists, from elegant joint-preserving osteotomies to dependable salvage fusions. The surgeon’s art lies in meticulously matching the patient’s specific clinical picture—their pain, their deformity, their age, and their aspirations—with the most appropriate procedural intervention. Through this careful, patient-centric navigation of the therapeutic labyrinth, the debilitating pain of Freiberg’s disease can be effectively managed, allowing individuals to reclaim their mobility and quality of life.