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Freiburg's Osteonecrosis - Avascular necrosis of the metatarsal head

What is Freiburg's Osteonecrosis?

This is a condition that usually occurs in the second metatarsal head.  This problem was first described in 1914 and was originally thought to have been associated with trauma to this region of the foot.  Later studies showed this localized issue was actually devitalized bone from one cause or another.  Occasionally, this can be seen in the third or fourth metatarsal heads as well, but very rarely the fifth metatarsal head.  Although this disorder can happen in any person at any age, it is more frequently seen in teenage females during skeletal growth.  It is seen 5:1 in females compared to males. 

There are three main theories of the cause of this disorder.  Traumatic activity and decreased vascularity (decreased blood flow) to this area are the main causative agents.  Additionally it has been suspected that various systemic disorders can play a significant role, although this has never found much support as actually being likely. 

Traumatic activities can include local contusions such as stubbing this joint or direct trauma.  Additionally, biomechanically the second metatarsal is usually the longest and thus carries the most weight.  This is more of a cummulative type of trauma due to the length and increased overall stress at this location.

Often times pain is the main presenting complaint at this location (usually the base of the second toe, less commonly at the bases of the other toes.).


Until you are able to be examined by a doctor, the “R.I.C.E.” method should be followed. This involves: 

  • Rest. It is crucial to stay off the injured foot, since walking can cause further damage. Non-weightbearing with crutches or a walker is ideal. For immobilization, a CAM walker is often ideal.   If surgery is necessary, the CAM walker will be used during the post-operative recovery period.  Often times a foot and ankle specialist may try to immobilize you in a CAM walker for 6 weeks prior to performing any surgery to see if this injury will heal on its own first. 
  • Ice. To reduce swelling and pain, apply a bag of ice over a thin towel to the affected area for 20 minutes of each waking hour. Do not put ice directly against the skin.
  • Compression. Wrap the ankle in an elastic bandage or wear a compression stocking to prevent further swelling.  An ACE bandage is often recommended as initial treatment.
  • Elevation. Keep the foot elevated to reduce the swelling. It should be even with or slightly above the hip level. 



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