Freiberg disease (Köhler II disease)

Anatomy: forefoot and metatarsal head

The forefoot consists of the five metatarsal bones (ossa metatarsalia) and the toes. The metatarsal heads form the metatarsophalangeal joints (MTP joints) with the basal phalanges. The transverse arch is stabilized via tendons, ligaments and the plantar plate; The load when rolling is distributed primarily on the 1st and 2nd metatarsal heads.

• The second metatarsal head often carries high peak loads (e.g. during sports, hard surfaces, high heels).
• The blood supply to the bone ends is finely branched and sensitive to pressure and shear forces.
• Disturbances in blood circulation and repeated microtraumas can damage the cartilage-bone interface.

What is Freiberg disease?

Freiberg's disease is an osteochondral damage with impaired circulation (osteonecrosis) of the metatarsal head, usually on the 2nd, rarely on the 3rd ray. It leads to cartilage and bone collapse, flattening of the head and joint wear. In German-speaking countries it is called Köhler II disease (Köhler I disease affects the scaphoid bone of the foot and is a different disease).

• Synonyms: Freiberg Infraction, Köhler II Disease
• Typical Age: Adolescence to young adulthood; Adults can also be affected
• Frequency peak: 2. Metatarsal head

Symptoms

• Forefoot pain under the second metatarsal head, initially dependent on stress, later also at rest
• Tenderness and swelling over the affected metacarpophalangeal joint
• Limited mobility, especially dorsiflexion; painful final stages
• Limp, roll over the outer edge, avoid toe-off
• Painful callus formation under the affected frog
• Sometimes a snapping/blocking in joint splinters or free joint bodies

Causes and risk factors

Freiberg disease usually arises from a combination of mechanical overload and sensitive blood supply to the metatarsal head. A single trauma is not absolutely necessary.

• Repetitive microtraumas (sprint/stop-and-go sports, dancing, long runs on hard surfaces)
• Biomechanical factors: long second metatarsal bone (index minus), hollow foot, splayfoot, limited metatarsophalangeal joint
• Footwear with high heels or very hard/stiff soles
• Systemic factors: rare circulatory or metabolic disorders
• Previous local inflammation or infection (rare)

Course of disease and Smillie classification

The course ranges from early changes, often only visible on MRI, to advanced joint destruction that is easily visible on radiographs. The Smillie classification describes typical stages.

Diagnostics in practice

Diagnosis is based on history, physical examination and imaging tests. The aim is to identify the stage and accompanying factors in order to treat in a targeted and gentle manner.

• Clinic: Local tenderness over the second metatarsal head, painful movement in MTP II, functional tests of the plantar plate and toe flexor tendons.
• X-ray under stress: assessment of flattening, sclerosis, fragments, joint space and metatarsal length.
• MRI (if the X-ray is unclear or the need for planning): bone marrow edema, cartilage defects, extent of subchondral damage.
• Sonography: effusion, synovitis; dynamic assessment of the plantar plate.
• Differential diagnoses: stress fracture, synovitis, plantar plate lesion without necrosis, Morton's neuroma, sesamoiditis (on the 1st ray), rheumatic arthritis.

Conservative therapy – make the most of it first

In the early and middle stages, consistent relief can slow down the progression and significantly alleviate symptoms. The conservative approach is consistent with guidelines and is consistently pursued over weeks to a few months.

• Load adjustment: reduction in running and jumping sports; Avoiding hard surfaces; Breaks instead of provoking pain.
• Short-term immobilization: splint or walker boots for 2-4 weeks in case of acute pain peak (medical indication).
• Shoe and insole care: Soft forefoot bed, pad/metatarsal padding for pressure redistribution, stiffer sole/rolling aid.
• Physiotherapy: mobilization of pain-free ranges of motion, stretching of the calf/plantar fascia, gait training, stability of the arch of the foot.
• Medical pain therapy: Anti-inflammatory analgesics for a short time as recommended by a doctor; local cooling.
• Adaptation to work and everyday life: Temporary reduction in long standing/walking phases; appropriate footwear for work.

Injections into the MTP joint are used cautiously. Corticosteroid injections may provide short-term pain relief but should be carefully indicated due to potential cartilage/tissue impairment. Biological procedures (e.g. PRP) are being investigated, the evidence is currently limited - we provide individual advice on this.

Surgical options – if conservative measures fail

Surgery is an option if, despite consistent protection, insoles and physiotherapy, relevant symptoms persist or there is advanced structural damage. The aim is to reduce pain and, if possible, preserve the joint.

• Joint-preserving (common in Smillie II–III): debridement of necrotic cartilage/bone, removal of free joint bodies; If necessary, microfracture or cartilage regenerative techniques in selected cases.
• Dorsal wedge osteotomy (Gauthier): Correction with rotation of the intact plantar cartilage into the articular surface; can improve joint function.
• Articular surface reconstruction: In selected cases, osteochondral autograft (OATS/mosaicplasty) – rare and with individual consideration.
• Joint stiffening (arthrodesis) of MTP II: Joint-removing option for severe osteoarthritis/deformity when joint-preserving measures do not make sense.
• Soft tissue/accompanying corrections: Treatment of plantar plate insufficiency, correction of misaligned toes to provide relief.

The choice of procedure depends on the stage, cartilage quality, accompanying deformities, stress requirements and individual goals. We discuss the benefits, limitations and possible risks (e.g. wound healing disorders, infection, thrombosis, residual pain, stiffness) in detail.

Rehabilitation, course and prognosis

• Conservative: improvement often within 6-12 weeks; Sport-specific return to work gradually with no pain.
• After joint-preserving surgery: Often partial weight-bearing in the forefoot relief shoe for 4–6 weeks; early, measured mobilization after release.
• After osteotomy: image checks; Gradual increase in load, return to sport depending on healing usually after 8-12+ weeks.
• After arthrodesis: Prolonged immobilization and gradual loading; The aim is pain-free everyday exercise; sports with high forefoot load may be restricted.

The prognosis is often good in the early stages with consistent relief. In advanced stages, residual stiffness may remain. Complete freedom from symptoms cannot be guaranteed; The aim is to achieve sustainable functional improvement and pain reduction.

Self-help and prevention

• Choose shoes with good cushioning, rather stiff soles and enough space in the forefoot area.
• Regular stretching and strengthening exercises for the calf muscles, arch of the foot and toe flexors.
• Increase the load slowly and incorporate training changes (e.g. swimming, cycling).
• Wear high heels only for short periods of time; If you have a job that involves a lot of standing, plan walking breaks.
• React to forefoot problems early instead of running “through the pain”.

Seek medical advice if forefoot pain lasts longer than 2-3 weeks, becomes nocturnal, swelling occurs or if you are significantly restricted in everyday life.

Special situations: sports, growth, everyday life

• Sport: Temporary break from sports and switch to forefoot-friendly activities. Insoles can reduce peak loads when running.
• Adolescents: As they grow, diagnostics must be planned carefully; Avoid excessive training volumes.
• Everyday life/work: Individual solutions for long periods of standing/walking (insoles, changing shoes, short breaks for relief).

Your treatment in Hamburg

We treat Freiberg disease with a clear step-by-step concept: conservatively first, surgically only if necessary. At Dorotheenstraße 48, 22301 Hamburg, you will receive structured diagnostics with functional analysis, stress-adapted imaging and individual therapy planning. The aim is to reliably relieve your symptoms and return to everyday life and sport - without unnecessary interventions.