Freiberg's Infraction

Freiberg's Infraction is a condition that affects the lesser metatarsal heads. The most common affected location is the second metatarsal followed by the 3rd 4th then 5th. This condition is also known as AVN (avascular necrosis). Freiberg's Infraction causes a loss of blood supply to the metatarsal head. The condition occurs at the metaphysis of the bone where the nutrient artery of the bone supplies the distal metatarsal. This results in a collapse of the metatarsal head. The condition is more common in females and usually occurs between ages 10-18 and can occur in adulthood.


Classification

Smillie’s classification (1967)


Stage 1: Subtle fracture line through the epiphysis.
Radiographic changes at this stage may be subtle.

Stage 2: Central depression of the articular surface.

Stage 3: Central depression leads to medial and lateral projections at the margins. Plantar hinge remains intact.

Stage 4: Central portion frees from the intact plantar hinge, forming a loose body. Fractures of the medial and lateral projections are present.

Stage 5: Flattening of the metatarsal head with secondary degenerative changes.


Contributing Factors:

Freiberg disease in adolescents is thought to be due to growth disturbances of the epiphysis or apophysis.

• Vascular insult- an injury of the blood supply to the metatarsal head
• Traumatic insult- a single acute injury or multiple repetitive injuries

Symptoms

• Local pain and Tenderness that usually increases with activity
• Stiffness
• Limping

Differential Diagnoses

• Metatarsalgia
• Morton neuroma
• Stress fracture

Treatment

Non Surgical:

• Stiff Soled shoe or Post Op Shoe
• Non weight-bearing cast
• Short leg walking cast or CAM boot
• Rest /Activity modification
• Steroid injection
  

Shoe Modifications:

• Metatarsal pads
• Rigid shanks
• Rocker bottom

Surgical Treatment:

• Simple debridement

Osteotomies:

• Dorsal closing wedge osteotomies- reorients the plantar intact cartilage to articulate with the proximal phalanx.
• Shortening osteotomies- metatarsal overloading of the is reduced

Arthroplaty

• Total joint arthroplasty- Utilizing an implant

Morton's Neuroma

Is a painful benign fibrotic enlargement of one of there common digital nerves. It is caused by a shearing force of the adjacent metatarsal bone. It most commonly affects the third common digital nerve. Morton's Neuroma is found to be more common in females. This may be related to the type of shoe gear often worn by females. It is most common in the 4th - 6th decade.


History

Obtaining an accurate history is important to making the diagnosis of Morton's neuroma.

Common Findings

• Pain in the forefoot and corresponding toes adjacent to the neuroma
• Pain is usually described as sharp and burning
• Pain may radiate proximal
• Numbness and tingling often is observed in the toes adjacent to the neuroma
• Intermittent pain
• Massage of the affected area may give some relief
• Narrow tight high-heeled shoes aggravate the symptoms
• Patients may feel as though they are walking on a wrinkle in there sock

Exam

• Firm squeezing of the metatarsal heads with one hand while applying direct pressure to the dorsal and plantar interspace with the other hand may elicit radiating pain.
• Mulder Sign - A silent palpable click produced by the lateral squeeze test. The neuroma moves between the metatarsals.
• Passive and active bending of the toe in an upward direction may aggravate symptoms.
• Sullivan's Sign - Toes adjacent to the affected interspace splay apart on weight bearing.

Imaging

• Ultrasonography
• MRI

Differential Diagnosis

• Stress fracture of the metatarsal
• Rheumatoid arthritis
• Hammertoe
• Metatarsalgia- plantar tenderness over the metatarsal head
• Neoplasms
• Metatarsal head osteonecrosis
• Freiburg osteochondrosis- characterized by interruption of the blood supply of a bone followed by localized bony necrosis.
• Ganglion cysts
• Intermetatarsal bursal fluid collections

Treatment

Treatment strategies for Morton's neuroma range from conservative to surgical management.


Conservative

Bio mechanical

• Orthotics

Medications

• Injections- Corticosteroid- Anti inflammatory agent
• Alcohol sclerosing- Causes a chemical neurolysis of the nerve and used as an alternative to surgery for Morton's neuroma
• NSAID's- Non Steroidal Anti Inflammatory such as Ibuprofen or Naprosyn
• Tricyclic Antidepressants- Amitriptyline(Elavil)
• Anticonvulsants- Neurontin (Gabapentin)
• Pregabalin (Lyrica)
• Duloxetine (Cymbalta)

Rehabilitation Program
Physical Therapy

• Cryotherapy-Cold Therapy- Cold may be applied using an ice bag or a cold pack
• Ultrasonography- Sound waves that are transferred to a specific body area via a round-headed probe. The sound waves travel deep into tissue, creating gentle heat. The heat helps relieve pain and inflammation
• Deep tissue massage
• Stretching exercises
• Phonophoresis- Has been used in an effort to enhance the absorption of topically applied analgesics and anti-inflammatory agents through the therapeutic application of ultrasound

Surgical Intervention

• Neurectomy- When conservative measures for Morton's neuroma are unsuccessful surgical excision may be beneficial