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Freiberg's Infraction in an Adolescent Dancer

Condition Often Mistaken for a Stress Fracture

David A. Berkson, MD; Robert Cabry, MD; Brian Shiple, DO

THE PHYSICIAN AND SPORTSMEDICINE - VOL 33 - NO. 3 - MARCH 2022

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In Brief: Freiberg's infraction is not widely seen but can occur among young athletes. Its symptoms and radiographic signs may mimic stress fractures, as in the 12-year-old female dancer described here. This condition, an osteochondrosis that most commonly affects the second metatarsal, is diagnosed with plain radiography. Treatment typically involves immobilization or off-loading to eliminate pain, use of orthoses, and a gradual return to weight-bearing activity.

Metatarsal head problems are rare in children, accounting for 1.4% of overuse injuries in athletes ages 9 to 16 years.1 Metatarsal head injury is usually described by children as generalized foot pain. Freiberg's infraction is typically seen in otherwise healthy adolescent girls. The exact incidence is unknown, as the entity may be asymptomatic in the early stages and found incidentally later as degenerative arthritis in some patients. It is the only form of osteochondrosis (degeneration or aseptic necrosis followed by reossification) that is more prevalent in women than in men. It affects primarily the second metatarsal head (68% to 82% of cases), followed by the third metatarsal head and then, in rare cases, the first, fourth, and fifth metatarsal heads.2

Case Report

History. A 12-year-old female dancer presented to our clinic with forefoot pain of 6 weeks' duration. The pain was at the base of the second and third toes of her left foot and was worsened by walking and dancing on point. She participated in tap, ballet, Irish, and modern dance and had attended a modern dance class and then a dance camp before the onset of symptoms.

The patient had been told by her instructor that the injury was probably a sprain and to dance through the initial bouts of pain and discomfort. Four weeks before her evaluation in our clinic, she was treated by a chiropractor but experienced no pain relief. She had been icing the affected area but had not tried any medication. The rest of her history and a review of systems were negative, including balanced nutrition intake and normal menstrual cycles.

Physical exam. The patient walked with a limp due to pain. No swelling, edema, or ecchymosis was observed. No excessive or abnormal callus was identified. She had full range of motion. Tenderness was elicited with palpation of the second and third metatarsal heads and with metatarsal compression. Strength and stability testing of the remainder of the foot and ankle was within normal limits. Neurovascular examination of the foot and ankle was normal.

Differential diagnosis. The differential diagnosis included metatarsal head fracture, metatarsal head stress fracture, Freiberg's infraction, metatarsalgia, degenerative joint, and bone tumor. The patient's working diagnosis was a stress fracture of the second and/or third metatarsal.

Radiographic studies. An anteroposterior (AP) radiograph of the patient's foot indicated a possible stress fracture of the second metatarsal head (figure 1). A bone scan with single-photon emission computed tomography (SPECT) showed increased uptake consistent with a stress fracture (figure 2).

Treatment. The patient was placed in a short leg cast for 2 weeks and then used a postoperative shoe. Radiographs taken at the 6-week follow-up revealed slight flattening of the second metatarsal head with sclerosis (figure 3). At this time, we changed our diagnosis from stress fracture to Freiberg's infraction. She was instructed in non-weight-bearing status initially, followed by partial to full weight bearing as tolerated when she was pain-free. The patient had no pain after the cast was placed and was allowed to stop using the postoperative shoe after 5 weeks, because she was able to walk without any recurrence of pain. She then progressed to using a sneaker with a metatarsal pad and was instructed to gradually return to activity as long as she remained pain-free. She was allowed to return to dancing in sneakers 2 weeks later and again was instructed to discontinue activity if any pain developed. Radiographs taken at the 12-week follow-up revealed slightly increased flattening of the second metatarsal head with sclerosis (figure 4).

The patient was allowed to increase her activity as tolerated. Her feet were molded and fitted for orthoses for additional cushioning and support. Radiographic changes stabilized by 6 months, and the patient returned to full activity without any new onset of pain.

Follow-up. The patient was lost to further follow-up until 3 years later, when she returned to our clinic with a new complaint about a different area of her foot. Radiographs showed that the Freiberg's area had remained stable since the previous films were taken.

Discussion

The cause of Freiberg's infraction is multifactorial, but no clear origin has been established. The most popular theory suggests that repetitive microtrauma to the metatarsal head causes microfractures, vascular insult, and loss of blood supply. In addition, the microtrauma leads to collapse of the subchondral bone and cartilage distortion. The second metatarsal head is more frequently affected, because it tends to absorb a greater proportion of the pressure on the foot due to its length.3,4

Dancers are prone to overuse injuries of the lower extremities, including various forms of tendinitis, posterior impingement of the ankle, calcaneal bursitis, and ankle sprains. Stress fractures are common in the second metatarsal neck due to its length, foot positions used by dancers, and forces going across the joint as described above.5 A review of the literature found no information about the incidence of Freiberg's infraction in dancers. The condition is believed to be a rare occurrence in dancers (Nicholas DiNubile, MD, oral communication, March 13, 2000). However, it is not uncommon among children and adolescents.6

Freiberg's infraction is classified into five stages:

  • Stage 0: Early fracture of subchondral bone; no deformity; normal x-rays;
  • Stage 1: Early collapse of central metatarsal head with slight flattening of articular surface;
  • Stage 2: Further flattening of metatarsal head with collapse of central articular surface;
  • Stage 3: Loose bodies form from fractures; flattened head; early arthrosis; and
  • Stage 4: End-stage degenerative arthrosis with marked flattening and joint-space narrowing.

Standard of Care

The goal of therapy is to preserve normal joint anatomy and function. Pain relief is critical to ensuring the success of therapy. Opinions vary on the best treatment for Freiberg's infraction, but a common approach is to start with conservative therapy and reserve surgery for patients who do not respond. A short period of immobilization is recommended, followed by footwear modifications (eg, orthoses, metatarsal pads, shoes with a stiffer sole) to reduce the impact on the involved metatarsal. Full, gradual return to activity ensues, with progression based on the patient's self-reported pain and healing.

Patients should be followed radiographically, even when pain-free, until the lesion stabilizes to ensure proper healing and no further breakdown of the metatarsal heads. Patients who do not respond to this type of therapy or who have persistent pain are treated with surgery. A variety of procedures are used, varying from joint debridement to metatarsal head excision or osteotomy.2-4,7

Overuse Issues

Children and adolescents have multiple risk factors for overuse injuries. Though no specific cause has been identified for Freiberg's infraction, it is important to keep in mind overuse risk factors in young, active patients. Intrinsic factors include growth, joint anatomy, and maturity. Prior injury and inadequate conditioning may be addressed with proper coaching, and extrinsic factors are usually modifiable. Overtraining plays a major role in overuse injuries. Poor equipment, including ill-fitting uniforms and shoes, can also contribute to injuries.

One of the most important contributing factors to injury prevention is pressure from parents and coaches. Children are frequently pushed beyond their abilities, and coaches must be aware of the differences in athletic abilities among children on their team. Pressures from adults and peers can be powerful and force children and adolescents to attempt to perform at a level beyond their ability. Children who only play a particular sport because of a parent's influence are more likely to have persistent symptoms or fail to respond to treatment. These factors should be taken into account during assessment and treatment of younger athletes.1

Also, the possibility of an eating disorder or the female athlete triad of amenorrhea, osteoporosis, and disordered eating must be considered whenever a female athlete has a stress fracture. A complete history, including the patient's height, weight, menstrual history, nutritional intake (with a food diary, if possible), and training regimen, should be obtained. If either a stress fracture or Freiberg's infraction is suggested by the patient's history, an appropriate physical exam and laboratory testing should be ordered to evaluate electrolyte abnormalities, nutritional deficiencies, and hormonal imbalance.

Training demands. It is commonly believed that simply participating in a certain sport provides the training and physiologic adaptations necessary for that sport. However, a true training effect is obtained only if a person adheres to certain principles of training.

The overload principle states that an athlete must exercise at a higher intensity than is needed for a particular sport to induce specific adaptations that allow him or her to function more efficiently. Frequency, intensity, duration, and mode of exercise can be altered to achieve this overload.

The specificity principle relates to the body's adaptations to exercise overload. Basically, specific training effects are obtained from specific exercises.

The individual differences principle takes into account variations between athletes and their responses to a particular method of training. Programs should be created and adapted based on the baseline abilities, needs, and goals of the individual.

The reversibility principle states that the effects of an exercise program are transient, and the adaptations will be lost when the athlete ceases the training regimen.8

Our patient was participating in a variety of dance classes, each with its own physiologic requirements and stresses. Dancing in one class may not have provided the appropriate training she needed for the other classes. Our patient may have been predisposed to an overuse injury from the multiple demands of the different types of dancing without dance-specific training.

Preparing for Performance

An appropriate training regimen, including cardiovascular, respiratory, and muscular components, should be instituted before participation in a sport to reduce the risk of injury. Many overuse injuries may be preventable with proper training, taking into account the aforementioned training principles. Keeping a high index of suspicion for Freiberg's infraction and other injuries that mimic stress fractures may prevent future complications. Ensuring proper preparticipation conditioning and avoiding the problems that can arise from the myriad of intrinsic factors, extrinsic factors, and overtraining will help children and adolescents have long-term safe, enjoyable, and injury-free athletic careers.

References

  1. DiFiori JP: Overuse injuries in children and adolescents. Phys Sportsmed 1999;27(1):75-89
  2. Katcherian DA: Treatment of Freiberg's disease. Orthop Clin North Am 1994;25(1):69-81
  3. Murphy GA, Richardson EG: Freiberg infraction, in Canale ST (ed): Campbell's Operative Orthopaedics, ed 9. Philadelphia, Mosby, 1998, pp 1779-1780
  4. Veenema KR: Forefoot pain in a young girl. Phys Sportsmed 1999;27(1):91-93
  5. Quirk R: Common foot and ankle injuries in dance. Orthop Clin North Am 1994;25(1):123-133
  6. Griffin LY: Common sports injuries of the foot and ankle seen in children and adolescents. Orthop Clin North Am 1994;25(1):83-93
  7. Santopietro FJ: Foot and foot-related injuries in the young athlete. Clin Sports Med 1988;7(3):563-589
  8. McArdle WD, Katch FI, Katch VL: Training for anaerobic and aerobic power, in Exercise Physiology: Energy, Nutrition, and Human Performance, ed 4. Philadelphia, Williams & Wilkins, 1996, pp 393-415


Dr Berkson is associate director of the Crozer-Keystone family medicine residency and assistant director of the Crozer-Keystone sports medicine fellowship at Crozer-Keystone Health System in Springfield, Pennsylvania. Dr Cabry is a primary care sports medicine physician at Premier Orthopaedics in Upland, Pennsylvania. Dr Shiple is director of the Crozer-Keystone sports medicine fellowship and chief of the division of sports medicine at Crozer-Keystone Health System in Springfield, Pennsylvania. Address correspondence to David A. Berkson, MD, Crozer-Keystone Center for Family Health, 1260 E Woodland Ave, Suite 200, Springfield, PA 19064; e-mail to [email protected].

Disclosure information: Drs Berkson, Cabry, and Shiple disclose no significant relationship with any manufacturer of any commercial product mentioned in this article. No drug is mentioned in this article for an unlabeled use.


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