Question
A 16 year old girl who dances has 6 months of forefoot pain under the second toe.
- What is the diagnosis and its classification?
- Why does it occur at this site?
- How is it managed?
Answer
Diagnosis
- Freiberg infraction, osteonecrosis of the second metatarsal head
- Most common in adolescent females
- Third metatarsal head is the next most frequent site
Smillie classification
| Stage | Description |
|---|---|
| I | Fissure fracture |
| II | Central collapse |
| III | Further collapse with an intact plantar hinge |
| IV | Loose bodies |
| V | Flattened head with arthritis |
Aetiology
- Repetitive loading of a long, stiff second metatarsal
- High heels and dance increase forefoot load
Management
- Stiff soled shoe, metatarsal bar or walking boot
- Joint debridement and loose body removal
- Dorsal closing wedge osteotomy to rotate healthy plantar cartilage into the joint
- Interposition arthroplasty or partial head excision for late stages
- Most early stages settle with offloading
Related pages
Author Contributions
Orthofracs team
Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.