Definition
- Childhood conditions of an epiphysis or apophysis
- Fragmentation and sclerosis, then reossification
Epidemiology
- Kohler, boys around 4 to 7 years
- Freiberg, lesser metatarsal head (second then third), adolescent girls
- Sever, active children around 8 to 12 years during a growth spurt
- Iselin, children around 10 to 14 years in running, jumping or cutting sports
Aetiology
- Kohler, compression of the navicular, the last tarsal bone to ossify
- Freiberg, associated with a long second metatarsal and repetitive loading
- Sever, traction apophysitis at the Achilles insertion
- Iselin, traction apophysitis at the peroneus brevis insertion
Clinical Features
- Kohler, medial midfoot pain, limp, walking on the lateral border and navicular tenderness
- Freiberg, MTP joint pain, swelling and stiffness with metatarsal head tenderness
- Sever, heel pain with running and jumping, positive calcaneal squeeze test and tight gastrocnemius
- Iselin, lateral foot pain, fifth metatarsal base tenderness, pain on resisted eversion
Classification
Smillie staging of Freiberg disease
| Stage | Features |
|---|---|
| I | Subchondral fissure fracture through the ischaemic epiphysis |
| II | Central bone resorption with early collapse of the articular surface |
| III | Further collapse with a central projection, plantar cartilage intact |
| IV | Fracture of the projection with loose body formation |
| V | Flattening and deformity of the head with arthrosis |
Investigations
- Kohler radiographs show a flattened, sclerotic, fragmented navicular
- Irregular navicular ossification can be normal, so correlate with symptoms
- Freiberg radiographs show sclerosis, flattening and collapse of the head
- Sever radiographs unnecessary in typical cases, as a sclerotic fragmented apophysis is normal
- Image heel pain that is unilateral, at rest or at night, to exclude fracture, infection or tumour
- Iselin apophysis lies parallel to the shaft on oblique views, whereas fractures are usually transverse
Management
- Kohler, a short leg walking cast for several weeks shortens symptoms
- Freiberg, activity modification, rocker shoes, metatarsal pads and a brief boot or cast
- Freiberg surgery, debridement, loose body removal and dorsal closing wedge osteotomy to bring in plantar cartilage
- Avoid metatarsal head excision, which causes transfer metatarsalgia
- Sever, activity modification, heel cups, calf stretching and ice, boot or cast if severe
- Iselin, rest, ice, stretching, boot if severe
Prognosis
- Kohler excellent, with navicular reconstitution
- Sever resolves with apophyseal closure
Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.