Avascular Necrosis: causes, symptoms and treatment options

Updated 1/9/2024

What Is Avascular Necrosis of the foot (Freiberg's Disease)? 

Avascular Necrosis (AVN), also called Freiberg's disease, osteonecrosis, or Freiberg infraction disease, is the death of bone tissue in the forefoot due to interruption of the blood supply. It’s an osteochondral condition, meaning it affects the cartilage and underlying bone in a joint.


It usually occurs in the second toe (the toe next to the big toe), but it can occur in the third or even fourth toes. It is a relatively rare musculoskeletal condition, though its complications can be quite serious. Freiberg disease in adults is possible, but it is more common in adolescents

What causes avascular necrosis? 

Freiberg's disease is a painful condition that can affect young athletes, especially teenage girls.


The causes of avascular necrosis are difficult to pin down. However, it is believed to be caused by a combination of factors, including repetitive stress, a change in biomechanics, vascular compromise, and genetic predisposition. 


In athletes, overuse, or what specialists refer to as "chronic microtrauma," can trigger Freiberg's disease. Certain weight-bearing activities can also make individuals more prone to avascular necrosis. Runners, soccer players, and dancers tend to be especially vulnerable as they repeatedly stress the growth plates in the ball of the foot. 


A stress fracture, or multiple fractures in the second metatarsal head or third metatarsal head, can block blood flow from reaching the ends of the metatarsal bones. When blood cannot reach the bone, its health begins deteriorating. Abnormal bone growth, sclerosis (hardening of the bone), and necrosis (death of the bone) can all occur.


Risk factors that impair circulation, such as chemotherapy, lupus, diabetes, and sickle cell disease, are associated with avascular necrosis as well. 


What are the symptoms of avascular necrosis? 

Because the injury develops over a long period, detecting avascular necrosis in its early stages can be challenging. If your child is complaining of these Freiberg’s disease symptoms, you may want to have them evaluated by our foot and ankle specialists:


  • Dull aching in the front of the foot
  • Redness and swelling at the metatarsal head
  • Stiffness and loss of range of motion in the affected toe
  • Joint pain and tenderness in the metatarsal head (at the base of the toe) when pushing off with the toes or wearing heels
  • Pain in the plantar (sole) as well as dorsal areas of the foot
  • Limping
  • The feeling of a hard lump or object in the ball of the foot during weight-bearing activities


Generally, symptoms of Freiberg's disease will start as mild but worsen over time. They can progress from irritating to chronic debilitation as they move through the Freiberg disease stages. 


How is Freiberg’s disease diagnosed? 

In order to properly diagnose and treat Freiberg’s disease, the orthopedic experts at University Foot & Ankle Institute will need to rule out foot and ankle conditions with similar symptoms. Hammertoe, rheumatoid arthritis, metatarsalgia, or Morton's neuroma can all cause ball of foot pain or difficulty walking. 


We’ll start by physically examining the foot and reviewing symptoms. To narrow down the diagnosis, we have access to radiographic imaging in most of our clinics.


In its early stages, avascular necrosis may look normal on an X-ray. Although our healthcare providers may be able to diagnose a fracture or fragmentation using this type of imaging, in most cases, we’ll do additional imaging tests. Magnetic resonance imaging (MRI) scans, computerized tomography (CT scans), or bone scans let us take a closer look at the metatarsophalangeal joint and surrounding soft tissue.


A clear indicator of AVN is the flattening and widening of the epiphysis, or end, of the bone. In the case of AVN, the joint surface of the metatarsal head becomes less rounded and increasingly flatter, making it difficult and painful to use the toe. Sclerosis is also present in the early to middle stages and can appear on imaging tests. If joint destruction and collapse have occurred, it can signal that you are in the advanced stages of the disease.


What is Freiberg's disease treatment? 

Avascular necrosis is easiest to treat when it is caught early. However, due to the progressive nature of the condition, many patients may not come in for evaluation until symptoms have already become debilitating. 


Treatment of Freiberg disease depends not only on the severity of the condition but also on the patient's age. In adults, severe cases of avascular necrosis may require surgery. Treatment is trickier for children and teens because their feet are still growing and the common surgical techniques used on adults can damage a young patient's growth plate and stunt growth of the bone.


Conservative treatment options 

For this reason, UFAI specialists recommend nonsurgical treatments to limit motion in the joint and relieve symptoms until the growth plate closes, at which time surgery may be recommended. 


In the meantime, we may recommend: 


  • Physical therapy to build the strength and flexibility of surrounding ligaments and tendons
  • Orthoses, such as rigid-soled shoes and custom-fitted orthotics with the metatarsal head cut-out
  • Anti-inflammatory medications, often in the form of corticosteroid injections
  • Limiting activities that worsen symptoms


If conservative treatment fails to manage the pain and stop the progression of the disease, surgical treatment may be discussed. 


Surgical Options 

Our specialist will closely monitor your child's injury and bone development while the area heals. After a few months or years, when the growth plate has closed, one or more surgical procedures may be performed; the correct procedures will be prescribed based on your child's case. 


Joint debridement (clean-up) 

An osteotomy procedure involves the removal of loose bodies and spurs in the joint. Reshaping of the joint, known as arthroplasty, may also occur during this procedure. 


Cartilage and/or joint replacement 

Grafting can be used to take healthy tissue from elsewhere in the foot and place it onto the collapsed metatarsal head, helping to reinforce and strengthen the area.



A surgical implant, typically made of either titanium or silicone rubber, is secured to the metatarsal bone to help reduce pressure on the joint and improve function. 


Metatarsal head resection 

This technique is not typically performed on younger patients due to their bones' continued growth and development. Additionally, this procedure is typically treated as a last resort for severe cases of Freiberg's disease. It involves removing the bone and replacing it with a surgical filler to maintain the length of the toe.


Reach out to UFAI for your pediatric foot and ankle conditions 

The physicians at the University Foot and Ankle Institute have decades of combined experience treating all forms of pediatric foot and ankle concerns. Our pediatric podiatrists use the latest technologies available, many of which we helped develop, to accurately diagnose and treat your child's painful symptoms with the least invasive treatment possible.


To schedule a consultation, please call (855) 872-5249 or make an appointment now.


University Foot and Ankle Institute is conveniently located throughout Southern California and the Los Angeles area. Our foot doctors are available at locations in or near Santa Monica, Beverly Hills, West Los Angeles, Manhattan Beach, Northridge, Downtown Los Angeles, Westlake Village, Santa Barbara, and Valencia.





Freiberg's disease FAQs

Freiberg's disease FAQs


How rare is Freiberg's disease?

Freiberg’s disease is considered rare and uncommon. Out of those with the condition, the most common age group affected is young adults between the ages of 12 and 20.


Can Freiberg's disease go away?

Most cases of Freiberg’s do not go away spontaneously on their own. However, mild to moderate cases may resolve with conservative treatment.


Are there Freiberg infraction taping techniques?

Your podiatrist may recommend taping techniques to provide strength and support to the area, such as buddy taping. Taping with the use of orthotics, like a toe pad, can also be beneficial.




Danger F, Wasyliw C, Varich L. Osteochondroses. Semin Musculoskelet Radiol 2018;22(1):118–24.

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