Case # 3 - Forefoot Pain in Volleyball Player
Updated: Sep 24, 2020
Disclaimer: The following case is for education purposes only and does not depict any actual person or patient.
A 16-year-old female volleyball athlete reports left foot pain for approximately 9 months. She states that she cannot recall any traumatic injury to the foot. She plays volleyball all-year-round; specifically, she plays with her school team in the fall and her club team in the spring and summer. Currently, she has pain at both rest and during normal activities of daily living. She reports that it is painful to participate in volleyball but she is able to push through the pain. Parents report that she has a limp after her matches that progressively has gotten worse.
On physical exam, the young lady is well appearing and well developed. She has a slightly abnormal gait pattern with noticeable limp. Specifically, she does not appear to be able to toe-off completely. A very subtle swelling is noticed on the dorsum of the forefoot. Diffuse tenderness to palpation is noted over the second and third metatarsals.
A foot x-ray was obtained in clinic which revealed the diagnosis.
AP & Oblique X-ray of Foot
What is the pathophysiology of this condition?
Freiberg disease is an osteochondrosis of the second metatarsal head that is caused by interruption of the blood supply to the bone that can progress to bony necrosis. One causative factor is thought to be an accumulation of microtraumas overtime in sports. An additional consideration is due to possible mechanical overload to the second metatarsal due to inherent foot mechanics. Lastly, it is also speculated that anatomic variants of the blood flow to the lesser metatarsals may play a role in this condition (1).
What is my treatment algorithm?
My recommendation on a plan of action for Freiberg disease depends on the individual level of pain and activity. Generally speaking, if the athlete has pain with walking I will treat them with a CAM boot and allow only activities that cause zero pain. After 4 weeks in the boot, if the athlete no longer has pain with barefoot walking, I will transition to a hard-soled shoe. Typically, the patient tends to still have pain with deep pressure to the head of the second metatarsal. I do like to start physical therapy at this stage, particularly in athletes anxious to return. Lastly, with continued improvement around the 8-week mark, I will transition to a normal supportive shoe with an over-the-counter full foot rigid shoe insert and a metatarsal pad. If treatment and physical therapy are progressing well I will start a progressive return to play.
When do you obtain an MRI or refer to surgery?
I do not know of any evidence-based guidelines that indicate when to either order an MRI or refer for surgery, therefore it is physician dependent. My experience is in younger patients, and if the diagnosis is clear by plain x-ray I will typically wait on the MRI and treat the patient conservatively as above. If the patient does not improve as expected I will proceed with an MRI to better understand the extent and stage of the bony injury. I have not needed to refer any cases for surgery, as likely younger patients tend to recover. However, I would refer for a surgical second opinion if no improvement is seen in 3 months. Interestingly, a case report in the literature describes a 20-year-old collegiate tennis player able to participate with relatively few symptoms with late-stage Freiberg disease (2).
Consider Freiberg disease in teenagers with forefoot pain, particularly with no reported trauma. However, the differential diagnosis also includes stress fracture.
Freiberg disease is relatively rare, but of the cases that do occur, adolescent athletic females tend to have a higher occurrence.
If the athlete presents very early , radiographic findings may not always be present within the first month of symptoms; therefore close follow up is critical.
Wax A, Leland R. Freiberg Disease and Avascular Necrosis of the Metatarsal Heads. Foot Ankle Clin. 2019;24(1):69-82. doi:10.1016/j.fcl.2018.11.003
Faircloth J, Mitchell JJ, Edwards DS. Late Stage Freiberg Infraction in a Division I Collegiate Tennis Player. J Orthop Case Rep. 2015;5(3):12-14. doi:10.13107/jocr.2250-0685.295