Working Diagnosis:
Freiberg infraction

Treatment:
A platelet rich plasma injection to the 2nd metatarsophalangeal joint was performed, which resulted in complete resolution of pain and return to long distance running (20 miles) within 4 months.

Outcome:
The platelet-rich plasma injection was a successful intervention for the patient which led to resolution of the swelling and pain in the 2nd metatarsal head and metatarsophalangeal joint enabling her to get back to her running and other daily activities. She did not require a second platelet-rich plasma injection or any other interventions other than the conservative management of using foot orthotics. The patient did not follow up as scheduled after the injection as she reported resolution of her pain and was back to her baseline activities. She followed up 4 months later for a different complaint and reported being able to run 18 to 20 miles pain-free while training for a marathon. She eventually ran the marathon and finished at 5 hours 27 minutes achieving her goal of being under 5 and half hours. She last reported still being pain free more than 5 months since the plasma-rich platelet injection.

Author's Comments:
Freiberg's infraction or osteochondrosis of the lesser metatarsal head is characterized by collapse of subchondral bone, osteonecrosis and cartilaginous fissures commonly involving the second metatarsal head. It is often due to vascular compromise from repetitive stress microtrauma. There is a female predominance (3:1) with peak age of onset during the second decade. Limited literature is available on the use of platelet-rich plasma injection for foot and ankle injuries but recent literature shows some benefit in the treatment of Achilles pathology, plantar fasciitis, osteochondral talus lesions, ankle osteoarthritis, and diabetic foot ulcers. There is currently no existing data or literature on platelet-rich plasma use with Freiberg's infraction but the pathophysiology of Freiberg's infraction and platelet-rich plasma’s mechanism of action makes a viable match.

Editor's Comments:
Freiberg disease most commonly affects the second metatarsal followed by the third metatarsal and rarely affects the first or the fifth metatarsals. A longer second metatarsal is a risk factor for development of Freiberg’s disease. Classification of Freiberg disease is most commonly done using the Smillie classification. Stage 1 shows fissuring of the epiphysis and may have normal x-rays. Stage 2 has central depression of the articular surface from subchondral cancellous bone resorption. Stage 3 is seen with central depression with resulting medial and lateral projections at the margins. Stage 4 shows a loose central body. Lastly, stage 5 has marked flattening and deformity of the metatarsal head with secondary degenerative changes and increased density of the shaft of the metatarsal. An x-ray is usually adequate for diagnosis unless the patient presents in stage 1 where a MRI may be needed. Early treatment focuses on conservative treatment to decrease mechanical irritation and inflammation with relative rest, hard sole shoe or metatarsal bar insert, and analgesia. Significant symptoms may need aggressive immobilization with a non-weight bearing cast. Individuals with stage 4 or 5 may require surgical management which could include osteotomy, debridement, and bone grafting.

References:
Cerrato RA. Freiberg's disease. Foot Ankle Clin. 2011;16 (4): 647-58

Seybold JD, Zide JR. Treatment of Freiberg's disease. Foot Ankle Clin 2018 Mar; 23(1): 157-169.

Ashman CJ, Klecker RJ, Yu JS. Forefoot pain involving the metatarsal region: differential diagnosis with MR imaging. Radiographics. 21 (6): 1425-40

El-Feky M, Jones J. Freiberg Disease. https://radiopaedia.org/articles/freiberg-disease, last reviewed January 2020

Fehr SD. Freiberg Disease Treatment & Management. eMedicine. Accessed July 8,2020 at https://emedicine.medscape.com/article/1236085

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