Working Diagnosis:
Osteonecrosis of the third metatarsal head (Freiberg's Infraction); Stage I.

Treatment:
CAM walker x 2 weeks, hard sole shoe x 4 weeks

Outcome:
Patient was pain free at 6 weeks, able to return to full play at 8 weeks

Author's Comments:
Osteochondrosis is a rare cause of foot pain, but if not diagnosed early can have a high complication rate. It presents predominantly in females between the ages of 11 and 17, and most commonly affects the second metatarsal head, but can affect the third metatarsal as in this case. The condition progresses through five radiographic stages. Stage I, like our patient had, includes a narrow fissure fracture of the epiphysis and sclerosis. Stage II shows early metatarsal head flattening and collapse of the overlying subchondral bone. In stage III further sclerosis occurs and the central portion of the metatarsal head sinks deeper, leaving projections on either side. In Stage IV these projections fracture to produce loose bodies and Stage V demonstrates arthrosis, severe flattening, and metatarsal shaft thickening. Early diagnosis is critical to good long-term outcomes since over 90% of patients with Stages I-III disease respond well to non-operative measures and avoid surgical intervention. Proven effective non-operative measures include offloading the metatarsal by the use of orthoses, metatarsal pads, hard-sole shoes or CAM walker. Surgical correction is recommended for Stages IV and V but commonly results in chronic foot pain. There is no consensus surgical procedure for this condition.

Close follow-up is important to ensure complete healing and compliance with recommended treatment. Young athletes notoriously return to play as soon as pain ceases. Early return to play can worsen the course of the osteochondrosis and advance the eventual course of the disease.

References:
Cerrato RA. Freiberg's disease. Foot Ankle Clin N Am. 2011: 16; 647-58.
Shane A, Reeves C, Wobst G, et al. Second metatarsophalangeal joint pathology and Freiberg disease. Clin Podiatr Med Surg. 2013: 30; 313-25.
Talusan PG, Diaz-Collado PJ, Reach Jr JS. Freiberg's infraction: diagnosis and treatment. Foot and Ankle Specialist. 2014: Feb; 52-56

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