Musculoskeletal systemCase Type
Michail E. Klontzas MD, PhD 1,2, Evangelia E. Vassalou MD, PhD 1,3, George Alexiadis, MD, PhD 4, Apostolos H. Karantanas MD, PhD 1,2,5Patient
7 years, male
A 7-year-old boy, Tae-Kwon-Do athlete, presented with insidious onset of pain and swelling of the right foot over two months, without any history of trauma. Pain initially presented during sports activities but gradually it became constant during everyday activities. Clinical examination revealed tenderness over the first metatarsal. Medical history was unremarkable.
Anteroposterior and oblique plain foot radiographs demonstrated flattening, sclerosis, without significant fragmentation of the distal first metatarsal epiphysis (Fig. 1). MR with STIR and T2-weighted (T2W) images confirmed articular collapse and necrosis of the distal epiphysis which appeared with low signal intensity surrounded by extensive high signal bone marrow oedema of the metatarsal diaphysis (Fig. 2). A subchondral linear fracture was also shown as a linear low signal intensity lesion within the bone marrow oedema.
Freiberg’s disease (FD) is an idiopathic avascular necrosis located in the second metatarsal head in 2/3 of cases and the third in about 1/3 . Involvement of the lesser toes and first metatarsal is extremely rare [1-3]. The pathophysiology of FD is still unclear. Vascular damage due to repetitive microtrauma and fractures of the subchondral bone may be the underlying cause . FD has been linked to high-heeled shoes and its prevalence is higher in women at their second decade of life [5,6].
Clinical examination reveals swelling and tenderness of the affected metatarsophalangeal joint. History may or may not reveal previous trauma. Disease progression leads to foot deformity with a claw or crossover toe appearance. Conservative treatment is the mainline of management, along with non-steroidal anti-inflammatory medication, activity modification and use of rocker bottom shoes. Surgical treatment is reserved only for cases of advanced disease or when conservative treatment has failed and includes a combination of debridement, loose body removal, osteotomies and core decompression [4,5]. In our case, repetitive microtrauma due to intensive Tae-Kwon-Do training was postulated to be the causative factor. Despite the atypical age, sex and location, imaging findings and clinical history were highly specific for FD.
Plain films may demonstrate sclerosis, flattening and fragmentation of the affected metatarsal head. MRI is the imaging modality of choice since it can detect the disease at early stages when findings in plain films are absent or subtle . At the initial stages, MRI shows low signal intensity of the metatarsal head on T1W and high signal intensity on fluid sensitive sequences. As necrosis evolves, the metatarsal head appears with low signal intensity on all pulse sequences. Bone marrow oedema of the surrounding bone, subchondral fracture lines and metatarsophalangeal joint effusion may also be present [1,6,7]. The disease can be classified to five stages of severity according to Smillie, which works both for plain films and MRI . Surgical treatment is reserved for advanced disease.
Conservative treatment usually provides full resolution of symptoms and imaging findings. In our case, due to the demand for return to high level of performance, the patient was treated surgically with debridement and core decompression. Complete resolution of symptoms and imaging findings were noted at the 1.5 year follow-up (Fig. 3).
Written informed patient consent for publication has been obtained.
 Couturier S, Gold G (2019) Imaging features of avascular necrosis of the foot and ankle. Foot Ankle Clin 24:17-33. (PMID: 30685010)
 Fu FH, Gomez W (1989) Bilateral avascular necrosis of the first metatarsal head in adolescence: A case report. Clin Orthop Relat Res;246:282-284. (PMID: 2766616)
 Suzuki J, Tanaka Y, Omokawa S, Takaoka T, Takakura Y (2003) Idiopathic osteonecrosis of the first metatarsal head: A case report. Clin Orthop Relat Res; 415:239-243. (PMID: 14612651)
 DiGiovanni CW, Patel A, Calfee R, Nickisch F (2007) Osteonecrosis in the foot. J Am Acad Orthop Surg 15:208-217. (PMID: 17426292)
 Seybold JD, Zide JR (2018) Treatment of Freiberg disease. Foot Ankle Clin 23:157-169. (PMID: 29362030)
 Achar S, Yamanaka J (2019) Apophysitis and osteochondrosis: common causes of pain in growing bones. Am Fam Physician 99:610-618. (PMID: 31083875)
 Hodes A, Umans H (2018) Metatarsalgia. Radiol Clin North Am 56:877-892. (PMID: 30322488)
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