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TC(1057).(05).Orthopedics Case No 135:- Freiberg Disease / Freiberg Infraction

Freiberg Disease / Freiberg Infraction — বাংলা নোট

Clinical warning: নিচের dose adult, non-pregnant, normal renal/liver function ধরে দেওয়া। একসাথে ২টি NSAID যেমন ibuprofen + naproxen/etoricoxib/aceclofenac দেওয়া যাবে না। PUD, CKD, uncontrolled HTN, IHD/stroke, anticoagulant use, pregnancy—এগুলো থাকলে dose/choice বদলাতে হবে।

1) Definition — সংজ্ঞা

Freiberg disease হলো metatarsal head—বিশেষ করে 2nd metatarsal head—এর osteonecrosis/avascular necrosis, যেখানে blood supply কমে গিয়ে metatarsal head flatten, collapse ও পরে MTP joint arthritis হতে পারে। Pain সাধারণত forefoot-এ weight-bearing করলে বেশি হয়।

2) Cause / Etiology — কারণগুলো

  • Repeated microtrauma: দৌড়ানো, jumping, dancing, high-impact sports, tight/high-heeled shoe—2nd MTP joint-এ বারবার চাপ দেয়।
  • Vascular compromise: metatarsal head-এর blood supply কমে গেলে bone infarction/osteonecrosis হয়।
  • Foot biomechanics: long 2nd metatarsal, short 1st metatarsal, hallux valgus, cavus/abnormal forefoot loading—2nd metatarsal head-এ excess load পড়ে।
  • Female adolescent predominance: teenage female/young athlete-দের মধ্যে বেশি দেখা যায়; তবে যেকোনো বয়সে হতে পারে।
  • Systemic associations: diabetes mellitus, SLE, hypercoagulable state, vasculopathy—কিছু ক্ষেত্রে associated থাকতে পারে।
  • Pathophysiology core: repeated stress + vascular compromise → subchondral bone ischemia → fissure/fracture → metatarsal head sclerosis/flattening → collapse → MTP joint arthrosis.

3) Symptoms — লক্ষণগুলো

  • Forefoot pain / metatarsalgia: সাধারণত 2nd বা 3rd MTP joint-এর উপর ব্যথা।
  • Weight-bearing pain: হাঁটা, দৌড়, সিঁড়ি ওঠা, push-off phase-এ pain বাড়ে।
  • “পায়ের নিচে পাথর আছে” অনুভূতি: রোগী অনেক সময় বলে পায়ের বলের নিচে শক্ত কিছু আছে।
  • Swelling: affected MTP joint ফুলে থাকতে পারে।
  • Tenderness: metatarsal head-এর dorsal/plantar aspect-এ চাপ দিলে ব্যথা।
  • Restricted MTP ROM: toe dorsiflexion/plantarflexion করলে pain ও stiffness।
  • Crepitus: advanced stage-এ joint movement-এ ঘষা/কড়কড় শব্দ বা অনুভূতি।
  • Callus formation: painful metatarsal head-এর নিচে plantar callus হতে পারে।
  • Late deformity: hammer toe, crossover toe, toe elevation, MTP subluxation/deformity হতে পারে।

4) Clinical Diagnosis — clinically কীভাবে ধরবেন

History

  • Gradual onset forefoot pain, acute trauma ছাড়াও হতে পারে।
  • Pain barefoot/high heel/tight shoe/athletic activity-তে বাড়ে।
  • Adolescent female athlete হলে suspicion বেশি, তবে middle-aged patient-এও possible.

Examination

  • 2nd/3rd MTP joint localized swelling ও tenderness।
  • Passive MTP ROM painful ও restricted।
  • Dorsiflexion pain prominent।
  • Crepitus/locking থাকলে loose body বা arthritis suspect।
  • MTP drawer / Digital Lachman test: proximal phalanx dorsally translate করলে pain/subluxation হলে plantar plate/MTP instability evaluate করা যায়।

5) Investigations — specific investigation

First-line

  • Weight-bearing X-ray foot: AP, lateral, oblique views
    • Early: joint space widening/effusion—symptom onsetের 3–6 সপ্তাহ পর subtle change।
    • Progressive: subchondral sclerosis, metatarsal head flattening/widening।
    • Late: central depression, loose bodies, joint-space narrowing, arthrosis.

Best for early disease

  • MRI foot
    • X-ray normal কিন্তু clinical suspicion থাকলে MRI সবচেয়ে useful।
    • Findings: metatarsal head marrow edema, T1 hypointensity, T2 mixed signal, early osteonecrosis/collapse.

Additional / selective

  • CT scan: surgical planning, bony collapse/loose body/articular congruity দেখতে।
  • Bone scan: early AVN সন্দেহ কিন্তু X-ray/MRI unavailable হলে; routine নয়।
  • Blood tests are not diagnostic, তবে differential exclude করতে করা যায়:
    • CBC, ESR/CRP — infection/inflammatory arthritis
    • Serum uric acid — gout suspicion
    • RF/anti-CCP — RA suspicion
    • FBS/HbA1c — diabetes association
    • ANA/APS workup — SLE/hypercoagulability suspicion

6) Differential Diagnosis

  • Metatarsal stress fracture
  • Morton neuroma
  • Plantar plate tear / MTP instability
  • Gout / pseudogout
  • Rheumatoid arthritis / inflammatory arthritis
  • Septic arthritis
  • Synovitis/capsulitis
  • Transfer metatarsalgia
  • MTP dislocation/subluxation
  • Osteochondral injury/tumor—rare

Freiberg disease-এর differential হিসেবে stress fracture, neuroma, plantar plate tear, RA/gout—এসব important।

7) Complications — জটিলতা

  • Chronic forefoot pain: হাঁটা বা দাঁড়ানোর সময় দীর্ঘমেয়াদি pain থাকতে পারে।
  • MTP joint stiffness: toe movement কমে যায়; footwear সমস্যা হয়।
  • Metatarsal head collapse: joint surface নষ্ট হলে arthritis শুরু হয়।
  • Degenerative arthritis: late stage-এ MTP joint arthrosis, persistent pain, limited ROM।
  • Toe deformity: hammer toe/crossover toe/subluxation হতে পারে।
  • Transfer metatarsalgia: wrong surgery বা excessive metatarsal shortening হলে adjacent metatarsal head-এ pain হতে পারে। Merck manual metatarsal head excision avoid করতে বলে, কারণ adjacent digits-এ transfer metatarsalgia হতে পারে।
  • Reduced sports/work capacity: athlete বা prolonged standing job-এ performance কমে যায়।

8) Treatment / Management

A) Non-pharmacological management — মূল চিকিৎসা

Early stage / Smillie I–III

  • Relative rest: running, jumping, prolonged standing কমানো।
  • Protected weight-bearing: stiff-soled shoe, walking boot, short cast, crutch if severe pain।
  • Off-loading orthosis: metatarsal pad/bar, custom insole, rocker-bottom shoe, low heel।
  • Ice pack 10–15 min, দিনে 2–3 বার, acute pain/swelling-এ।
  • Physiotherapy: pain কমলে MTP ROM, calf stretching, gait retraining।
  • Follow-up: 4–6 সপ্তাহ পর pain ও function reassess; X-ray/MRI stage অনুযায়ী plan.

Conservative treatment হিসেবে activity modification, protected weight-bearing, shoe modification, orthoses with metatarsal bar, immobilization ও oral anti-inflammatory drugs ব্যবহার হয়।

Late stage / failed conservative

  • Orthopedic foot & ankle referral।
  • Surgical options: debridement, core decompression, dorsal closing-wedge osteotomy, osteochondral grafting, microfracture, interposition arthroplasty, implant arthroplasty, metatarsal shortening arthroplasty। Early disease-এ nonoperative treatment best; ineffective হলে surgery consider করা হয়।

9) Bangladesh prescription-context drug list

9.1 Paracetamol — mild pain control

  1. Generic name: Paracetamol / Acetaminophen
  2. Therapeutic category: Analgesic, antipyretic
  3. Pharmacological class: Para-aminophenol derivative; non-opioid analgesic
  4. Bangladesh available brand name: Napa 500 mg, Ace 500 mg, Reset 500 mg, Fast 500 mg, Aceta 500 mg. MedEx lists these as paracetamol brands/strengths.
  5. Dose: 500–1000 mg PO every 6–8 hours PRN; safer max 3 g/day, selected low-risk adult max 4 g/day under supervision.
  6. Duration: 3–5 days PRN; persistent pain হলে reassess।
  7. কেন use হয়: Freiberg disease-এ mild–moderate pain কমাতে; inflammation কমায় না।
  8. Side effects: nausea, rash, rare hepatotoxicity; overdose হলে acute liver failure।
  9. Interaction: alcohol, chronic liver disease, enzyme-inducing drugs, warfarin long-term use—caution।

9.2 Ibuprofen — pain + inflammation

  1. Generic name: Ibuprofen
  2. Therapeutic category: NSAID; osteoarthritis/rheumatoid arthritis pain drugs
  3. Pharmacological class: Non-selective COX-1/COX-2 inhibitor
  4. Bangladesh available brand name: Advel 200/400 mg, Flamex 200/400 mg, Profen 400 mg, Intaflam 400 mg, Reumafen 200/400 mg, Inflam 200/400 mg, Iburex 200/400 mg. MedEx lists ibuprofen brands and class as NSAID.
  5. Dose: 400 mg PO 2–3 times daily after meal; max usually 1200 mg/day OTC range, higher only physician-supervised।
  6. Duration: 5–7 days; longer হলে renal function/BP/GI risk review।
  7. কেন use হয়: MTP joint inflammation, swelling, weight-bearing pain কমাতে।
  8. Side effects: dyspepsia, gastritis/ulcer, GI bleeding, dizziness, renal impairment, fluid retention, BP rise, bronchospasm in NSAID-sensitive asthma।
  9. Interaction: aspirin/other NSAID, warfarin/DOAC, antiplatelet, SSRI, steroid, ACEi/ARB + diuretic, lithium, methotrexate, cyclosporine/tacrolimus—caution/avoid. MedEx NSAID interaction cautions similar drugs with ibuprofen.

9.3 Naproxen / Naproxen sodium — longer-acting NSAID

  1. Generic name: Naproxen / Naproxen sodium
  2. Therapeutic category: NSAID; pain and inflammatory joint disease
  3. Pharmacological class: Non-selective COX inhibitor
  4. Bangladesh available brand name: Naprosyn 250/500 mg, Naprox 250/500 mg, Anaflex 250/500 mg, Ecless 250/500 mg, Napro-A 250/500 mg, Napsod 275/550 mg, Napryn 500 mg, Aktivex 250/500 mg. MedEx lists many naproxen sodium brands/strengths.
  5. Dose: 250–500 mg PO twice daily after meal; max 1000 mg/day।
  6. Duration: 5–10 days; persistent symptoms হলে stage reassess।
  7. কেন use হয়: longer duration analgesia দরকার হলে; walking-related inflammatory pain কমাতে।
  8. Side effects: heartburn, abdominal pain, nausea, diarrhea, headache, dizziness, edema, GI bleeding, renal impairment। MedEx naproxen side effects হিসেবে GI symptoms, headache/dizziness, edema ইত্যাদি উল্লেখ করে।
  9. Interaction: warfarin/DOAC/antiplatelet/SSRI → GI bleed risk; ACEi/ARB/diuretic → renal risk; methotrexate/lithium toxicity; other NSAID avoid.

9.4 Etoricoxib — COX-2 selective NSAID

  1. Generic name: Etoricoxib
  2. Therapeutic category: NSAID
  3. Pharmacological class: Selective COX-2 inhibitor
  4. Bangladesh available brand name: Etorix 60/90/120 mg, Algirex 60/90/120 mg, Vericox 60/90/120 mg, Torcox 90 mg, Temcox 60 mg. MedEx lists etoricoxib brands/strengths and class as NSAID.
  5. Dose: 60 mg PO once daily; severe short-term painে 90 mg once daily may be used, lowest effective dose।
  6. Duration: 3–7 days preferred; CV risk থাকলে avoid/alternative।
  7. কেন use হয়: pain + inflammation control; nonselective NSAID-এ GI intolerance থাকলে selected patient-এ consider করা হয়।
  8. Side effects: palpitation, fatigue, edema, BP rise, dyspepsia, chest pain/TIA risk rare but important, renal/hepatic issues, rash/hypersensitivity.
  9. Interaction: warfarin/oral anticoagulants ↑PT/bleeding risk; ACEi/ARB/diuretic effect কমতে পারে ও renal risk; lithium ↑; cyclosporine/tacrolimus nephrotoxicity।
  10. Avoid: uncontrolled HTN, IHD/stroke/PAD, CHF, severe CKD, pregnancy/lactation, active GI bleed/ulcer.

9.5 Aceclofenac — commonly used NSAID

  1. Generic name: Aceclofenac
  2. Therapeutic category: NSAID; osteoarthritis/rheumatoid arthritis pain drugs
  3. Pharmacological class: Phenylacetic acid derivative NSAID; COX inhibitor
  4. Bangladesh available brand name: Reservix 100 mg/SR 200 mg, Acebid 100 mg, Acedol 100 mg/SR 200 mg, Acefenac 100 mg, Aceflex 100 mg, Aceclofenac 100/200 mg. MedEx lists aceclofenac as NSAID with many available brands.
  5. Dose: 100 mg PO twice daily after meal; SR 200 mg once daily।
  6. Duration: 5–7 days; longer হলে GI/renal/CV monitoring।
  7. কেন use হয়: forefoot inflammatory pain ও swelling control।
  8. Side effects: dyspepsia, abdominal pain, nausea, diarrhea, dizziness, edema, renal impairment, GI bleed।
  9. Interaction: anticoagulant, antiplatelet, steroid, SSRI, ACEi/ARB/diuretic, lithium, methotrexate—caution।

9.6 Diclofenac topical gel — local pain relief

  1. Generic name: Diclofenac sodium topical gel
  2. Therapeutic category: Topical NSAID
  3. Pharmacological class: Non-selective COX inhibitor; phenylacetic acid derivative
  4. Bangladesh available brand name: Voligel 1% w/w, Diclofen gel 1% w/w, DicloGel 1% w/w, Diclomol gel 1%, Volinac 1% w/w, Volicool 1% w/w. MedEx lists diclofenac gel brands and diclofenac gel dose.
  5. Dose: 2–4 g apply over painful MTP area 3–4 times/day; wash hands after use।
  6. Duration: 7–14 days।
  7. কেন use হয়: localized pain/swelling; oral NSAID avoid করতে হলে useful adjunct।
  8. Side effects: local burning, rash, itching, photosensitivity; large area/long use করলে systemic NSAID effects rare।
  9. Interaction: oral NSAID/anticoagulant use করলে caution; broken skinে apply নয়।

9.7 PPI gastroprotection — NSAID দিলে gastric protection

  1. Generic name: Pantoprazole / Esomeprazole / Omeprazole
  2. Therapeutic category: Anti-ulcerant
  3. Pharmacological class: Proton pump inhibitor
  4. Bangladesh available brand name:
    • Pantoprazole: Pantonix 20/40 mg
    • Esomeprazole: Maxpro 20/40 mg, Maxpro MUPS 20/40 mg, Sergel 20/40 mg
    • Omeprazole: Seclo 20/40 mg
      MedEx lists pantoprazole for NSAID-induced ulcer/prophylaxis, esomeprazole for NSAID-associated gastric ulcer risk reduction, and omeprazole for NSAID-associated ulcer/prophylaxis.
  5. Dose: Pantoprazole 20 mg OD or Esomeprazole 20 mg OD or Omeprazole 20 mg OD, breakfastের 30 min আগে।
  6. Duration: NSAID course চলাকালীন; high GI risk হলে 2–4 weeks বা physician plan।
  7. কেন use হয়: NSAID-induced gastritis/ulcer/bleeding risk কমাতে।
  8. Side effects: headache, diarrhea, abdominal pain, flatulence; long-termে B12 deficiency, hypomagnesemia, osteoporosis/fracture risk। Pantoprazole long-term therapy-তে B12 malabsorption/osteoporosis-related risk উল্লেখ আছে।
  9. Interaction: Omeprazole/esomeprazole CYP2C19 interaction—diazepam, phenytoin, warfarin monitoring; gastric pH-dependent absorption—ketoconazole/iron/digoxin affected হতে পারে।

9.8 Calcium + Vitamin D — routine নয়, deficiency থাকলে

  1. Generic name: Calcium carbonate + Vitamin D3 / Cholecalciferol
  2. Therapeutic category: Mineral + vitamin supplement
  3. Pharmacological class: Calcium salt + fat-soluble vitamin
  4. Bangladesh available brand name: Calcin-D 500 mg+200 IU, Calcin-DX 600 mg+400 IU, Calcibo D 500 mg+200 IU, Oscal-D Forte 600 mg+400 IU, Calbo-D-type preparations, D-Rise 20000/40000 IU. MedEx lists many calcium + vitamin D3 brands and D-Rise cholecalciferol dose.
  5. Dose:
    • Calcium + D3: 1 tab daily after meal, if dietary deficiency/osteopenia risk।
    • Vitamin D3 deficiency: e.g., cholecalciferol 20,000 IU every 2 weeks for 6 weeks per product schedule; lab-based correction preferred।
  6. Duration: 6–8 weeks then reassess 25-OH vitamin D/calcium risk profile।
  7. কেন use হয়: Freiberg disease cure নয়; deficiency/poor bone health থাকলে bone metabolism support।
  8. Side effects: constipation, bloating, hypercalcemia, renal stone risk।
  9. Interaction: calcium reduces absorption of levothyroxine, tetracycline/quinolone, iron—2–4 hours gap।

10) Bangladesh doctors’ practical prescription pattern — কেন কোন drug দেয়

  • Mild pain: Paracetamol → pain control; safest first-line when inflammation severe নয়।
  • Pain + swelling: Ibuprofen / Naproxen / Aceclofenac → inflammatory pain কমায়; short course।
  • GI-risk but low CV-risk patient: Etoricoxib → COX-2 selective; stomach symptoms তুলনামূলক কম হতে পারে, কিন্তু CV/BP risk বেশি গুরুত্ব দিয়ে দেখতে হবে।
  • Localized pain: Diclofenac gel → local pain relief, systemic adverse effect কম।
  • NSAID course + gastritis/PUD risk: Pantoprazole/esomeprazole/omeprazole → ulcer prophylaxis।
  • Vitamin D deficiency/low bone health: Calcium + vitamin D3 → deficiency correction; Freiberg-specific curative drug নয়।
  • Bisphosphonate: Some early AVN case-based use আছে, কিন্তু Freiberg disease-এ routine Bangladeshi prescription হিসেবে standard নয়; orthopedic specialist ছাড়া prescribe করা উচিত নয়। StatPearls একটি early-stage AVN case approach হিসেবে zoledronic acid/alendronate উল্লেখ করেছে, কিন্তু এটিকে routine first-line ধরা যাবে না।

11) Prevention — কীভাবে প্রতিরোধ/প্রগ্রেশন কমাবেন

  • High-impact activity কমানো: running/jumping/dancing pain থাকলে stop বা modify।
  • Low-heeled, wide toe-box, stiff-soled shoe ব্যবহার।
  • Metatarsal pad/bar বা custom orthotic দিয়ে 2nd metatarsal head off-load।
  • Sudden training increase এড়ানো; gradual return-to-sport।
  • Body weight optimize করা।
  • Hallux valgus/long second metatarsal/abnormal gait থাকলে footwear/orthotic correction।
  • Pain শুরু হলে early X-ray/MRI করে stage ধরুন; late collapse হওয়ার আগে off-loading শুরু করলে prognosis ভালো।
  • Diabetes/SLE/hypercoagulability থাকলে disease control ও specialist follow-up।
  • Repeated steroid injection বা unnecessary systemic steroid avoid, কারণ osteonecrosis risk-contextে caution দরকার।

Overview / Summary

Freiberg disease হলো 2nd metatarsal head-এর osteonecrosis, যা forefoot pain, swelling, restricted MTP movement ও weight-bearing pain করে। Diagnosis clinical suspicion + weight-bearing X-ray দিয়ে শুরু, early disease-এ MRI সবচেয়ে helpful। Early stage-এ off-loading, immobilization, orthotic, activity modification এবং short-course analgesic/NSAID ভালো কাজ করে; late collapse/arthritis বা failed conservative care হলে foot-ankle orthopedic surgery consider করতে হয়।

Actionable Plan / Steps

  1. Suspect করুন: young female/athlete বা forefoot MTP pain + swelling + walking pain।
  2. Initial test: weight-bearing foot X-ray AP/lateral/oblique।
  3. X-ray normal কিন্তু suspicion high: MRI foot।
  4. Start conservative care: stiff sole/walking boot + metatarsal pad/bar + rest 4–6 weeks।
  5. Pain medicine: paracetamol or one NSAID only; GI risk থাকলে PPI।
  6. Review after 4–6 weeks: pain, ROM, gait, X-ray/MRI stage।
  7. Refer: severe collapse, deformity, loose body, arthritis, persistent pain >6–12 weeks despite off-loading।

Reference List — Textbook + Guideline/Review + DOI

Textbook

  1. Campbell’s Operative Orthopaedics, 14th ed. Chapter: Foot and ankle disorders / lesser metatarsal conditions.
  2. Mann’s Surgery of the Foot and Ankle, 9th ed. Sections on lesser metatarsalgia and Freiberg infraction.
  3. Rockwood and Green’s Fractures in Adults, 9th ed. Foot/metatarsal disorders section.
  4. Davidson’s Principles and Practice of Medicine, 24th ed. Musculoskeletal pain/osteonecrosis overview—supportive reference, not Freiberg-specific.

Guideline / clinical reference

  1. Merck Manual Professional, “Freiberg Disease,” reviewed/revised Oct 2025—diagnosis with radiographs/MRI; management with immobilization, orthotics, sometimes surgery.
  2. StatPearls, “Freiberg Infraction,” last update Nov 22, 2023—clinical features, Smillie staging, imaging, conservative and surgical management.

Peer-reviewed journals with DOI

  1. Yoshimura I, Takao M, Wagner E, et al. Evidence-Based Treatment Algorithm for Freiberg Disease. Cartilage. 2024;15(1):58–64. DOI: 10.1177/19476035231205676.
  2. Carmont MR, Rees RJ, Blundell CM. Current concepts review: Freiberg’s disease. Foot & Ankle International. 2009;30(2):167–176. DOI: 10.3113/FAI-2009-0167.
  3. Schade VL. Surgical Management of Freiberg’s Infraction: A Systematic Review. Foot & Ankle Specialist. 2015;8(6). DOI: 10.1177/1938640015585966.
  4. Chao KH, Lee CH, Lin LC. Surgery for symptomatic Freiberg’s disease: Extraarticular dorsal closing-wedge osteotomy. Acta Orthopaedica. 1999;70(5):483–486. DOI: 10.3109/17453679909000985.

Md.Rafiqul Islam Lipu,Date:-18-06-2026 Thursday,Time:-1-33-12 Pm

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