• Johnson J
• Littrell TA

• Case Reports
• Cerebral Palsy
• Foot Diseases / diagnostic imaging
• Male
• Metatarsal Bones / diagnostic imaging
• Middle Aged
• Osteochondrosis / diagnosis

Objective: This case report will describe the clinical presentation, radiographic examination, diagnosis of Freiberg disease, and appropriate referral in a male patient with non-resolving foot pain. Clinical Features: A 52-year-old male sought care at a chiropractic college outpatient clinic for low back pain and right foot pain near the head of the second metatarsal. A complicating factor to his care included cerebral palsy creating a scissoring gait with inability to fully extend the right leg during heel strike, and toe walking on the right side. Prior podiatric management of the foot pain included orthotics which the patient believed to have worsened his foot and low back pain. Chiropractic evaluation and manipulation of both feet began at the second treatment visit and evolved over six treatment visits with no resolution of foot pain. 

Intervention and Outcome: The patient’s low back pain symptoms were successfully reduced and managed with chiropractic care. Upon non-resolution of right foot pain, radiographic examination and identification of a flattening deformity and focal decreased bone density with slightly sclerotic border at the articular surface of the second metatarsal head, consistent with avascular necrosis known as Freiberg disease, was completed. Magnetic resonance imaging examination was advised by the radiologist for further identification of pathological destruction of tissue but has yet to be completed to date. The patient was referred to the treating podiatrist for management. 

Conclusion: Freiberg disease is osteonecrosis of one or more metatarsal heads, predominantly seen in adolescent female athletes.¹  The pathophysiology of Freiberg disease is complicated by numerous factors including trauma, altered foot biomechanics, genetic predisposition² , systemic disorders, and arterial insufficiency.¹  While trauma and vascular compromise are believed to be the most common causes, diabetes mellitus, systemic lupus erythematosus and hypercoagulability are also implicated in metatarsal head osteonecrosis.³  Early detection and treatment with conservative management to reduce the burden on the joint space can slow or limit progression of osteonecrosis and the need for surgical intervention.¹ While not commonly diagnosed in the chiropractic profession, knowledge of the impact of long-term altered foot biomechanics, as in this case due to cerebral palsy, in the development of Freiburg disease can benefit the patient through early intervention, podiatric referral, and conservative management. 

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