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Just after some advice here. I saw a 15 year old girl initially about 2 months ago. She presented with a 10 month history of left forefoot pain after kicking a soccer ball (she's a top soccer player). Her GP gave a intra-articular corticosteriod injection into the 2nd metatarsophlangeal joint (MPJ) about 3 weeks after the initial injury. She continued to have pain over the next 10 months. She saw a podiatrist who prescribed orthotics. She found these uncomfortable so she didn't wear them much. She continued to play soccer (she was limping by the end of games) though she required daily NSAIDs and analgesics (and her mum is a pharmacist!). She is amenorrheic and has a calcium deficiency.
By the time she presented to me, it was 10 months down the track from the initial injury. I sent her for an MRI which confirmed Freiberg's infarction of the 2nd metatarsal head. On advice from the radiologist, we also got a plain x-ray done. I've attached a couple of the MRI image and the medial oblique x-ray.
I put her into a cam walker immediately and got her into custom orthotics to offload the 2nd metatarsal head. During this time, she consulted an orthopaedic surgeon. He told her that the cam walker wouldn't do any good and just to get out and play soccer because she can't make it any worse. I saw her a few days ago (when she told me about seeing the ortho). She'd been in the boot for 6 weeks. Clinically there was little, if any, improvement. She was still tender to palpate over the dorsal aspect of the metatarsal head and was quite painful to plantarflex the 2nd MPJ. She just wants to get back playing soccer and is happy to put up with the pain. I'm a little more concerned about doing more damage, requiring surgery etc.
I suppose my question is can she make it worse by playing soccer again now? Also, would a bone stimulater work for this as per fractures? I suspected with the amenorrhea that she may take longer than normal to heal. I would have liked to see her without any tenderness before going back to play soccer. Taping the toe in plantarflexion (as you would tape the toe for a plantar plate injury) reduces the pain so she just wants to play with the toe taped and the orthotics in her soccer boots.
These invariably turn into post traumatic DJD long term.
Taping the toe may assist with the current level of pain and swelling, but the MT head will continue to square off and the articular cartilage will probably erode further.
By late teens/early 20s this becomes a painful enlarged degenerative joint, depending on activity. Its a similar process to hallux limitus form there on. SOmetimes I have seen these remodel into something approaching normality. By and large they mostly end up needing surgical remodelling and reshaping of the MT head like a cheilectomy.
The more she uses it, the faster this will happen. She just needs to weigh up fitness benefits vs/ foot deterioration.
LL
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***************************************** Remember, it's just a foot.
Her GP gave a intra-articular corticosteriod injection into the 2nd metatarsophlangeal joint (MPJ) about 3 weeks after the initial injury.
Were you the first to organise an Xray?!?
Sport may be everything to an adolescent athlete, but they rarely consider the long term effect of injuries. This is something that they later regret...
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Craig Tanner
Podiatrist ASPETAR-
Qatar Orthopaedic and Sports Medicine Hospital
Doha
QATAR http://www.aspetar.com/
Sport may be everything to an adolescent athlete, but they rarely consider the long term effect of injuries. This is something that they later regret...
No, the GP did an x-ray shortly after the injury which did not reveal any abnormality. Why in the following 10 months no other imaging was done is completely beyond me!
These invariably turn into post traumatic DJD long term.
Taping the toe may assist with the current level of pain and swelling, but the MT head will continue to square off and the articular cartilage will probably erode further.
By late teens/early 20s this becomes a painful enlarged degenerative joint, depending on activity. Its a similar process to hallux limitus form there on. SOmetimes I have seen these remodel into something approaching normality. By and large they mostly end up needing surgical remodelling and reshaping of the MT head like a cheilectomy.
The more she uses it, the faster this will happen. She just needs to weigh up fitness benefits vs/ foot deterioration.
LL
LL, so if soccer is everything to her, are you saying she's OK to play so long as she knows that she'll more than likely require surgery at some point? Will loading it a lot now potentially change the surgical procedure required (and obviously long-term function)?
LL, so if soccer is everything to her, are you saying she's OK to play so long as she knows that she'll more than likely require surgery at some point? Will loading it a lot now potentially change the surgical procedure required (and obviously long-term function)?
My view is to put things into perspective and let the patient/parent make the decision.
Its too easy to focus on the foot, and forget the health benefits of exercise, particularly as childhood obesity increases. Most stuff we see is worsened by weight bearing exercise one way or another.
What is the worst that can happen? I mean - the damage is now done. Its just a matter of degrees from now on.
Many Frieberg's need surgery later down the track as the joint enlarges and becomes painful. If the patient/guardian/parent is aware of this, then they can make their own decision on soccer. I wouldn't stand in their way.
If a bit of taping +/- an orthotic allows this patient to keep active and enjoying sport, then I think that's the main game. Heart health beats foot health.
LL
__________________
***************************************** Remember, it's just a foot.
My view is to put things into perspective and let the patient/parent make the decision.
Its too easy to focus on the foot, and forget the health benefits of exercise, particularly as childhood obesity increases. Most stuff we see is worsened by weight bearing exercise one way or another.
What is the worst that can happen? I mean - the damage is now done. Its just a matter of degrees from now on.
Many Frieberg's need surgery later down the track as the joint enlarges and becomes painful. If the patient/guardian/parent is aware of this, then they can make their own decision on soccer. I wouldn't stand in their way.
If a bit of taping +/- an orthotic allows this patient to keep active and enjoying sport, then I think that's the main game. Heart health beats foot health.
LL
So when do you decide to have the surgery done? I spoke with the Mum last night. The patient went to school yesterday without the cam walker and was in a lot of pain last night.
The ortho she saw the other was told her there was nothing that he could do - i.e. no surgery.
So when do you decide to have the surgery done? I spoke with the Mum last night. The patient went to school yesterday without the cam walker and was in a lot of pain last night.
The ortho she saw the other was told her there was nothing that he could do - i.e. no surgery.
Kent
The is always the question...when should someone have surgery. My personal thoughts are that aside from trauma (eg #), there are very few acute foot conditions that demand foot surgery. Rather, chronic conditions that are unresponsive to normal conservative care. Juvenile avascular necrosis needs to play its way out to a consolidative stage, before you need to worry about the long term issues.
Considering the pathophysiology of Frieberg's and the typical prognosis, I would be recommending either activity modification and continued immobilisation until the inflammatory stage has settled, and there is less oedema in the joint. This could take weeks to months. Wean off the CAM walker and look at taping and an orthosis to offload the MT head. Obviously bone remodelling will continue, and progressive degenerative changes will occur similar to OA over a period of several years.
The cases I have seen intraoperatively have usually been women in their 30's who have painful enlargement of the joint, and pain presenting similarly to hallux limitus. They have generally failed to get meaningful benefit from orthoses etc. and usually require a cheilectomy type procedure to remodel the joint back to a more normal appearance and function.
So, how long is a piece of string?
I would suggest the best advice is a wait and see approach. Short term RICE, activity modification, then gradual return to weight bearing exercise to tolerance. Then perhaps annual monitoring.
She may never *need* surgery, but this will depend on future occupation, activities etc.
LL
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***************************************** Remember, it's just a foot.
Agreed Tony - this young lady may never need surgery once over the inflammatory stage and the degenerative process advances. Always amazes me when I see severe degenerative changes following presumed Freiberg's in older folk who have very little discomfort or dysfunction.
I have to chime in here. There is a surgical option that I have used in children, before the degenerative changes occur and that is core decompression and subchondral bone grafting. It is a proactive way to give the bone a chance to heal/revascularize and re-establish the shap of the met. head. It can only help and not make things worse. Food for thought.....
Jeff
Personally, I wouldn't perform surgery on these individuals since, if you treat them like you would a metatarsal fracture, they eventually get better with minimal to no symptoms. And nearly all the ones that are symptomatic respond very well to custom foot orthoses with accommodations for the affected metatarsophalangeal joint. I have seen numerous adults with healed Freiberg's infractions on the radiographs that are asymptomatic at that joint and don't even remember having pain in that joint earlier in life.
However.... as I was taught in my podiatric surgery courses......even the normal foot can be surgically corrected.
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Sincerely,
Kevin
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Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
To true in adults; however,when the cartilage shell is viable, especially in kids, you can get full revascularization with this procedure. If not, then I off-load them, let it burn out and treat conservatively as long as possible.
I think it is best to wait it out and treat it however you like to try and allow her to continue sports. If it gets to be unbearable then Sx is best option. I would first try Bone Stim and Walker boot for 3 months. If this did not work then you can do Sx and be prepared for 3 options.
1) Osteocure-Bone plug graft I think Tournier may make this??
2) Osteotomy to bring good cartilage dorsal. Dorsal based wedge
3) Titanium implant- Osteomed makes a nice one...
4) Fusion is an option but not in an athlete
Advice on a Freiberg's case
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