# Lower Limb Osteochondrosis and Apopbysitis in Young Athletes--A Comprehensive Review
## 8 Freiberg Disease: Presentation, Diagnosis, and Management  
Freiberg disease is an idiopathic avascular necrosis that primarily affects the second metatarsal head, although other small metatarsal heads may also be affected [103]. The etiology of this condition is thought to be multifactorial. Contributing factors include repeated microtrauma, ischemia due to vascular disturbances, and systemic diseases such as diabetes mellitus [104]. In addition, a genetic predisposition may also play a role in the development of [PERSON]'s disease [105]. Epidemiologically, this condition is more common in females, with a female-to-male ratio of five to one [104]. In 68% of cases, the second metatarsal bone is affected, followed by the third metatarsal bone in 27% and the fourth metatarsal in 3% of cases [104; 106]. It is also observed that the dominant foot is affected in 36% of cases, with the highest incidence between 11 and 17 years of age [107].  
The clinical evaluation of [PERSON]'s disease includes a thorough patient history and physical examination, with a focus on localized pain, swelling, and functional impairment of the metatarsophalangeal joint (MTP joint). Patients typically present with pain and swelling localized to the affected metatarsal head in the forefoot [108]. Symptoms usually occur gradually without a clear acute triggering event. It generally worsens with weight-bearing activities, especially when walking barefoot or wearing shoes with a raised heel [103]. On physical examination, the affected toe may show marked swelling, particularly around the MTP joint [109]. Dorsiflexion of the toe may be observed, with a limited range of motion of the MTP joint. Palpation may reveal crepitus, indicating an irregularity in articulation [108]. In the diagnosis of this disease, imaging studies, especially X-rays, are of utmost importance. This damage progresses from sclerotic crack fractures in the ischemic epiphysis and altered articular surfaces in the early stage to severe bone collapse, fragmentation, and osteoarthritis with deformity of the metatarsal head in the advanced stage [108]. In addition to X-rays, MRI and bone scintigraphy are valuable diagnostic tools that facilitate the early detection of [PERSON]'s disease [109].  
Treatment of [PERSON]'s disease focuses on conservative treatment strategies in the early stages to alleviate symptoms and prevent the progression of arthritis [109; 110; 111]. The literature underscores the paramount importance of activity modification (avoidance of high-impact activities such as running and jumping), as well as the need for appropriate adjustment of footwear and administration of oral anti-inflammatory medications [109; 111]. Furthermore, customized orthoses can be used to distribute the mechanical load away from the affected metatarsal head [109; 111]. There is evidence in the literature that the use of stiff-sold shoes with a rocker bottom or metatarsal pads may be helpful in the treatment of this condition [109]. In cases where conservative measures do not provide satisfactory results or the disease progresses, surgical alternatives may be considered to restore joint congruency. These options include debridement, arthroplasty, osteotomy, microfracture, and grafting [111]. A study conducted by [PERSON] et al. [112] involving twenty-two patients provided evidence that surgical intervention is an effective and reproducible method for managing Freiburg disease. These findings are consistent with those of [PERSON] et al. [113], who demonstrated that osteotomy results in the restoration of metatarsal head sphericity, with favorable clinical outcomes and minimal morbidity.