Freiberg’s Disease: Ball-of-Foot Pain in Young Women 2026

Freiberg's disease is avascular necrosis of a metatarsal head — almost always the second metatarsal — and it shows up as aching, swelling, and stiffness under the ball of the foot in teenage girls and young women. It is a bone problem, not a soft-tissue strain, and treating it like plantar fasciitis or a stone bruise usually delays the real diagnosis by months.

Why Freiberg's disease matters for young women

The second metatarsal is the longest bone in the forefoot and carries the most load during the push-off phase of walking, running, and jumping. That mechanical setup, combined with a growth-plate blood supply that is still maturing in adolescence, is why metatarsalgia and ball-of-foot pain from Freiberg's disease clusters in girls between roughly 11 and 17, with a female-to-male ratio commonly cited around 5:1 in orthopedic literature.

Dancers on pointe, gymnasts, and runners load that same joint repeatedly in a flexed position, which is why this segment sees more Freiberg's disease than sedentary peers. A young woman who describes pain that builds during releve, sprinting, or push-off — rather than pain from a specific twist or fall — fits the classic pattern.

Freiberg's disease is a bone-level injury under the ball of the foot, and it responds best to offloading and imaging done early, not to stretching or arch supports alone.

Recognize the specific symptoms

Generic "ball of foot pain" covers a lot of ground. Freiberg's disease has a narrower symptom pattern worth checking against before assuming it's a callus or a strain.

• Swelling localized directly over the second metatarsal head, not spread across the whole forefoot
• Pain that's worse barefoot or in soft, flexible flats than in a stiff shoe
• Sharp pain specifically during the push-off or toe-off phase of walking, running, or releve
• Limited or painful range of motion when the second toe joint is flexed upward
• No history of a specific twisting injury, sprain, or direct trauma

Get the right imaging early

An X-ray taken in the first two to three weeks of symptoms can look completely normal, which is the single biggest reason Freiberg's disease gets missed or misdiagnosed as a sprain.

• Start with a weight-bearing X-ray of the forefoot, even if early films are unremarkable
• Request an MRI if pain persists beyond 2-3 weeks with a negative X-ray — MRI picks up marrow changes before bone flattening is visible
• Ask your podiatrist to stage the finding using the Smillie classification (stage I through V), which tracks how much the metatarsal head has flattened
• Repeat imaging around the 6-8 week mark to confirm the bone is healing rather than progressing
• Don't accept a diagnosis based on a physical exam alone if symptoms don't improve in two weeks

Offload the joint immediately

Once Freiberg's disease is confirmed or strongly suspected, the priority is taking load off the second metatarsal head, not stretching around it.

• Switch to a stiff-soled shoe or a shoe with a rocker-bottom sole that reduces bend at the forefoot
• Add a metatarsal pad or bar placed just behind — not directly under — the second metatarsal head
• Consider a walking boot for 4-6 weeks during an acute flare, especially in a younger patient still growing
• Avoid barefoot walking on hard tile or concrete floors during the acute phase
• Cut running, jumping, and pointe work entirely until pain with push-off resolves

Modify footwear and activity for the long term

Once acute pain settles, the shoes and activities that caused the repetitive load need to change, or the pain returns within a season.

• Retire unsupportive flats, thin sandals, and flip-flops for daily wear
• Avoid high heels, which shift weight forward directly onto the metatarsal heads
• Choose shoes with a wider toe box and a stiffer forefoot rather than a soft, bendy sole
• Cross-train with swimming or cycling instead of running while the joint settles
• For dancers, work with an instructor on technique adjustments that reduce time spent in full releve

Build custom support once acute pain settles

A stiff shoe and a drugstore metatarsal pad handle the acute phase, but a young woman returning to dance, running, or court sports usually needs support built around her specific foot shape and gait. Custom orthotics for ballet and dance place the offloading pad exactly where the second metatarsal head sits rather than approximating it, which matters more in this segment than in a general adult population. A podiatrist maps the pressure points during a gait exam before fitting custom orthotics, rather than guessing at pad placement.

Strengthen and rehab the surrounding structures

Once the acute bone pain has calmed down, weak intrinsic foot muscles and a stiff calf make a young woman more likely to reload that second metatarsal the same way.

• Intrinsic foot strengthening (towel scrunches, short foot exercises) 3-4 times a week
• Calf and ankle mobility work to reduce compensatory forefoot loading
• A graded return-to-running or return-to-dance protocol over several weeks, not a single cleared-to-play day
• A gait check to confirm push-off mechanics have actually changed, not just that pain is gone

Know when to consider surgery

Most Freiberg's disease cases in the early stages resolve with offloading and activity changes over a matter of months. Surgery becomes a real conversation only in specific situations.

• Pain persists past 6 months of consistent conservative treatment
• Imaging shows joint collapse or flattening consistent with advanced Smillie staging (III-V)
• Loose bone fragments are causing the joint to catch or lock
• A foot and ankle surgeon determines joint debridement, a dorsal closing wedge osteotomy, or joint reconstruction is the better path based on imaging and function

Comparing treatment options for Freiberg's disease

Verdict: for a young woman with new ball-of-foot pain over the second metatarsal, a stiff-soled shoe plus a properly placed offloading pad resolves most early Freiberg's disease cases — surgery is a last resort, not a first step.

Common mistakes young women make with Freiberg's disease

• Writing off early symptoms as "growing pains" and continuing full dance or running training through the flare
• Assuming a bunion or hammertoe is the source and buying wider shoes without addressing offloading at the second metatarsal
• Accepting a normal X-ray as the final answer instead of pushing for MRI when pain doesn't improve in two to three weeks
• Returning to pointe work or sprinting the moment pain eases, before the bone has had time to remodel
• Never ruling out Morton's neuroma or a plantar plate tear, both of which mimic Freiberg's disease but need different treatment

FAQ

One last thing

The second metatarsal is affected in the large majority of Freiberg's disease cases, with the third metatarsal a distant second — which is exactly why pain isolated to that one joint, without a trauma history, should raise suspicion in 2026 the same way it would have decades ago. The diagnosis hasn't changed; what's changed is how fast a young woman with unexplained ball-of-foot pain can get an MRI and a staged treatment plan instead of months of guessing. Naples Podiatrist sees this pattern regularly in active teens and young women across Southwest Florida, and catching it before joint collapse is what keeps most cases out of the operating room.

Related guides

• How to treat metatarsalgia and ball-of-foot pain
• Morton's neuroma: burning pain in the ball of your foot
• Why your second toe hurts: understanding plantar plate tears
• Custom orthotics for ballet and dance
• How to get custom orthotics from a podiatrist