Journal of Pediatric Orthopaedics - 2026-07-20 - Journal Article
Provider-Cleared Return-to-Sport After Freiberg Infraction in Adolescent Athletes.
Touban BM, Amaral JZ, Chhabra BN, Miggins J, Kushare I
Topics
Key Takeaway
Among adolescent athletes with symptomatic Freiberg infraction, 84% achieved provider-cleared return-to-sport without surgery at a median of 3.7 months, while the 16% requiring operative intervention took a median of 8.8 months.
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Summary
This retrospective case series characterized time to provider-cleared RTS in adolescent athletes (≤18 years) with symptomatic Freiberg infraction at a single institution from 2010–2023. All patients underwent initial nonoperative management; 84% (16/19) achieved RTS without surgery at a median of 3.7 months, while 3 patients requiring operative intervention (metatarsal head drilling or joint debridement) reached RTS at a median of 8.8 months. The cohort was 68% female, median age 12.7 years, with 90% presenting as Smillie stage I–III.
Key Limitation
The 19-patient cohort from a single institution over 13 years reflects extreme rarity and selection bias, limiting generalizability and precluding any statistical comparison between treatment groups.
Original Abstract
BACKGROUND
Return-to-sport (RTS) is an important clinical concern for adolescent athletes, but sport-related outcomes in symptomatic Freiberg infraction (FI) remain poorly characterized. The purpose of this study was to describe time to provider-cleared RTS in adolescent athletes with symptomatic FI and to report provider-cleared RTS according to treatment course.
METHODS
This retrospective case series included patients aged 18 years or younger with symptomatic FI treated at a single institution between 2010 and 2023. Inclusion required clinical and imaging confirmation of symptomatic FI and documented follow-up through provider-cleared RTS. Provider-cleared RTS was defined as documented clearance for unrestricted sport participation by the treating orthopaedic provider. All patients underwent an initial trial of nonoperative management; patients who ultimately underwent surgery were reported descriptively as a subgroup within the overall treatment course. Available radiographs and magnetic resonance imaging studies were reviewed by 2 fellowship-trained pediatric orthopaedic surgeons, and Smillie stage was assigned by consensus. Descriptive statistics were calculated.
RESULTS
Of 65 patients identified by diagnostic code screening, 19 met inclusion criteria after review, representing 21 affected metatarsals. The cohort was predominantly female (68%) and had a median age of 12.7 years (range: 9.7 to 17.8 y). The second metatarsal was most commonly involved (67%), and 90% of affected metatarsals were Smillie stage I to III. The most common sports were dance (32%), soccer (27%), and track (18%). Of the 19 included patients, 16 (84%) reached documented provider-cleared RTS without surgery, most commonly after treatment with a controlled ankle motion boot or casting. Three patients (16%) ultimately underwent operative intervention after initial nonoperative management, including metatarsal head drilling (n=2) and joint debridement with fragment excision (n=1). The median time to provider-cleared RTS for the overall cohort was 4.5 months (range: 1.4 to 21.1 mo). Patients who reached provider-cleared RTS without surgery had a median time to provider-cleared RTS of 3.7 months (range: 1.4 to 21.1 mo). The 3 patients who ultimately underwent operative intervention after initial nonoperative management had a median time to provider-cleared RTS of 8.8 months (range: 8.5 to 10.4 mo).
CONCLUSION
Among adolescent athletes with symptomatic FI and documented provider-cleared RTS follow-up, the median time to provider-cleared RTS was 4.5 months from initial orthopaedic evaluation. Most patients (84%) reached provider-cleared RTS without surgery, with a median time of 3.7 months. The 3 patients who ultimately underwent operative intervention after initial nonoperative management had a median time to provider-cleared RTS of 8.8 months. These findings provide preliminary descriptive data that may cautiously help inform counseling of adolescent athletes and their families regarding provider-cleared RTS, although further study is needed to clarify management strategies and long-term outcomes in this rare condition.
LEVEL OF EVIDENCE
Level IV-therapeutic.