Provider-Cleared Return-to-Sport After Freiberg Infraction in Adolescent Athletes

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.

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.

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).

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 IV-therapeutic.