Kohler’s Disease: Understanding Pediatric Avascular Necrosis of the Navicular Bone
Kohler’s Disease is a rare but significant condition affecting the foot, primarily in young children. It is characterized by avascular necrosis (loss of blood supply) to the navicular bone—a critical component of the midfoot. First described in 1908 by Alban Köhler, this self-limiting condition presents distinct clinical and radiographic features and often resolves with conservative management.
What Is Kohler’s Disease?
Kohler’s Disease is a self-limiting osteochondrosis, meaning it is a disorder of bone growth that resolves on its own over time. It specifically involves the navicular bone, which sits at the top of the midfoot and plays a key role in foot structure and arch stability.
Epidemiology
- Age Group: Most commonly seen in children aged 4 to 5 years, though it may occur as early as age 2.
- Sex: Predominantly affects boys, though girls can be affected—typically at a slightly younger age due to earlier ossification (bone development).
- Laterality: Usually unilateral (one foot).
Case Presentation: A Typical Example
A representative case involved a 4-year-old girl who presented with intermittent right foot pain for a week. The pain intensified after outdoor play, and she eventually refused to put weight on the right foot.
Clinical Examination
- Tenderness over the dorsomedial midfoot (top-inner part of the foot)
- No external skin changes
- Antalgic gait (limping to avoid pain), bearing weight on the lateral (outer) side of the foot
Radiographic Findings
X-rays revealed:
- A collapsed, flattened, and radiodense navicular bone
- Disruption of the normal trabecular pattern
- Sclerosis (increased bone density) and rarefaction (loss of bone substance)
These findings are classic signs of avascular necrosis of the navicular bone, confirming a diagnosis of Kohler’s Disease​
Pathophysiology: Why Does It Happen?
The navicular bone is the last tarsal bone to ossify, making it particularly vulnerable during early childhood. As children grow and gain weight, mechanical forces increase on the midfoot.
Here’s how the disease develops:
- The already ossified talus and cuneiform bones exert compressive forces on the softer navicular bone.
- These forces compress the blood vessels around the navicular’s cartilage ring (perichondral ring).
- The central spongy portion of the navicular becomes ischemic, leading to avascular necrosis.
Despite the necrosis, the navicular bone has a radial blood supply—allowing for spontaneous healing and excellent long-term outcomes in most cases​.
Diagnostic Imaging
Radiographic features vary but generally include:
- Increased density (sclerosis) of the navicular bone
- Loss of trabecular pattern
- Fragmentation or collapse of the bone
- Occasionally, the bone may appear normal in shape but denser than usual
These findings are essential in distinguishing Kohler’s Disease from other causes of pediatric foot pain such as:
- Tarsal coalition
- Stress fractures
- Infections
- Tumors
Treatment Options
Conservative Management
Since Kohler’s Disease is self-limiting, the focus of treatment is symptom relief and support.
1. Pain Management:
- Over-the-counter pain medications such as acetaminophen or ibuprofen
2. Foot Support:
- Use of soft arch supports
- Medial heel wedge in shoes
3. Immobilization (if needed):
- Short-leg walking cast for 4 to 6 weeks in severe cases
- Leads to faster resolution of symptoms
Duration of Symptoms
- With treatment: Symptoms usually resolve in 3 months
- Without treatment: May persist for up to 15 months​
Prognosis
The outlook for Kohler’s Disease is excellent.
- Most children recover full function
- Radiographic normalization typically occurs within 6 to 18 months
- There is no long-term deformity or loss of function
Notably, treatment type does not influence the radiographic course or final outcome—early intervention simply reduces the duration of symptoms​
When to Suspect Something Else
Persistent pain beyond the expected recovery period or an atypical clinical presentation warrants evaluation for other conditions such as:
- Tarsal coalition
- Accessory navicular syndrome
- Juvenile idiopathic arthritis
- Osteomyelitis (bone infection)
Advanced imaging such as MRI may be needed if the diagnosis is unclear or if symptoms persist.
Summary
Feature: Description
Disease: Kohler’s Disease
Bone Involved: Navicular bone (foot)
Age of Onset: 2 to 5 years (peak at 4–5)
Gender: More common in boys
Symptoms: Midfoot pain, limping, refusal to bear weight
Imaging: Findings Flattened, dense navicular; loss of trabeculae; possible fragmentation
Treatment: Pain control, shoe inserts, possible short-leg cast for 4–6 weeks
Prognosis: Excellent; full recovery expected
Clinical Pearls
- Think of Kohler’s Disease in any young child with midfoot pain and limp.
- Early imaging helps differentiate from other serious foot conditions.
- The navicular’s unique ossification timeline makes it vulnerable—but also resilient.
- A radial pattern of vascularization allows for spontaneous recovery even after ischemia.
- Early treatment significantly shortens the duration of disability but does not affect long-term outcomes.
If your child is experiencing midfoot pain or is walking with a limp, it is important to seek evaluation by a healthcare professional. Kohler’s Disease, while rare, is easily diagnosable and manageable with timely care.
For expert diagnosis and treatment, Complete Orthopedics is here to help you and your child get back on your feet—literally.
Do you have more questions?
Q. What is Kohler’s disease?
A. Kohler’s disease is a rare condition where a bone in the foot called the navicular bone loses its blood supply, leading to bone collapse and regeneration.
Q. Who typically gets Kohler’s disease?
A. Kohler’s disease typically affects children, most commonly boys between the ages of 3 and 7.
Q. What causes Kohler’s disease?
A. Kohler’s disease is caused by a temporary loss of blood supply to the navicular bone during its development, but the exact reason for the loss of blood supply is unknown.
Q. What are the symptoms of Kohler’s disease?
A. Symptoms include pain, swelling, tenderness over the arch of the foot, and a limp.
Q. How is Kohler’s disease diagnosed?
A. Kohler’s disease is diagnosed through a physical examination and confirmed with X-rays showing changes in the navicular bone.
Q. What does an X-ray show in Kohler’s disease?
A. X-rays typically show the navicular bone as dense, flat, and fragmented.
Q. How is Kohler’s disease treated?
A. Treatment usually includes rest, immobilization with a cast or brace, and pain management.
Q. Does Kohler’s disease require surgery?
A. Surgery is rarely needed for Kohler’s disease.
Q. How long does Kohler’s disease take to heal?
A. Healing generally occurs within several months to up to two years, and most children recover completely without long-term problems.
Q. What is the prognosis for Kohler’s disease?
A. The prognosis is excellent, and most children recover full function without any permanent deformity.
Q. Can Kohler’s disease affect both feet?
A. Yes, although it is less common, Kohler’s disease can affect both feet.
Dr. Mo Athar
