Kohler’s Disease

(Navicular Avascular Necrosis in Children)

Summary

Kohler’s disease is a relatively uncommon foot condition that leads to pain and swelling in a child’s foot. It is named after a German radiologist (Alban Kohler 1874-1947) who described the condition. It is caused by a loss of blood supply to one of the bones in the midfoot, (the navicular bone) which leads this bone to collapse before it has fully hardened (become ossified). Treatment involves time and symptom control, including efforts to limit activities until the symptoms have resolved. As the blood supply returns to the bone, the symptoms will usually resolve.

Clinical Presentation

Kohler’s disease typically occurs in children between the ages of 4 and 9 and tends to be more common in boys. The navicular, which is a bone in the mid part of the foot, loses a portion of its blood supply. This causes the bone to collapse and causes the patient to have pain and swelling in the foot. It is unclear exactly why some children develop this condition. It may be related to repetitive trauma in this area, particularly as the navicular bone is the last bone in this area to ossify (become bony). In addition, blood abnormalities, such as sickle cell anemia, may increase the chance of a child developing Kohler’s disease.

Physical Examination

Children are likely to have generalized pain in the midfoot, particularly on the inside. Patients will often walk with a limp and there may be some associated swelling. Movement of the mid and hindfoot may create discomfort. The rest of the examination is likely to be normal.

Imaging Studies

The condition is diagnosed on plain x-rays. The navicular is the last bone in the foot to ossify in children. The x-rays will show areas of loss of the normal shape of bone, and the bone itself will appear collapsed. There will be increased density in the bone.

Treatment of Kohler’s Disease

Treatment is symptomatic and may include:
Children are placed in comfortable supportive shoes or a walker boot to limit the loading to this area.
Minimize weight-bearing activities: Children should be encouraged to avoid any significant activity loading activities, such as running or jumping, until the condition settles.
Casting: If the symptoms of Kohler’s disease does not settle, it may be necessary to put children in a short-leg walking cast for up to six weeks, followed by comfort shoes. This will often allow the bone to settle and the symptoms to improve.

Prognosis of Kohler’s Disease

Usually the condition is self-limiting, and in rare instances, the patient may have residual symptoms as adults.

Edited April 17, 2017

Previously edited by Dave Townshend MD

mf/ 6.26.18