Köhler's disease

What is Köhler's disease?

Köhler's disease is a childhood condition of the navicular (the boat-shaped bone on the inner side of the midfoot)¹². The bone temporarily loses its blood supply, then heals and rebuilds¹.

It mostly affects young children, usually aged about 4 to 7 years, though some are older or younger¹². Boys are affected more often than girls¹².

It's rare, but it isn't clear how common it is³. It can be missed or mistaken for something else⁴.

What causes it, and who gets it?

The exact cause isn't fully understood, and most children have no identified cause³⁵. The navicular is the last foot bone to harden⁴³⁶. In a young child it sits under a lot of stress between its neighbouring bones⁴. Being squeezed there may disrupt its blood supply⁷⁴.

A bone that hardens later than usual may be more easily affected, and the shape of the foot may add stress¹. Nothing a family did is known to have caused it.

What does it feel like, and how is it diagnosed?

The main sign is pain in the midfoot that tends to get worse when your child puts weight on it and may ease with rest¹. Your child may also have mild swelling, tenderness over the bone and a limp¹. The pain usually builds gradually and can be worse with activity⁸⁶. Some children have no symptoms, and the condition is found by chance on an x-ray¹⁶.

When there is pain, an x-ray is the main test¹. Early x-rays can be normal, so the results are read alongside your child's symptoms⁸⁹. Infection and a fracture need to be ruled out before Köhler's disease is diagnosed⁶. Other conditions can look similar, such as a stress fracture or inflammatory arthritis⁶.

Some signs are more serious sooner.

What helps first?

First-line care aims to ease symptoms while the bone heals¹³. It means resting the foot or cutting back on weight-bearing, avoiding high-risk activities, and using ice¹⁶. Non-steroidal anti-inflammatory drugs (NSAIDs) are used for pain, and your child's doctor can advise on pain relief¹⁴⁶.

Some children use crutches, a controlled ankle motion boot or a short leg walking cast²⁴. A cast is for more severe symptoms, for 4 to 6 weeks, and shouldn't go beyond 6 weeks, to avoid ankle stiffness³⁴. A short time in a cast may shorten symptoms, though long-term results are good either way². Rigid-sole shoes and arch supports are also used⁶.

If a cast or boot is used, agree how long with your child's doctor, and plan a review. It isn't clear yet how well casting, footwear, arch supports or anti-inflammatory pain relief work for Köhler's disease, or what cast duration works best¹²³.

What helps if that isn't enough?

A GP can examine your child and may arrange an x-ray or other tests, or a referral to a paediatric orthopaedic surgeon¹⁰.

Surgery is uncommon¹. It's generally kept for severe pain after several months of failed conservative treatment⁴⁵. It carries risks such as foot scarring and tendon adhesion (tendons sticking)⁴. Whether it helps isn't clear yet, because the bone can improve on its own⁴.

How long does it take to get better?

The outlook is usually very good⁷. Köhler's disease tends to settle by itself, and it isn't known to cause long-term problems with the foot⁷. On x-ray, the bone typically looks completely back to normal by about 9 years⁸.

A short time in a walking cast may shorten how long symptoms last, but the long-term result is favourable whichever treatment is used². Symptoms can sometimes last several months, and occasionally years⁴. There is no known way to prevent it, and it isn't clear whether it can come back.

What can make it serious?

• Your pain is getting worse, or doesn't settle with rest, less activity or pain relief.
• You have lost weight without trying.
• Your child has a limp that hasn't improved after a week, limps without pain, or doesn't want to put weight on their foot.
• Your child has a fever with a limp or a painful, red, hot or swollen joint, or seems very unwell with foot or leg pain.
• Your child suddenly has severe pain in one joint and is limping.