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Kohler's Disease

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Other Names

  • Avascular Necrosis of the Navicular
  • Aseptic Necrosis of the tarsal navicular

Background

  • Osteochondrosis is the process of necrosis of the ossification center of bone followed by regeneration
  • Occurs in children 2-7 yo
  • Occurs in males > Females (4x more common in males)
  • Bilateral in 15-25% of cases

Pathophysiology

  • Vascular supply for the central 1/3rd of the navicular is a watershed zone
    • Increased susceptibility to avascular necrosis and stress fractures
  • Navicular is the last bone to ossify
    • Typical ossification between 18-24 mo in girls; 30-36 mo in boys
    • More common to have later ossification in those with more than 1 ossification center in navicular
    • Increases the opportunity for mechanical compression and injury
    • Results in a dense and irregular navicular



Risk Factors

  • Repetitive micro-trauma to the maturing navicular
  • Delayed ossification
  • Compression of the bony nucleus at critical phases of growth



Clinical Features

  • Pain over the mid-foot
  • Repetitive micro trauma (sports)
  • Pain or limp which occurs over days to months
  • Localized edema and warmth over the navicular
  • ROM of ankle and subtalar joints will be normal

Differential Diagnosis

  • Normal variants
  • Osteochondritis dissecans
  • Fracture
  • Infection

Evaluation

  • X-rays
    • AP, lateral, and oblique
    • Findings of navicular sclerosis, flattening of the navicular, loss of trabecular pattern, and fragmentation
  • Bone scintigraphy
    • Decreased uptake at the navicular show interrupted blood supply in early phases
    • Increased uptake in later phases show revascularization

Classification


Management

  • Self-limited condition
  • Ice to midfoot
  • NSAIDS and Tylenol
  • Immobilization with short leg walking cast for at least 8 weeks (decreases symptoms by ~1 year though does not change outcomes)
    • May continue to be weight bearing as does not effect outcomes
  • PT not indicated
  • Orthotics not effective
  • Surgery rarely required
  • Orthopedic referral if not resolved with conservative management

Return to Play

  • Return to play once symptoms have resolved

Complications

  • Intermittent symptoms for 1-3 years after diagnosis
  • No increased rate of arthritis or chronic foot problems
  • Complete resolution of symptoms with reconstitution of navicular in all patients
  • No evidence of cartilage degeneration

See Also


References

Created by:
John Kiel on 30 June 2019 20:56:07
Last edited:
7 April 2020 15:47:46
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