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Kohlers Disease

From WikiSM

Other Names

  • Avascular Necrosis of the Navicular
  • Aseptic Necrosis of the tarsal navicular
  • Osteochondrosis of the tarsal navicular
  • Kohlers Disease
  • Kohler's Disease

Background

  • This page refers to avascular necrosis of the navicular, eponymously termed Kohler's Disease

History

  • First case published in the literature by Kohler in 1908[1]

Epidemiology

  • Occurs in children 2-7 yo
  • Occurs in males > Females (4x more common in males)
  • Bilateral in 15-25% of cases

Introduction

Illustration of the navicular
Classic radiographic appearance of Kohler's disease (left) compared to a normal navicular (right)[2]

General

  • This is a rare, idiopathic and self-limited cause of foot pain in children
  • Diagnosis is made with plain radiographs of the foot
  • Management is non-surgical with a brief period of immobilization and typically full recovery

Etiology

  • Not well understood
  • One Hypothesis[3]
    • Because it is the last tarsal bone to ossify, it is susceptible to mechanical compression
    • The talus and cuneiform bones are already ossified
    • Blood vessels are compressed, resulting in ischemia and avascular necrosis
  • Second hypothesis
    • Delayed bone age has been noted in some 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

Anatomy of the Navicular

Risk Factors

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

Differential Diagnosis

Differential Diagnosis Foot Pain

Clinical Features

History

  • Pain over the mid-foot
  • Some sort of history of repetitive microtrauma (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

Physical Exam: Physical Exam Foot

  • Swelling may be seen over the navicular, with or without erythema
  • The navicular bone is typically very tender

Special Tests

  • Needs to be updated

Evaluation

a, b Lateral (a) and anteroposterior (b) foot radiographs demonstrate sclerosis, collapse and fragmentation of the navicular (arrow). c Sagittal post-gadolinium T1-weighted MR image shows decreased signal intensity and lack of enhancement within the navicular (arrow) as well as surrounding increased enhancement within the soft tissues, corresponding to inflammation[4]
Köhler disease in a 7-year-old boy with a limp. (a) Sagittal T1-weighted MR image of the foot shows a small low-signal-intensity ossification center in the navicular (arrow) (b) Sagittal postcontrast T1-weighted MR image demonstrates absence of enhancement in the navicular (arrow) and edema in the surrounding soft tissues (arrowhead).[5]

Radiographs

  • Standard Radiographs Foot
  • Findings
    • Navicular sclerosis
    • Flattening of the navicular/ wafer like
    • Loss of trabecular pattern
    • Fragmentation
    • Often associated soft tissue swelling

CT

  • Cross sectional imaging not usually required to make the diagnosis
  • Can be obtained if pain is persistent or diagnosis is unclear

MRI

  • Cross sectional imaging not usually required to make the diagnosis
  • Can be obtained if pain is persistent or diagnosis is unclear

Bone Scintigraphy

  • Decreased uptake at the navicular show interrupted blood supply in early phases
  • Increased uptake in later phases show revascularization

Classification

  • Needs to be updated

Management

Non-Operative

  • Self-limited condition
  • Ice to midfoot
  • NSAIDS and Tylenol
  • Immobilization with short leg walking cast
    • Duration for at least 8 weeks
    • Decreases symptoms by ~1 year though does not change outcomes
    • May continue to be weight bearing as does not affect outcomes
  • PT not indicated
  • Orthotics not effective

Surgical

  • Surgery rarely required
  • Orthopedic referral if not resolved with conservative management

Rehabilitation and Return to Play

Rehabilitation

  • Needs to be updated

Return to Play

  • Return to play once symptoms have resolved

Prognosis and Complications

Prognosis

  • Use of walking casts
    • Patients with cast application had complete resolution at 3 months
    • Patients treated without casts had complete resolution at 10 months
  • Overall prognosis is excellent
    • Almost all patients have complete resolution of symptoms between 4 months and 4 years[6]

Complications

  • Complications are rare
  • Patient with persistent symptoms who have been treated correctly need to be evaluated for other causes of foot pain

See Also

Internal

External

References

  1. ↑ Ely, Leonard W. "Köhler's Disease." Archives of Surgery 16.2 (1928): 560-568.
  2. ↑ Image courtesy of podiatryhq.com.au
  3. ↑ Shastri, Nirav, Lauren Olson, and Milton Fowler. "Kohler's disease." Western Journal of Emergency Medicine 13.1 (2012): 119.
  4. ↑ West, Elizabeth Yuan, and Diego Jaramillo. "Imaging of osteochondrosis." Pediatric radiology 49.12 (2019): 1610-1616.
  5. ↑ Jaimes, Camilo, et al. "MR imaging of normal epiphyseal development and common epiphyseal disorders." Radiographics 34.2 (2014): 449-471.
  6. ↑ Borges, Jorge Luiz P., James T. Guille, and J. Richard Bowen. "Köhler's bone disease of the tarsal navicular." Journal of Pediatric Orthopaedics 15.5 (1995): 596-598.
Created by:
John Kiel on 30 June 2019 20:56:07
Last edited:
1 June 2025 14:29:35
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