Köhler Disease
A 5-year-old male with medial foot pain. Diagnosis? Eponym? • Radiology Case of the Week
Figure 1. 5-year-old male with medial foot pain. Diagnosis? Eponym?
Figure 2. Radiographs of the foot (A–C) show thinning and mild fragmentation of the navicular (red arrows) with extensive sclerosis throughout and mild overlying soft tissue swelling. Diagnosis: Köhler disease.
Epidemiology
Köhler disease is a rare, self-limiting osteonecrosis of the tarsal navicular in children. It typically presents between 4 and 7 years of age, although onset as early as 2 years has been described [1,2]. Boys are affected more often than girls, with StatPearls citing a roughly five-fold male predominance [1]. The disease is usually unilateral, and about 25% of cases are reported to be bilateral [1].
Clinical Findings
Children present with pain and swelling of the dorsomedial midfoot [3]. Examination may show point tenderness over the navicular, with or without redness, warmth, or swelling. Affected children often have an antalgic limp, bearing weight along the lateral foot [4]. A blood count and inflammatory markers are obtained when infection is suspected.
Pathology The cause remains uncertain. The navicular is the last tarsal bone to ossify. As the child grows heavier, it may be compressed between the talus and cuneiforms, compromising its blood supply and causing central ischemia. Delayed ossification may contribute, and the central third of the navicular is a watershed area prone to avascular necrosis.
Radiographic Features
Plain radiographs are the imaging modality of choice. The navicular may appear thinned (wafer-like), flattened or collapsed, and fragmented, with patchy sclerosis, loss of the normal trabecular pattern, and overlying soft tissue swelling. Fragmentation should not be mistaken for a fracture. CT and MRI are usually unnecessary but may be considered if pain persists or the diagnosis is unclear. If symptoms persist, tarsal coalition should be considered [5,6]. In this patient, the navicular is thinned and mildly fragmented with extensive sclerosis and mild soft tissue swelling, consistent with Köhler disease.
Treatment and Prognosis
Management is conservative, and surgery is not indicated. A short leg walking cast for 4 to 6 weeks may shorten symptom duration. In one series, symptoms lasted an average of 15 months without casting and less than 3 months with a short leg cast [5]. At an average follow-up of 31.5 years, treatment did not affect the final outcome [6]; in another series, all 12 patients were asymptomatic at an average of 33 years [7]. Radiographic improvement typically occurs 6 to 48 months after symptom onset.
Conclusion
Köhler disease is a self-limiting osteonecrosis of the tarsal navicular in young children, most often boys, who present with medial midfoot pain, that worsens with weight bearing. Radiographs showing a thin, fragmented, sclerotic navicular establish the diagnosis. Management is conservative, and the prognosis is usually excellent.
References:
Trammell AP, Davis DD, Scott A. Kohler Disease. In: StatPearls. Treasure Island (FL): StatPearls Publishing; August 7, 2023. https://pubmed.ncbi.nlm.nih.gov/29939608/
Shastri N, Olson L, Fowler M. Kohler's Disease. West J Emerg Med. 2012;13(1):119 120. DOI: 10.5811/westjem.2011.1.6691
Holley KW, Price BJ, McCormick WF Jr, Littlefield ZL, Green BM. Kohler Disease With Concurrent Avascular Necrosis of the Medial Cuneiform: A Report of Two Cases. Cureus. 2025;17(8):e89411. Published 2025 Aug 5. DOI: 10.7759/cureus.89411
Achar S, Yamanaka J. Apophysitis and Osteochondrosis: Common Causes of Pain in Growing Bones. Am Fam Physician. 2019;99(10):610-618. https://pubmed.ncbi.nlm.nih.gov/31083875/
Williams GA, Cowell HR. Köhler's disease of the tarsal navicular. Clin Orthop Relat Res. 1981;(158):53-58. https://pubmed.ncbi.nlm.nih.gov/7273526/
Borges JL, Guille JT, Bowen JR. Köhler's bone disease of the tarsal navicular. J Pediatr Orthop. 1995;15(5):596-598. DOI: 10.1097/01241398-199509000-00009
Shastri N, Olson L, Fowler M. Kohler's Disease. West J Emerg Med. 2012;13(1):119 120. DOI: 10.5811/westjem.2011.1.6691
Umaiza Ihsan, MD is a medical graduate of King Edward Medical University, Pakistan. She completed her internship at Mayo Hospital, Lahore, including a three month rotation in Radiology, which further strengthened her interest in diagnostic imaging. She has gained additional clinical exposure in Radiology through observerships at Mon Health Morgantown and the University of Maryland, Baltimore. She has a strong interest in Radiology, particularly diagnostic imaging and its role in clinical decision making, and is actively interested in clinical research, with experience in systematic reviews and medical research. All posts by Umaiza Ihsan, MD
Kevin M. Rice, MD is the president of Global Radiology CME and is a radiologist with Cape Radiology Group. He has held several leadership positions including Board Member and Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator. He was once again a semifinalist for a "Minnie" for 2021's Most Effective Radiology Educator by AuntMinnie.com. He has continued to teach by mentoring medical students interested in radiology. Everyone who he has mentored has been accepted into top programs across the country including Harvard, UC San Diego, Northwestern, Vanderbilt, and Thomas Jefferson.
Follow Dr. Rice on Twitter @KevinRiceMD
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