Köhler's Disease

Köhler's disease typically presents with an insidious painful limp in a young child, often without a clear injury, although minor trauma or a recent increase in activity may be reported. The child tends to walk on the lateral border of the foot to offload the medial arch, producing an antalgic gait. Pain and tenderness are localised to the dorsomedial midfoot, directly over the navicular, and there may be mild local swelling, warmth or redness. Symptoms are usually worse with weight-bearing and activity and ease with rest.

The examination should localise tenderness to the navicular and assess the rest of the foot, along with the joints above and below, to look for alternative sources of pain. The main differentials for medial midfoot pain include a navicular stress fracture, a symptomatic accessory navicular (more often in older children and adolescents, with a medial bony prominence and activity-related pain), tarsal coalition, osteomyelitis, inflammatory arthritis, a retained foreign body and, rarely, malignancy. The key task in any limping child is to exclude the serious causes before settling on a benign diagnosis, so fever, systemic upset, severe or worsening pain, night pain, or a complete inability to weight-bear should prompt urgent assessment for other pathology.

Plain radiographs of the affected foot are first-line and are usually diagnostic. Anteroposterior, lateral and oblique views are appropriate, and weight-bearing views can be added if the child tolerates them, but should not be insisted on in a painful or non-weight-bearing child.

The affected navicular characteristically appears sclerotic and increased in density, flattened into a thin disc, and sometimes fragmented, while the adjacent joint spaces are preserved. The navicular may also look irregular or relatively sclerotic during normal ossification, and a symptomatic accessory navicular is a separate normal variant that usually appears later in childhood, so the diagnosis should never rest on the radiograph alone: the imaging changes must match focal tenderness over the navicular. A contralateral comparison view is not routine and adds radiation to an asymptomatic foot, so it should be reserved for genuine diagnostic uncertainty, suspected bilateral disease, or after senior radiology or orthopaedic discussion.

Further imaging is not usually required. Magnetic resonance imaging (MRI) is reserved for diagnostic uncertainty or to exclude other pathology, and would show marrow changes in keeping with avascular necrosis. Blood tests such as a full blood count (FBC), C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) help when infection or inflammatory arthritis is being considered, but a limping child with fever, systemic upset, severe pain or an inability to weight-bear is not a routine outpatient blood-test scenario. That child needs urgent same-day paediatric or orthopaedic assessment, with inflammatory markers, blood cultures where infection is suspected, and appropriate imaging.

Köhler's disease is managed non-operatively in every case, and the cornerstone is reassurance, since the natural history is benign and the long-term outcome is excellent.

For milder symptoms, relative rest with activity modification, avoiding high-impact activity until pain settles, together with simple analgesia or a non-steroidal anti-inflammatory drug (NSAID) as needed, is usually sufficient. A medial longitudinal arch support or insole can improve comfort during weight-bearing while the bone recovers.

If symptoms are more marked, a below-knee walking cast for about four to six weeks can shorten the duration of symptoms, and is supported by long-standing evidence that casting settles symptoms faster than activity modification alone. If pain persists despite an adequate period of immobilisation, reassess the diagnosis and consider conditions such as tarsal coalition, a symptomatic accessory navicular, fracture or infection, rather than simply extending the cast. There is no role for surgery, injections or other invasive treatments in true Köhler's disease.

Refer to paediatric orthopaedics or a paediatric fracture clinic if the diagnosis is uncertain, if symptoms are severe or prolonged, if immobilisation is needed and cannot be arranged locally, or if red flags are present. Physiotherapy is rarely required, but can help if a gait adaptation persists after the pain has settled.

Recovery is guided by symptoms rather than by the radiographic appearance. As pain settles, the child returns to weight-bearing and then to normal activity and sport at their own pace, with no need to restrict activity once they are comfortable. Most children are symptom-free within a few weeks to several months.

The radiographic reconstitution of the navicular lags well behind clinical recovery and can take up to two to three years to complete, but this does not delay return to activity and need not be confirmed before the child resumes sport. Families should be reassured that the bone reshapes to normal and that long-term problems such as deformity or arthritis are not expected. No specific strengthening or stretching programme is required; the emphasis is on comfort, a graded return to activity, and reassurance.

• •Köhler's disease is a self-limiting osteochondrosis of the navicular with an excellent prognosis, and this benign natural history underpins a conservative, reassurance-based approach.
• •Long-standing comparative evidence shows that a below-knee walking cast shortens the duration of symptoms compared with activity modification alone.
• •National Institute for Health and Care Excellence (NICE) Clinical Knowledge Summaries and Royal College of Emergency Medicine (RCEM) guidance on the limping or unwell child support a structured approach to excluding serious causes before diagnosing a benign condition.
• •Köhler's disease should be distinguished from the normal irregular ossification of the navicular, from a symptomatic accessory navicular, and from Müller-Weiss disease in adults.

• •Köhler's disease is a self-limiting avascular necrosis of the tarsal navicular, classically in boys aged four to seven.
• •The child limps on the lateral border of the foot, with tenderness over the dorsomedial midfoot.
• •Foot radiographs show a sclerotic, flattened, sometimes fragmented navicular, but a normal navicular can also ossify irregularly, so correlate with focal tenderness.
• •Management is always non-operative; a below-knee walking cast for four to six weeks shortens symptom duration in more painful cases.
• •The prognosis is excellent, with the navicular reossifying and remodelling to normal over months to a few years.
• •In any limping child, exclude septic arthritis, osteomyelitis, fracture, inflammatory arthritis and malignancy before settling on Köhler's disease.