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Updated: Nov 2 2022

Kohler's Disease


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  • summary
    • Kohler's Disease is a rare idiopathic condition caused by avascular necrosis of the navicular bone that occurs in young children and presents with pain on the dorsal and medial surface of the foot.
    • Diagnosis is made with radiographs of the foot showing sclerosis, fragmentation, and flattening of tarsal navicular bone.
    • Treatment is usually nonoperative with NSAIDs and a short period of cast immobilization as the condition typically resolves over time. 
  • Epidemiology
    • Demographics
      • occurs in young children (usually age 4-7 yrs)
      • four times more common in boys than girls
        • 80% of cases in boys
    • Anatomic locations
      • can be bilateral in up to 25% of cases
  • Etiology
    • Pathophysiology
      • the blood supply of the central one third of the navicular is a watershed zone
        • accounts for the susceptibility to avascular necrosis and stress fractures
      • the navicular is the last bone to ossify
        • increases its vulnerability to mechanical compression and injury
    • Associated conditions
      • infection
        • Kohler's disease is often misdiagnosed as infection
  • Classification
    • There is no widely used classification system for this condition
  • Presentation
    • History
      • patient may not have complaints as disease can be asymptomatic
      • characteristically described as midfoot pain with an associated limp
    • Symptoms
      • pain in dorsomedial midfoot
      • may have swelling, warmth, and redness
      • point tenderness over the navicular
    • Physical exam
      • antalgic limp (may place weight on lateral side of foot)
  • Imaging
    • Radiographs
      • characteristic sclerosis, fragmentation, and flattening of tarsal navicular
      • most tarsal navicular bones reorganize after disease has run its course
        • some continue to be deformed but almost all of those remain asymptomatic
  • Treatment
    • Nonoperative
      • NSAIDs
        • short course can be used to decrease symptoms
      • immobilization with short leg walking cast
        • indications
          • pain with activities
        • outcomes
          • studies have shown treatment in a short leg walking cast will decrease the duration of symptoms
          • radiographs improve at around 6-48 months from onset of symptoms
          • no reports of long-term disability
    • Operative
      • surgery
        • indications
          • not indicated for this disease
  • Prognosis
    • Typically a self-limiting condition
    • Intermittent symptoms for 1-3 years after diagnosis
      • typically associated with activity
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