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What is Kohler disease?
Symptoms
Causes
Diagnosis
Treatment
Prevention
Complications
FAQs

Kohler disease causes foot pain at the front of the ankle, and affects children most often between the ages of three and seven years. 

What Is Kohler Disease?

Kohler disease is a condition seen in children where the blood flow to a bone called the navicular, which is located right in front of the ankle (on the inside edge of the foot), is interrupted. As our bones rely on good blood flow to stay healthy and strong, having an insufficient blood supply in this area can lead to bone damage, including microcracks (stress fractures) in the bones. This can be painful, uncomfortable and limiting in terms of the ability to stay mobile and active.

Kohler disease is a type of avascular necrosis, where the blood supply is limited to an area for some time - often months or years - before bone tissue death occurs. The navicular bone already naturally has poorer vascularisation, making it vulnerable. Our podiatrists see Kohler disease most often in young children. It usually affects just one foot and is seen in boys more than girls by up to five times. It is also commonly misdiagnosed for other causes of ankle pain or infection.

Symptoms Of Kohler Disease

The symptoms of Kohler disease tend to come on gradually over time, making it easy to overlook the symptoms until they can no longer be ignored. It also means that children often can’t identify an event or moment where their symptoms started, instead mentioning that their foot has been sore “for a while”. Symptoms can include:

• Foot pain and swelling
  
• Redness or warmth in the area in front of the ankle
  
• Pain radiates along the arch, as well as being present at the front of the ankle at the affected bone
  
• Difficulty putting weight on the foot, leading to limping when walking
  

Causes Of Kohler Disease

While the exact cause of Kohler disease has not been identified in the research, it is thought to be caused by overloading and excessively stressing the navicular bone, leading to the reduced blood supply to the area. The navicular is actually the last of all of the tarsal bones (located in the midfoot) to ossify and harden. As it hardens more slowly, it remains weaker than the surrounding tarsal bones, meaning that when the area is placed under strain, it is the navicular that will be compressed between the ‘harder’ and stronger bones. Overloading and straining the navicular affects the vessels to and within the bone, which interrupts or impairs the blood supply to the area. Contributing factors to the injury may include:

• An ankle or foot injury
  
• Gaining weight in childhood which further compresses a weakened navicular bone
  
• Genetic factors
  
• Abnormalities of the navicular bone
  

Diagnosing Kohler Disease

While a clinical assessment is enough to strongly suspect Kohler’s, it will be important to get medical imaging, such as an x-ray of the foot and ankle, to confirm the diagnosis. What we look for on an x-ray is flattening, sclerosis (hardening) or fragmentation of the navicular bone. Interestingly, the navicular does tend to ‘reorganise’ over time.

Treating Kohler Disease

While Kohler disease is self-limiting, meaning that it does resolve over time (on average, 6-12 months), it can be exceptionally difficult for a parent to watch their child in pain or limping day after day, which is why we work closely with many children and their parents to help best manage the symptoms and monitor their progress. 

While you’re at home with your child, painkillers (non-steroidal anti-inflammatory medication) may be used, under advice from your doctor, to help manage the pain. We also recommend modifying existing physical activities to avoid further straining and overloading the navicular bone, and engaging in some much-needed rest instead. To help, our Brisbane podiatrists may use:

• A moon boot, walker or brace immobilisation: in some cases, particularly if the pain is severe and significantly interfering with daily life, it may be best to offload and immobilise the foot and ankle using a boot or brace, which our podiatrists can prescribe.
  

• Custom foot orthotics: custom-made foot orthotics can go a long way in helping to offload the navicular while keeping the foot and ankle stable and supported - and moving as comfortably as possible.
  

• Footwear recommendations: we’re always happy to recommend the best shoes for your child’s foot type and characteristics so that they can get the best support and comfort. These shoes will work as a team with your child’s orthotics (if indicated) to help reduce their pain and improve their mobility and comfort. We can also make modifications to your child’s existing footwear to help.
  

Surgery is not indicated in the management of Kohler’s disease. The outlook for those diagnosed with Kohler disease is very positive, with most making a full recovery.

Prevention Tips For Kohler’s

While it may not be possible to completely prevent Kohler’s disease given that children love to be active on their feet, minimising stress on the navicular bone as much as possible during its vulnerable developmental stages may help. You can try:

• Encouraging proper footwear use. Ensure that your child wears supportive and well-fitted shoes that provide cushioning and stability as much as possible, especially during physical activities.
  

• Limit high-impact activities. Reduce the frequency and intensity of activities that involve repetitive stress on the feet, such as running or jumping, particularly during the ages when Kohler disease is more common (3 to 7 years old).
  

• Promote balanced physical activity. Encourage your child to participate in a variety of low-impact activities that promote overall physical fitness without placing excessive strain on the feet. Swimming, bike riding, and non-competitive sports can be good alternatives.
  

• Monitor for signs of foot discomfort. Pay attention to any complaints of foot pain, limping, or reluctance to participate in physical activities, especially in young children who may not communicate their symptoms clearly.
  

• Ensure proper nutrition. Adequate intakes of calcium, vitamin D, and other essential nutrients are crucial for bone health. A balanced diet rich in dairy products, leafy greens, and fortified foods can support healthy bone development.
  

• Book in for treatment early. If a child experiences persistent or worsening foot pain, seek medical attention promptly for proper evaluation and management. Early detection and treatment of foot abnormalities can help prevent complications and long-term consequences.
  

Complications Of Kohler Disease

Kohler disease typically resolves spontaneously, but in some cases, complications may arise. These complications can include chronic foot pain, altered gait patterns, and foot deformities such as flat feet. Children with Kohler disease may experience limitations in physical activities and may face psychosocial challenges due to pain and functional restrictions. 

Frequently Asked Questions

What age does Kohler disease typically occur?

Kohler disease typically affects children between the ages of 3 and 7 years old, with peak incidence around 4 years of age.

Is Kohler disease permanent?

Kohler disease is usually not permanent and tends to resolve spontaneously as the affected navicular bone matures and remodels.

Can Kohler disease affect both feet?

Yes, Kohler disease can affect both feet simultaneously or independently.

What can I do to alleviate the pain associated with Kohler disease?

To alleviate pain associated with Kohler disease, you can encourage your child to rest as much as possible, applying ice packs to the ankle, and wearing supportive footwear. You can also use pain killers (non-steroidal anti-inflammatories) as per the guidance by your doctor.

How long does it take for Kohler disease to heal?

The healing time for Kohler disease varies, but symptoms typically improve within several months to a year as the navicular bone heals and matures. Most, if not all, cases of Kohler disease we have seen have resolved within 2 years.