Köhler disease

In summary: Köhler’s disease is a condition affecting the navicular bone, common in children, which causes midfoot pain and usually has a very good prognosis. We manage it with offloading and monitoring until the bone normalises. In Martorell, Barcelona (Teknon) and Igualada.

Köhler’s disease is an osteochondrosis of the navicular bone: the bone temporarily loses its blood supply, becomes denser, and is painful while it reorganises. It occurs mainly in childhood and, with patience, the bone eventually recovers its shape and function.

The navicular is a small bone located on the inner side of the midfoot, between the ankle and the bones that make up the forefoot. It plays an important role in the arch of the foot and in load transmission when we walk. During a growth stage, its blood supply can be particularly vulnerable. When this happens, the bone may undergo temporary changes that cause pain and difficulty bearing weight.

It is not an infection, nor is it usually the result of a specific knock. Sometimes it appears after a period of physical activity or overuse, but there is not always a clear trigger. The fact that a child has flat feet or a particular way of walking does not, on its own, allow for a diagnosis. It is necessary to assess the overall symptoms and physical examination.

What symptoms may it present

The most common symptom is pain on the inner side of the midfoot, especially when the child walks, runs, or jumps. It can start gradually and worsen with activity. Some children limp, avoid bearing weight on the affected foot, or stop participating in games and sports they previously did normally.

There may also be tenderness when pressing on the navicular area and some swelling. In general, significant visible deformity or systemic symptoms are not common. If the pain is severe, appears after major trauma, if there is a fever, marked redness, or the child cannot bear weight on the foot, it is advisable to seek medical assessment without delay.

The disease usually affects only one foot, although this is not an absolute rule. The pain can be confused with a sprain, overuse, a stress fracture, or other causes of midfoot pain. For this reason, especially if it persists or limits activity, it is preferable not to simply attribute it to growing pains.

How we diagnose it

During the consultation, we listen and ask when the pain started, which activities trigger it, and whether there has been a knock. We then observe the way the child walks and bears weight on the foot, check the movement of the ankle and foot, and pinpoint the painful area precisely. We also compare both feet and assess whether there is inflammation, stiffness, or alignment abnormalities.

An X-ray is often the main test. It may show that the navicular is denser, flatter, or irregular during the active phase of the process. These changes must be interpreted taking into account the age and examination, as an image alone does not always explain the intensity of the pain.

Depending on the case, we may complete the assessment with an ultrasound, especially to examine the soft tissues and rule out other sources of pain. A gait analysis study can also be useful when we want to understand how loads are distributed or if there is a functional abnormality contributing to the overload. Not all tests are necessary for all children.

How we manage it

The goal is not to “cure” a bone that already tends to recover on its own, but to make the pain manageable and prevent the child from stopping moving. Adequate offloading —often using custom orthotics— and monitoring the progression are usually sufficient. In adults, if we suspect Freiberg’s disease in the forefoot, the approach changes and we will detail this during the consultation.

The first step is usually to temporarily reduce activities that cause pain: running, jumping, or playing impact sports. Not all cases require immobilisation. We want the child to maintain comfortable activity, without forcing the foot or turning the pain into an endurance test.

Footwear also matters. It must support the foot well, have a stable sole, and allow the toes to move. In some cases, an orthotic can help distribute loads better and reduce pressure on the navicular. Its prescription depends on the examination and the way the child walks; not all orthotics serve the same purpose.

If the pain is more intense or walking becomes difficult, we may consider temporary immobilisation with a boot or another offloading system. This decision is made individually, depending on the symptoms, tenderness in the area, and progression. Any measure must allow for a review of the child to confirm that the pain is improving.

Monitoring serves to control symptoms, adjust the offloading, and confirm that the bone is progressing as expected. Imaging may continue to show changes while the child is already feeling better; therefore, we always assess the clinical presentation alongside the test results. Recovery is progressive, and it is not advisable to rush the return to impact activities if there is still pain.

Surgery is exceptional in childhood Köhler’s disease. If the pain does not follow the expected progression, if the test results do not fit the diagnosis, or if other signs appear, we review the case and rule out different causes. In adults, pain in the navicular or forefoot may have other origins and may require specific investigation and treatment.

Contact us if the pain persists, recurs, alters the way the child walks, or prevents them from carrying out normal daily activities. An early assessment allows us to confirm what is happening, reassure the family, and choose the most appropriate offloading strategy without restricting the child more than necessary.