The patient presented with pain and swelling over his right foot.
The patient presented with pain and swelling over his right foot.
Plain radiographs of his foot (two views) were performed. Plain films showed a dense navicular bone with evidence of fragementation, consistent with changes of osteochondritis of the navicular - Koehler's disease.
Koehler's disease, first described in 1908, is a self-limiting condition of the tarsal navicular associated with flattening, sclerosis and irregular rarefaction. It is relatively rare(incidence described to occur in 1-2 %), occuring more frequently in boys (6:1 as compared with females). It commonly occurs between the ages of 3 and 7 years, and 75-80% of cases occur unilaterally. Few cases give a history of trauma.
Radiographically, early changes are seen as an increase in density, nodularity and fragmentation with multiple ossific nuclei. Soft tissue swelling may be present. The navicular bone is diminished in size and flattened, giving a wafer-like appearance. However, the space between the navicular and the adjacent bones can be maintained. There is overlap with normal patterns of ossification leading to difficulty in diagnosis. However, diagnosis is made if the changes are detected in a previously normal navicular bone and there are findings of resorption and reossification of Koehler's disease. A comparison view of the other foot may be helpful since developmental normal variants can mimic changes of osteochondritis and are frequently bilateral. Bone scintigraphy may show decreased uptake in Koehler's disease.
The disease is self-limiting with the radiographic changes reversible. Spontaneous or post-traumatic osteonecrosis of the navicular bone seen in adults is unrelated to Koehler's disease.
Koehler's disease
Based on the provided X-ray films of the right foot in the AP (and lateral if visible) views, there is a notable increase in density, irregular shape, and local flattening in the region of the tarsal navicular, appearing as a “thin-slice” change. Mild soft tissue swelling may be present. The surrounding joint spaces are relatively preserved, and there is no obvious fracture line or soft tissue calcification. Compared to the contralateral side (if available), the changes in navicular shape and density on the affected side are more pronounced.
Based on the child’s age (8 years), clinical symptoms (foot pain and swelling), imaging findings (increased navicular density, flattening, fragmentation), and the self-limiting nature of the condition, the most likely diagnosis is Koehler’s Disease. This condition usually resolves spontaneously during childhood and gradually returns to normal bone structure.
1. Conservative Treatment: Since Koehler’s disease is usually self-limiting, management may include using foot orthoses or cast immobilization to reduce weight-bearing, and oral non-steroidal anti-inflammatory drugs (NSAIDs) for pain relief. Many patients show gradual improvement with rest and symptomatic treatment.
2. Follow-up and Symptom Evaluation: Regular follow-up X-ray examinations of the foot are recommended to monitor changes in the navicular’s shape and density and to assess the progress of bone remodeling. If symptoms worsen or persist, further evaluation to rule out other potential causes is advisable.
3. Rehabilitation and Exercise Prescription (FITT-VP Principle):
● Initial Phase: Focus on reducing stress and swelling. Low-impact activities such as swimming or simple non-weight-bearing exercises (e.g., supine straight leg raises, mild ankle exercises) are recommended. Frequency: 2-3 times per week, 15-20 minutes each session, with low intensity so that the child can complete them comfortably.
● Progression Phase: Once pain and swelling have significantly improved, gradually increase weight-bearing time and intensity under the protection of orthoses or braces, such as short-distance walking or static squat balance training. Frequency: 3-4 times per week, 20-30 minutes each session.
● Strengthening Phase: When recovery is better, introduce gentle jumping and slow running exercises, closely monitoring pain and swelling. Frequency: 3-5 times per week, around 30 minutes each session, keeping intensity at a level that does not cause significant discomfort.
● Individualized Adjustment: If there are any comorbidities or the patient’s foot bones are more fragile, reduce impact accordingly. If necessary, seek individualized guidance from a professional rehabilitation therapist or physician.
Disclaimer: The above report is for reference only and cannot replace a face-to-face consultation or professional medical advice. If you have any further questions, please consult an orthopedic or foot and ankle specialist promptly.
Koehler's disease
