A 6-year-old girl was referred to our hospital with persistent localised midfoot pain and limp a few weeks ago. No history of trauma was reported. No ecchymosis, bruising or bleeding was observed. Plain radiography was assisted to exclude coalition of tarsal bones. MRI was suggested due to plain radiography findings.
Anteroposterior and lateral plain radiography (Fig. 1) of foot and ankle were obtained. A sclerotic, collapsed and fragmented tarsal navicular bone was depicted. Kohler’s disease was the most probable diagnosis. The MR imaging examination was performed with a 1.5 Tesla scanner using standard sequences. The fat suppressed axial PD-w MR image shows diffuse high signal intensity in keeping with bone marrow oedema as well as cystic appearance at the lateral fragmented side (Fig. 2). The fat suppressed contrast enhanced sagittal T1-w MR image shows moderate and homogenous enhancement of the talar navicular indicating viability of the bone marrow (Fig. 3).
Kohler’s disease is an uncommon idiopathic transient avascular necrosis of the talar navicular bone. The disease is affecting usually children around 4-6 years old. It is commonly unilateral, 2 to 3 times more frequent in boys than in girls in whom it could appear at a younger age. Kohler’s disease occurs when arterial supply is disrupted. Talar navicular bone avascular necrosis is thought to be associated with the fact that is the last bone to be ossified in the tarsus. This normal delay in ossification may result in the vulnerability of the navicular bone to withstand regular loads [1, 2].
Children present clinically with limp and moderate midfoot pain. Laboratory examinations are normal and usually there is no history of trauma. Imaging can diagnose the presence of Kohler’s disease and exclude other entities such as various types of coalition [2].
In plain radiographs, flattening, fragmentation and osteosclerotic navicular combined with the young age indicate the proper diagnosis [1, 2]. In addition, MR imaging can depict bone marrow oedema in keeping with the pain as well as the viability of the bone in case that enhancement is observed after intravenous contrast administration. The final diagnosis is based on the age of the patient, the clinical history and the imaging findings.
The treatment is symptomatic. Our patient was treated with below-the-knee-walking cast for 4 weeks and after removing there was slow and progressive return to prior activities. The overall outcome was excellent. Imaging in the case presented herein was useful in terms of excluding other pathology such as bone coalition, which would require surgical treatment [2, 3].
In young children with midfoot pain and no history of trauma, Kohler’s disease should be added to the differential diagnostic list because it is self-limited with an excellent prognosis.
Kohler’s disease
According to the provided X-ray and MRI images, an abnormal local morphology can be seen in the right navicular bone (talar navicular bone), presenting as:
These imaging findings are consistent with bony changes caused by impaired blood supply to the navicular bone, and there are no clear signs of coalition.
Based on the patient’s age, medical history, and imaging findings, the following diagnoses can be considered:
Considering the patient’s age (6 years), clinical symptoms (midfoot pain, limping), no history of trauma, and imaging findings (navicular flattening, sclerosis, fragmentation, and bone marrow edema), the most likely diagnosis is:
Juvenile Navicular Avascular Necrosis (Köhler’s disease)
This condition is generally self-limiting, and complete recovery is often achieved with conservative management.
Treatment Strategy:
Rehabilitation/Exercise Prescription Suggestions (FITT-VP Principle):
During rehabilitation, regular evaluations of foot pain, function, and local stability should be performed. If there is a significant increase in pain or other abnormalities, return for follow-up or adjust the rehabilitation program as needed.
This report is a reference-based medical analysis based on the current available data. It does not replace in-person consultation or professional medical advice. Specific diagnosis and treatment plans require comprehensive evaluation by qualified physicians, integrating clinical examinations, laboratory tests, and other specialized diagnostic results.
Kohler’s disease
