Peer Reviewed

What's Your Diagnosis?

What Is Causing a 5-Year-Old Boy’s Limp?

Laura R. Meidl
Natalie C. Stork, MD
Julia G. Harris, MD
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  • Answer: Kӧhler disease

    The radiograph revealed sclerosis and decreased height of the right navicular, consistent with Kӧhler disease (Figure 1). The patient was referred to orthopedics. Treatment options of observation versus casting were discussed with the family, and observation with 6-month follow-up radiographs was the chosen plan.

    Kӧhler disease

    Figure 1. Radiograph of right foot with sclerosis and decreased size of the right navicular bone.

    DISCUSSION

    Kӧhler disease is an osteochondrosis of the tarsal navicular bone.1 This syndrome occurs more commonly in males, with an average age of onset between 2 and 9 years.1,2 Necrosis of the ossification center in the navicular may be caused by decreases in blood supply due to compression by the talus and cuneiform bones.2 Trauma may also play a role in this disease, but the exact etiology remains unclear.2

    The most common presenting complaint is medial foot pain and limp, generally worse with weight-bearing physical activity.1,2 There may be tenderness, swelling, and/or erythema over the dorsum and/or medial aspect of the foot.1,2 The child may walk on the lateral aspect of the affected foot.1

    Diagnosis is made by clinical examination and radiographic findings. On radiographs, the navicular may appear sclerotic, fragmented, and flattened.1,2 Kӧhler disease is unilateral in 75% to 85% of cases,2,3 so it is helpful to obtain radiographs of both feet for comparison.1 It is important to note that a fragmented-appearing tarsal navicular bone in the toddler age range may be considered a normal ossification variant if the clinical picture is not consistent with Kӧhler disease.4 Laboratory studies are not necessary unless there is high suspicion for infection.

    Kӧhler disease is self-limited and will generally resolve as the navicular bone regenerates (between 4 months to 4 years).5 Treatment is variable and based on symptomatic relief. Immobilization with a short-leg walking cast may decrease symptom duration.6 Additional treatment may include rest, ice, analgesics, and orthotics.1,5,7 Consider referral to an orthopedic physician if diagnosis is unclear, if there is persistent pain, and/or if the patient’s family wishes to try casting.   

    References:

    1. Gillespie H. Osteochondroses and apophyseal injuries of the foot in the young athlete. Curr Sports Med Reps. 2010;9(5):265-268.

    2. Tuthill HL, Finkelstein ER, Sanchez AM, Clifford PD, Subhawong TK, Jose J. Imaging of tarsal navicular disorders: a pictorial review. Foot Ankle Spec. 2014;7(3):218-219.

    3. Stanton BK, Karlin JM, Scurran BL. Kohler’s disease. J Am Podiatr Med Assoc.. 1992;82(12):625-629.

    4. Mosca VS. The Foot. In: Weinstein SL, Flynn JM, eds. Lovell & Winter’s Pediatric Orthopaedics. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2013:1491-1492.

    5. Borges JL, Guille JT, Bowen JR. Kӧhler's bone disease of the tarsal navicular bone. J Pediatr Orthop. 1995;15(5):596-598.

    6. Williams GA, Cowell HR. Kӧhler’s disease of the tarsal navicular. Clin Orthop Relat Res. 1981;158:53-58.

    7. Ippolito E, Pollini R, Falez F. Köhler's disease of the tarsal navicular: long-term follow-up of 12 cases. J Pediatr Orthop. 1984;4(4):416-417.