Kohler’s Disease: Avascular Necrosis of the Navicular in Children

Quick answer: Kohlers Disease Navicular Avascular Necrosis Children 2 is a clinical condition that responds to evidence-based treatment when caught early. Symptoms include pain, swelling, and altered function. Diagnosis requires clinical exam, often imaging. Treatment ladder: conservative care first (4-6 weeks), then targeted interventions if needed. Call (810) 206-1402.

Medically reviewed by Dr. Tom Biernacki, DPM — Board-Certified Podiatric Surgeon — Balance Foot & Ankle, Howell & Bloomfield Hills, MI. Last updated April 2026.

What Causes Kohler Disease

The navicular is the last tarsal bone to ossify, typically beginning at age 3-4 in boys and 2-3 in girls. During this ossification window, the navicular is vulnerable because it is compressed between the already-ossified talus and cuneiforms while its blood supply is establishing through a single entry point.

The exact etiology remains debated, but the leading theory involves mechanical compression of the immature navicular’s blood supply during peak body weight loading. The navicular bears significant compressive force as the keystone of the medial longitudinal arch. When the developing vascular network is transiently disrupted, avascular necrosis follows.

Kohler disease affects boys 4-5 times more frequently than girls, likely because boys ossify later and are typically more physically active during the vulnerable period. In our clinic, we typically see 3-5 cases per year, most commonly in active 4-6 year old boys whose parents notice a limp that developed without clear injury.

Symptoms and Diagnosis

The classic presentation is a limping child with medial midfoot pain and no history of trauma. The child may walk on the lateral edge of the foot to offload the medial arch. Palpation over the navicular produces tenderness, and there may be mild local swelling. Weight-bearing reproduces the pain.

Standing AP foot X-rays are diagnostic. The affected navicular appears sclerotic (dense and white), fragmented, and flattened compared to the normal side. The navicular may be coin-shaped or wafer-thin on the lateral view. Comparison films of the opposite foot are helpful but not always necessary when the findings are classic.

MRI is generally unnecessary for typical presentations. It is reserved for atypical cases, older children (where Mueller-Weiss disease — the adult equivalent — enters the differential), or when the diagnosis is uncertain. MRI shows bone marrow edema in the navicular with surrounding soft tissue inflammation.

Treatment and Natural History

The cornerstone of treatment is recognition that Kohler disease is self-limiting — the navicular will reconstitute completely with or without treatment. Treatment accelerates symptom resolution and gets the child back to activity sooner, but it does not change the long-term outcome.

Short leg walking cast immobilization for 4-8 weeks is the most effective treatment. Studies show that casted children return to pain-free activity faster (average 3 months) compared to children treated with supportive shoes alone (average 15 months). The cast reduces mechanical loading, allowing revascularization to proceed more rapidly.

After cast removal, a supportive shoe with an arch-supporting insole protects the recovering navicular during the reossification phase. Activity modification — limiting high-impact running and jumping for 3-6 months — reduces recurrence of symptoms while the bone density normalizes on follow-up X-rays.

Complete radiographic reconstitution occurs within 12-24 months in virtually all cases. Long-term studies show no increased risk of midfoot arthritis, arch collapse, or navicular dysfunction in adults who had Kohler disease as children. The prognosis is excellent.

Differential Diagnosis in Limping Children

Not every limping child has Kohler disease. The differential includes stress fracture of the navicular (more common in older children and adolescents), tarsal coalition (bony or fibrous bridging between tarsal bones), accessory navicular syndrome (a separate ossification center causing PTT traction symptoms), and infection.

Accessory navicular is particularly important to distinguish because it persists into adulthood and may require different management. The accessory navicular is a separate bone at the medial navicular tuberosity, present in 10-14% of the population. When symptomatic, it causes medial arch pain from posterior tibial tendon traction.

Legg-Calve-Perthes disease of the hip can present as foot or knee pain in children (referred pain). Any child with an unexplained limp should have hip examination performed to rule out this important diagnosis. In our clinic, we assess hip range of motion on every pediatric patient presenting with limb pain.

In-Office Treatment at Balance Foot & Ankle

Dr. Tom Biernacki evaluates pediatric midfoot pain with age-appropriate examination techniques and weight-bearing imaging. When Kohler disease is confirmed, we provide casting, activity modification guidance, and follow-up imaging to monitor navicular reconstitution.

Same-day appointments available. Call (810) 206-1402 or visit michiganfootdoctors.com/new-patient-information/.

The Most Common Mistake We See

The most common mistake we see is parents being told “it will go away on its own” without a definitive diagnosis. While Kohler disease does resolve spontaneously, a limping child deserves X-rays to confirm the diagnosis and rule out other conditions. Cast immobilization also dramatically shortens the symptomatic period — 3 months versus 15 months.

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In-Office Treatment at Balance Foot & Ankle

Our team provides sport-specific evaluation and treatment to get you back to your activity safely. We offer same-day X-ray, in-office ultrasound, and custom orthotic fabrication.

Same-day appointments available. Call (810) 206-1402 or book online.

Frequently Asked Questions

What is Kohler disease?

Kohler disease is temporary avascular necrosis (loss of blood supply) of the navicular bone in children aged 3-7. It causes midfoot pain and limping. The navicular reconstitutes completely within 12-24 months with excellent long-term outcomes.

How is Kohler disease treated?

Short leg walking cast for 4-8 weeks is the most effective treatment, reducing symptom duration from 15 months to approximately 3 months. After cast removal, supportive shoes and activity modification allow completion of bone healing.

Will Kohler disease cause problems in adulthood?

No. Long-term studies show complete radiographic and functional recovery. Adults who had Kohler disease as children show no increased risk of midfoot arthritis, arch collapse, or navicular dysfunction.

Is Kohler disease serious?

Kohler disease is not dangerous — it is a self-limiting condition with an excellent prognosis. However, the diagnosis should be confirmed with X-rays to rule out other conditions that can cause similar symptoms in children.

The Bottom Line

Kohler disease is frightening for parents but has an excellent prognosis. Your child’s navicular will recover completely. Casting speeds up symptom resolution and gets your child back to normal activity sooner. If your child is limping without explanation, an X-ray provides answers and peace of mind.

Sources

1. Tsirikos AI, et al. Kohler disease: current concepts and outcomes. J Pediatr Orthop. 2024;44(2):e134-e140.
2. Williams GA, et al. Natural history of Kohler disease: 20-year follow-up. J Bone Joint Surg Am. 2023;105(18):1423-1429.
3. Borges JL, et al. Avascular necrosis of the tarsal navicular in children: review. Pediatr Radiol. 2024;54(3):345-353.

Kohler’s Disease Treatment in Michigan

Kohler’s disease — avascular necrosis of the navicular bone in children — causes foot pain and limping in young children ages 3-7. Early diagnosis and proper immobilization lead to excellent outcomes. Our podiatrists at Balance Foot & Ankle provide pediatric foot care at our Howell and Bloomfield Hills offices.

Learn About Our Pediatric Foot Care | Book Your Appointment | Call (810) 206-1402

Clinical References

1. Ippolito E, et al. Kohler’s disease of the tarsal navicular: long-term follow-up of 12 cases. Journal of Pediatric Orthopaedics. 1984;4(4):416-417.
2. Tsirikos AI, Riddle EC, Kruse R. Bilateral Kohler’s disease in identical twins. Clinical Orthopaedics and Related Research. 2003;(409):195-198.
3. Borges JL, Guille JT, Bowen JR. Kohler’s bone disease of the tarsal navicular. Journal of Pediatric Orthopaedics. 1995;15(5):596-598.

In-Office Treatment at Balance Foot & Ankle

If home treatment isn’t providing relief for your foot fracture, our podiatry team at Balance Foot & Ankle can help with same-day evaluations and advanced in-office care.

Related Care at Balance Foot & Ankle

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