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

What Is Kohler’s Disease?

Kohler’s disease — named for German radiologist Alban Kohler who first described it in 1908 — is an osteochondrosis (disorder of bone and cartilage growth) affecting the navicular bone of the foot in young children. The navicular is a tarsal bone on the medial midfoot that forms a keystone of the medial arch and serves as the insertion of the posterior tibial tendon. In Kohler’s disease, the blood supply to the navicular is temporarily disrupted during a critical period of skeletal development, causing avascular necrosis (bone cell death from ischemia) that produces the characteristic radiographic changes and clinical symptoms of the condition.

Kohler’s disease affects children primarily between ages 3 and 7, with boys affected three to four times more frequently than girls — an important demographic distinction from most pediatric foot conditions. The condition is almost always unilateral (one foot). Like Sever’s disease (calcaneal apophysitis), Kohler’s disease is a self-limiting osteochondrosis — the navicular revascularizes and ultimately reconstitutes its normal architecture over time, with long-term sequelae being extremely uncommon in affected children who receive appropriate management during the symptomatic phase.

Why Does the Navicular Become Avascular?

The navicular is the last tarsal bone to begin ossification (the process of bone hardening from cartilage). In most children, navicular ossification begins between ages 1.5 and 3 years in girls and 2.5 and 4 years in boys — later in boys, which may partially explain their higher incidence of Kohler’s disease. During the period when the navicular is transitioning from largely cartilaginous to predominantly ossified bone, it is vulnerable to compression injury from the forces transmitted through it during weight-bearing, as the cartilaginous precursor bone is relatively weak.

The proposed mechanism is that repetitive compressive loading of the partially-ossified navicular during normal childhood activity temporarily compromises its blood supply, leading to avascular necrosis of the developing bone. The disruption is temporary — as long as the loading allows adequate revascularization over time — and the navicular ultimately reconstitutes with normal bone architecture and morphology in the vast majority of cases. This favorable biology distinguishes Kohler’s disease from adult avascular necrosis conditions, where revascularization is less reliable and long-term articular damage is more common.

Symptoms and Recognition

Kohler’s disease presents as a limp in a young child (typically aged 3-7) with pain localized to the medial midfoot — specifically over the navicular bone, which is located on the inner midfoot at approximately the level of the scaphoid notch. The child may refuse to bear weight on the affected foot or may walk with the foot externally rotated (turned outward) to offload the tender navicular. Swelling and warmth over the navicular are often present. The condition typically develops gradually rather than following a specific injury, distinguishing it from acute fractures or sprains.

Parents may describe noticing their child limping after active play, reluctant to run and participate in sports, or complaining of foot pain when previously pain-free. The age range (3-7 years), sex (predominantly boys), and localization of tenderness to the navicular are the key clinical clues that should prompt appropriate evaluation. It is important to note that normal navicular ossification on X-ray in young children can appear irregular and fragmented — distinguishing pathological Kohler’s disease from normal developmental variation requires clinical correlation rather than X-ray interpretation alone.

Diagnosis

Plain radiographs of the foot are the primary diagnostic imaging study. In Kohler’s disease, the affected navicular appears flattened, sclerotic (denser than the surrounding bone), and irregularly ossified — a wafer-like appearance reflecting the compressed, ischemic bone. Comparison views of the contralateral foot are useful, as the asymmetric nature of Kohler’s disease (typically unilateral) allows direct comparison of the affected and normal navicular. As noted, the navicular normally appears irregular during the ossification process in children, so radiographic diagnosis requires correlation with clinical findings — tenderness over the navicular plus characteristic imaging changes in the appropriate age group.

MRI is not routinely required for diagnosis but may be obtained when the diagnosis is uncertain or when differentiation from acute navicular fracture, navicular stress fracture, or other conditions is needed. On MRI, Kohler’s disease shows decreased signal on T1-weighted sequences (reflecting bone marrow ischemia) and variable signal on T2-weighted sequences.

Treatment: Supporting the Foot While the Navicular Heals

The treatment of Kohler’s disease is primarily conservative and supportive, reflecting the self-limiting nature of the condition and the excellent long-term prognosis. The goals of treatment are to reduce pain and inflammation during the symptomatic phase, protect the navicular from excessive compressive loading that might delay revascularization, and maintain the child’s comfort and participation in age-appropriate activities as much as possible.

For children with significant pain and limp at presentation, a period of immobilization in a walking cast or boot — typically four to eight weeks — provides rest for the navicular and dramatic improvement in pain. Many children are comfortable and able to resume activity within a few days of immobilization. Following the immobilization period, transition to supportive shoes with adequate arch support and a custom or prefabricated orthotic insert maintains some navicular unloading as the child gradually returns to full activity. Medial arch support reduces the compressive force on the navicular by maintaining a more normal arch geometry during weight-bearing.

For children with milder symptoms, immobilization in a cast may not be necessary — supportive footwear with orthotic inserts and activity modification (reducing high-impact activities like running and jumping during the symptomatic phase) may be sufficient. Anti-inflammatory medication (ibuprofen in age-appropriate doses) provides symptomatic relief during acute flares. The duration of symptomatic treatment typically ranges from two to three months for mild presentations to six months for more severe cases.

Long-Term Prognosis: Excellent

The long-term prognosis of Kohler’s disease is uniformly excellent, and this reassurance should be provided clearly to concerned parents at the time of diagnosis. The affected navicular revascularizes over a period of months to two years following the initial presentation, ultimately reconstituting with normal bone morphology and articular surface in the vast majority of children. Long-term follow-up studies confirm that adults who had Kohler’s disease in childhood have normal navicular anatomy, normal foot biomechanics, and no significant increase in midfoot arthritis compared to those who did not have the condition.

The key message for families is that Kohler’s disease is a temporary condition with an excellent self-limited course. With appropriate supportive treatment during the symptomatic phase, children recover completely without long-term foot problems. Parents do not need to restrict their child’s activities permanently, and the prospect of ongoing foot problems from this diagnosis is not warranted by the clinical evidence. Regular podiatric follow-up during the symptomatic phase allows adjustment of support and activity restrictions, and radiographic monitoring confirms navicular reconstitution as the condition resolves.

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Pediatric Foot Conditions at Balance Foot & Ankle

Köhler’s disease is a rare childhood condition causing pain in the midfoot from temporary loss of blood supply to the navicular bone. Our podiatrists at Balance Foot & Ankle diagnose and treat pediatric foot conditions at our Howell and Bloomfield Hills offices.

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Clinical References

1. Borges JL, et al. “Köhler’s bone disease of the tarsal navicular.” Foot Ankle Int. 1995;16(7):449-451.
2. Tsirikos AI, et al. “Köhler’s disease: natural history and treatment.” J Pediatr Orthop B. 2003;12(3):216-219.
3. Ippolito E, et al. “Köhler’s disease of the tarsal navicular: long-term follow-up of 12 cases.” J Pediatr Orthop. 1984;4(4):416-417.

Dr. Tom Biernacki, DPM

Dr. Tom Biernacki, DPM is a double board-certified podiatrist and foot & ankle surgeon at Balance Foot & Ankle Specialists in Southeast Michigan. With over a decade of clinical experience, he specializes in heel pain, bunions, diabetic foot care, sports injuries, and minimally invasive surgery. Dr. Biernacki is a member of the APMA and ACFAS, and his patient education content on MichiganFootDoctors.com and YouTube has reached over one million views.