Differential Diagnosis

  • Osteomyelitis
  • Osteosarcoma
  • Freiberg disease
  • Grierson-Gopalan syndrome
  • Kohler’s disease
  • Navicular fracture


This patient was diagnosed with Kohler’s disease, indicated by a small, flattened, wafer-like navicular tarsal bone with sclerosis and fragmentation. Note localized soft tissue swelling. This condition is also known as avascular necrosis of the navicular tarsal bone.

Learnings/What to Look for

  • Generally, isolated bony tenderness without trauma in children is concerning for bony infection, especially if fever is present. X-ray is helpful to evaluate for other pathology such as tumors, trauma, and avascular necrosis
  • The diagnosis of Kohler’s disease is made on plain radiographs which show a small, thin, sclerotic and often fragmented navicular tarsal bone. MRI could be complimentary
  • Most children present between age 4 and 5 years of age with limp, a painful inner arch of foot, swelling, and tenderness in the region of the navicular bone
  • Kohler’s disease occurs in children during the developmental phase prior to complete ossification of the navicular bone
  • Kohler’s disease is caused by excessive repetitive strain on the bone and its blood supply, leading to a temporarily compromised blood supply and resulting in avascular necrosis

Pearls for Initial Management

  • Management requires immobilization and referral to a pediatric orthopedic specialist. The bone eventually heals and results in normal growth, rarely requiring surgical care

Acknowledgment: Image and case presented by Experity Teleradiology (www.experityhealth.com/teleradiology).

A 5-Year-Old with Foot Pain of Unknown Origin
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