Köhler's disease I and II

Anatomy of the foot: where Köhler's disease occurs

The foot consists of the hindfoot, metatarsal and forefoot. Two regions are crucial for Köhler's disease: the scaphoid bone (os naviculare) on the inner side of the metatarsal bone and the heads of the metatarsal bones (metatarsal heads) in the forefoot.

• Os naviculare (scaphoid): important for the medial longitudinal arch; Insertion point of the tibialis posterior tendon.
• Metatarsal head II: forms the MTP joint with the basal phalanx and carries high loads when rolling.
• Growth phases: Apophyses and epiphyses are particularly sensitive to overload in childhood and adolescence.

What is Köhler's disease I and II?

Köhler's disease describes osteochondrotic changes in growth: temporary disturbances in bone development and blood circulation in children's bone nuclei. It is not an infection or a tumor, but rather a mostly self-limiting maturation disorder.

• Köhler's disease I: affects children (often 3–7 years old), boys somewhat more often. Localization on the navicular bone. Stress pain in the inner metatarsal with temporary limping is typical.
• Köhler II disease (Freiberg disease): tends to affect girls and young women (often 11–17 years old). Localization on the metatarsal head II (less often III). Stress-dependent forefoot pain under the second frog, often with swelling, is typical.

Important: The course and therapy differ. Köhler I usually heals completely with relief. Köhler II can persist - especially in advanced stages - and requires a structured conservative approach, in individual cases surgical intervention.

Symptoms

• Köhler I: Pressure pain over the inner metatarsus (scaphoid), limping after exertion, occasionally redness/swelling, shoe pressure problems. Children sometimes refuse to walk or jump for long periods of time.
• Köhler II: Pinpoint pain under the second metatarsal head, increased with sports and tight/stiff shoes, sometimes palpable swelling, pain when rolling, sometimes restricted movement in the MTP joint II.

Warning signs that should be clarified promptly: pain at night when resting, fever, significant redness/warmth, increasing misalignment, accident event with severe persistence of pain.

Causes and risk factors

The development is multifactorial. What is crucial is a temporary reduced blood flow and excessive stress on the immature bone core.

• Growth phase: vulnerable epiphyses and apophyses.
• Mechanical overload: lots of sport, hard surfaces, stiff shoes.
• Foot shape: pronounced arch or splay foot tendency can promote local load peaks.
• Rare: systemic factors such as endocrine influences or metabolic stress; The cause is usually not clear.

Diagnostics in practice

Diagnosis is based on history, clinical examination and targeted imaging. In our Hamburg practice, we value an approach that is as low-radiation and child-friendly as possible.

• Differential diagnoses Köhler I: accessory tibial bone (additional bone core), stress fracture, juvenile idiopathic arthritis, osteomyelitis.
• Differential diagnoses Köhler II: metatarsalgia in splayfoot, Morton's neuroma, stress fracture of the metatarsal, sesamoiditis (on the metatarsophalangeal joint of the big toe), capsular ligament injury.

Conservative therapy: the standard

The vast majority of cases can be treated successfully without surgery. The aim is to relieve pain, calm inflammation, protect the affected bone and gradually build up the load.

• Load adaptation: temporary break from sports, avoidance of jumping and impact loads, pain-adapted activity.
• Shoe advice: well-cushioned, sufficiently wide shoes; Köhler II has a solid outsole with a slight rolling aid.
• Inserts and padding: Longitudinal arch support for Köhler I; in Köhler II, soft retrocapital pads to redistribute pressure from the metatarsal head II.
• Immobilization: if the pain is severe, short-term immobilization (e.g. walker or lower leg cast) for 2-6 weeks, especially with Köhler I.
• Physiotherapy: gentle mobilization, stretching of calf muscles, strengthening of foot muscles, gait training.
• Pain management: local cooling, needs-based anti-inflammatory medication in low doses after medical examination and age-appropriate approval.

Additional regenerative procedures (e.g. platelet concentrates) are not routinely used in Köhler's disease. In individual cases where symptoms persist, such options can be discussed. The evidence is limited; a clear benefit is not assured.

Surgical options: rare and well considered

Operations are practically never necessary for Köhler I disease. In Köhler II disease, they can be useful in advanced stages or when conservative therapy has failed. The procedure and technique depend on the stage and joint involvement.

• Joint-preserving measures (Köhler II): arthroscopic or open debridement, drilling of subchondral areas for reperfusion, and in selected cases cartilage reconstructive procedures.
• Corrective osteotomy: dorsal wedge osteotomy on the II metatarsal to restore the articular surface and redistribute pressure.
• Resection procedure: only in severe, painful final stages with significant joint destruction; careful indication is necessary.

As with all interventions, the benefits and risks are weighed individually. A robust educational discussion is a prerequisite; Promises of healing are not given.

Course and prognosis

• Köhler I: very good prognosis. With relief and insoles, the symptoms usually subside within weeks to a few months. The scaphoid matures regularly.
• Köhler II: the earlier detected, the better. In the early stages, lasting improvement in symptoms can often be achieved with conservative measures. Late stages may be prone to joint stiffness and recurrent metatarsalgia.

Return to sport is symptom-guided. A gradual build-up with breaks, appropriately cushioned shoes and, if necessary, padding prevents relapses.

Tips for everyday life, school and sport

• Control stress: wait for a pain-free period of 24-48 hours before increasing the intensity.
• Footwear: enough space, soft insoles, Köhler II has a firm sole with a rolling aid; In everyday life, wear flat rather than high heels.
• Surface: prefer soft training surfaces; Reduce jump and sprint sequences.
• Foot care: regular stretching of the calves and soles of the feet, proprioceptive exercises for the arch of the foot.
• School and daycare: temporary exemption from sports, alternative activities without jumping load.

Frequently asked questions about Köhler's disease

The most important answers summarized in a compact manner.