kohler's disease

Kohler’s Disease: 

Kohler ’ s Disease Date: October 12, 2011 Group: Brittany Tipley, Carli Whiteside, Brigette Villuga

General Description: 

General Description Type of Osteochondroses Avascular necrosis of tarsal navicular bone

Signs & Symptoms: 

Signs & Symptoms Early phase: the patient will have no symptoms 1 Revascularization phase: the patient may have antalgic gait due to mild pain of midfoot 1 Local tenderness over navicular on medial aspect of foot 2 Patient has increased weightbearing on lateral foot 2 Soft tissue redness and swelling 2

Incidence: 

Incidence Typically in children ages 4-8 1 Boys>Girls 1 Normally unilateral involvement of the navicular 1 Occasionally bilateral involvement 1

Diagnosis: 

Diagnosis Based upon patient ’ s clinical symptoms that may persist for up to 2 years 3 pain, swelling, warmth, and limping 3 Along with presentation of characteristic radiographic abnormalities 3

Prognosis: 

Prognosis Typically healing complete in 2 years 1 Rarely residual deformity 1 Excellent if the patient receives treatment 1

Impact of Functioning: 

Impact of Functioning Dependent upon the phase and severity of the condition Patient will have limitations with recreational and school/work related activities

Role of Imaging: 

Role of Imaging Key contributor for diagnosis and management of condition Best Imaging: MRI Avascular necrosis can be shown on a ny imaging method once its estabilshed 4 However, avascular necrosis can be shown with a MRI within 2 weeks of vascular insult 4 MRI will provide the physical therapist with information in regards to the condition of the soft tissues aiding with patient treatment

Imaging- MRI: 

Imaging- MRI

Imaging- Radiograph: 

Imaging- Radiograph http:// www.pedsradiology.com / Historyanswer.aspx?qid =60&fid=1

Imaging Findings-MRI: 

Imaging Findings-MRI Alignment: Regarding the general skeletal architecture, the navicular is present but is decreased significantly in size compared to normal navicular imaging. The surrounding bones appear to be of normal size. Related to the general contour of the navicular bone, the borders are not smooth and continuous throughout specifically at the navicular articulation with the cuneiform. Also, there appears to be an irregularity on the dorsal aspect of the navicular and talus indicating possible pathology. There appears to be a normal alignment and positioning of the navicular in relation to adjacent bones. However, there are degenerative and alignment changes in the 1 st MTP.

Slide 12: 

Bone Density: The general bone density of the navicular is abnormal in comparison to the surrounding bones, except the cuneiform which has some degenerative changes. The navicular is dark so it is not displaying the normal radiodensity, appearing relatively white on imaging in comparison to the surrounding bones which are bright white indicating they have adequate bone density.  In regards to textural abnormalities, the trabeculae have a smudged appearance. The bone density locally is decreased in comparison to surrounding bones.

Slide 13: 

Cartilage Space: The joint space between the navicular and talus is intact, whereas the joint space between the navicular and the cuneiform is decreased. Also, there is decreased joint space at the 1 st TMT due to degenerative changes. No significant findings regarding subchrondral bone. No applicable findings for epiphyseal plates. Soft Tissues: There is no indication of muscle wasting or swelling. The navicular pathology does not appear to be affecting the condition of the fat pad. The joint capsule and periosteum do not exhibit any abnormalities. There are degenerative changes of plantar ligaments.

Predictor Variables: 

Predictor Variables Behavior of the lesion: There is osteolytic bone activity in the form of geographic destruction in that a large area of the bone is radiolucent in appearance. Bone or Joint Involved: Navicular Locus within a bone: The entire bone is involved. Age, Gender, and Race of Patient : Kohler ’ s disease is common in children between ages 4 to 8, particularly in boys.

Slide 15: 

Margin of Lesion : The navicular appears to be poorly defined and lesion is aggressive because the entire navicular is involved due to the pathology. Shape of Lesion: The necrotic pathology consumes the entirety of the navicular, altering the shape of the bone. The navicular appears to be wider than long. Joint Space Crossed/Joint Space Preserved: The disease process occupies the joint space between the navicular and the cuneiform

Slide 16: 

Bony Reaction: Not significant. Matrix Production: Not applicable. Soft Tissue Changes: Not applicable. History of Trauma or Surgery: Not applicable.

Impairments: 

Impairments Complaints of mild midfoot pain Increased weight-bearing on lateral foot Antalgic gait along with limping Soft tissue redness and swelling, warmth Local tenderness over navicular on medial aspect of foot Decreased ankle AROM secondary to pain Strength testing not assessed secondary to pain with MSTT

Questions: 

Questions What are other foot pathologies that may have a similar presentation to Kohler’s Disease and what differences would you find on imaging? What would you expect the navicular of an adult patient with a history of Kohler’s Disease to appear like on a radiograph?

References: 

References 1. Salter, RB. Textbook of Disorders and Injuries of the Musculoskeletal System .  3rd ed.  Baltimore, MD:  Lippincott Williams & Wilkins; 1999. 2. Vargas B. Kohler Disease. http://emedicine.medscape.com/article/1234753-overview#a0112. Updated February 5, 2009. Accessed October 10, 2011. 3. Sharp RJ, Calder JDF, Saxby, TS. Osteochondritis of the navicular: A case report. Foot and Ankle International . 2003;24(6):509-513. 4. Imaging Course Notepacket