Pain guide · Foot pain

Köhler's disease (Kohler's disease): a young child's limp from the navicular, and how it settles

Köhler's disease (often spelled Kohler's disease) is a painful limp in young children, usually aged about 4 to 7, when the navicular, a small bone on the inner side of the midfoot, temporarily loses part of its blood supply. The bone flattens, then rebuilds itself, and children followed into adulthood had normal feet. But a limp always needs checking first: the NHS says a limp with no obvious cause should always be checked by a GP, and some signs need A&E.

This guide is for parents. It starts with those warning signs, then explains how Köhler's disease is diagnosed and why an X-ray alone isn't enough, when a short walking cast or boot is used for the pain, why physiotherapy is rarely needed, how long it usually takes to settle, and gentle ways back to normal play.

3-stage exercise plan When to get help 26 sourcesUpdated 21 October 2026

When to get help first

Exercise is for pain that has been checked or is clearly mild and settling.

Get urgent medical help if

Call 999 or go to A&E if your child gets sudden pain in their hip, knee or thigh (hip problems can sometimes be felt in the thigh or knee), can't put any weight on their leg, their leg has changed shape or is pointing at an odd angle, they feel generally unwell and have a high temperature, or feel hot, cold or shivery, they also have severe pain in the lower part of their tummy, or their symptoms get worse.
Call 999 or go to A&E if your child seems seriously unwell and you think it could be sepsis: they're breathing very fast or having difficulty breathing; have blue, grey, pale or blotchy skin, lips or tongue; have a rash that does not fade when you press it; are confused, not responding like they normally do, difficult to wake or more sleepy than usual; feel very hot or cold to the touch or are shivery; or, if they're under 5, haven't had a pee for 12 hours.
Pain, swelling, redness and warmth over a bone, or a very high temperature with feeling generally unwell: ask for an urgent GP appointment or contact NHS 111. It could be a bone infection. Take your child to a GP if they don't want to use a leg and seem irritable: young children don't always get a high temperature with a bone infection.
Ask for an urgent GP appointment or get help from NHS 111 for severe pain in 1 joint that started suddenly, swelling around a joint, skin over a joint that has changed colour, or difficulty moving a joint, especially with a high temperature or feeling hot, cold or shivery: it could be a joint infection.
A child who has hurt their foot or may have broken a toe: don't treat it yourself; take them to an urgent treatment centre or A&E.
Same day: in a cast or boot, pain that is getting worse, toes that are numb or burning, a cast that feels too tight, toes that are swollen, blue or white, or a bad smell from under the cast.
If your child has been diagnosed with Köhler's disease, get help the same day (NHS 111, or the hospital team if they gave you a number) if they become unwell or get a high temperature (38°C or more), can't put any weight at all on the leg even after pain relief, develop pain at night or night sweats, their pain can't be controlled with children's painkillers, or another joint becomes painful, swollen or red.

See a doctor or physiotherapist if

See a GP if your child has a limp and you're not sure what's causing it: a limp with no obvious cause should always be checked by a GP.
After a GP or A&E has checked your child and found no serious cause: if the limp is no better within 48 hours, or not back to normal within 7 days, go back to your GP surgery.
See a GP if your child has a rash, swelling or unusual bruising on the legs, leg pain and a high temperature, is unusually tired or sleepy a lot of the time, or doesn't want to eat or is losing weight.
See a GP for bone pain or tenderness, particularly if it's worse at night, or a lump or swelling that is growing.
Painful, swollen joints that last longer than 6 weeks: see a GP. It can be a type of juvenile arthritis.
After a diagnosis of Köhler's disease: a limp that is getting worse rather than better, pain starting in the other foot, or pain still there several months after any cast or boot comes off: see your GP or the clinic again.

Understand it

First, the checks a limp needsStrong evidence

Most limps in children aren't serious and get better by themselves. The NHS says limping is often from a sprain, strain, blister, cut, bruise or broken bone, but not to self-diagnose: a limp with no obvious cause should always be checked by a GP, as it could be a sign of something serious. Its list of other causes includes irritable hip, a slipped upper femoral epiphysis (a problem at the top of the thigh bone), juvenile arthritis, Perthes' disease and, rarely, a cancer such as leukaemia, sarcoma or lymphoma (a lump on the leg, weight loss or pain at night).

A child with a fever who has a swollen limb or joint, won't use a limb or won't put weight on it may have a bone or joint infection, NICE (the National Institute for Health and Care Excellence) says, and UK orthopaedic standards say a joint infection needs draining, ideally within 24 hours. That's why a doctor examines a limping child before anything else, and why Köhler's disease is a diagnosis made after these checks.

Sources 1, 2, 3, 4

What Köhler's disease is

The navicular is a small, boat-shaped bone on the inner side of the midfoot, in front of the ankle. In Köhler's disease it temporarily loses part of its blood supply, so it flattens and looks dense and broken up on an X-ray, then rebuilds itself. A Canadian children's hospital explains that this causes pain and swelling of the foot. Alban Köhler first described it in 1908.

The navicular is the last bone of the foot to start turning from cartilage into bone, at about 18 to 24 months in girls and 30 to 36 months in boys, and that late start is thought to make it more vulnerable to pressure from walking and running. A classic study of 52 normal children's feet and 62 children with Köhler's disease concluded that pressure on a late-forming navicular explains the irregular bone, and that further pressure brings on the symptoms. It gets better on its own.

Sources 5, 6, 7, 8

Who gets itEmerging evidence

Young children: it's seen between about 2 and 10, most often at 4 to 7, though one medical manual gives 3 to 5. Boys get it 4 to 5 times as often as girls. It's usually in one foot; both feet are affected in about 1 in 4 or 5 children.

Sources 8, 6, 5, 9

What you might notice

Pain on the top and inner side of the midfoot, worse with walking and better with rest; mild swelling; tenderness over the navicular; and a limp, sometimes walking on the outer edge of the foot. In some children the limp is the only sign at first, which can delay the diagnosis.

Sources 5, 6, 9, 10

How it's diagnosed, and what the X-ray does and doesn't meanEmerging evidence

A doctor examines the foot and arranges an X-ray. The navicular looks flattened and dense, and later in pieces, and an X-ray of the other foot can help in doubtful cases. A magnetic resonance imaging (MRI) scan is occasionally used to rule out an infection or a tumour.

The X-ray needs the examination to go with it. Irregular bone formation is part of how some normal naviculars form, and in 2,166 children's foot X-rays taken for any reason, 3% showed something unusual about the navicular, and about 80% of those findings were judged incidental, not the cause of the child's symptoms. The X-ray also takes 1 to 2 years to look normal again after the bone has healed, so it can't tell you when your child is ready to play.

Sources 5, 6, 9, 11, 7, 12

How it usually goesEmerging evidence

It gets better with time. In 12 children reviewed 33 years later, all were free of symptoms with no deformity or arthritis, and the bone took an average of 8 months to rebuild, whatever the treatment. In 14 children (16 feet) reviewed after about 31 years, 12 feet had a good result and 2 a fair one because of other foot problems, and the authors expect a normal foot in adulthood. In 20 children, every navicular rebuilt and function was excellent.

Estimates of how long it takes differ: a Canadian children's hospital gives 6 months to 3 to 4 years for full healing, and a medical manual says it rarely lasts more than 2 years. These are small, old studies and broad estimates, but they agree on the ending.

Sources 13, 14, 11, 5, 9

Look-alikes

An accessory navicular, an extra bone at the same spot, usually starts hurting at 10 to 15 and leaves a bump. Sever's disease hurts at the heel, and Iselin's disease on the outer edge of the foot, in older, active children. Each has its own guide. A broken bone, an infection, juvenile arthritis and the hip conditions are why the limp is checked first: if you think a foot bone or a toe is broken, the NHS says not to treat it yourself but to contact NHS 111, and to take a child who has hurt or broken a toe to A&E.

In adults, a similar-looking navicular problem, Müller-Weiss disease, is a different condition, mostly in women, and a specialist manages it.

Sources 1, 15, 16, 17

What helps, and how strong the evidence is

Rest, comfort and pain reliefStrong evidence

Hospital and medical sources agree on the basics: take weight off the foot, stop or change the activities that hurt, and give pain relief. A medical manual says children should rest, have pain relievers such as ibuprofen, and stay off the foot as much as possible. Give children's painkillers at the dose on the packet; NHS advice for children's leg pain is children's ibuprofen or paracetamol, and no aspirin under 16 unless a doctor prescribes it.

Sources 5, 9, 18

A short cast or boot for the pain: one older seriesEmerging evidence

A medical manual says a plaster walking cast worn for a few weeks may help some children, by taking weight off the foot and keeping it still; crutches often aren't needed with a walking cast. A Canadian children's hospital uses a walking boot if it's very painful.

The main evidence is one older series of 20 children treated in the US between 1948 and 1974, which wasn't randomised. On average, symptoms lasted less than 3 months in the children who had a short walking cast for about 8 weeks, against 15 months in those who didn't. Two other small series, of 12 and 14 children, also found that a cast shortened the pain, and all three found the long-term result was the same either way. Reviews say a short spell in a cast may shorten the symptoms, and cast lengths in the sources run from a few weeks to 3 months.

So a cast isn't needed for the foot to recover. Your child's doctor decides whether a cast or boot is worth it for the pain.

Sources 9, 5, 11, 13, 14, 8, 6

Physiotherapy, insoles and exerciseMixed evidence

A Canadian children's hospital says physiotherapy is rarely needed, and doesn't take referrals for Köhler's disease because it gets better on its own. In the older series of 12 children, arch supports only lessened the pain, which lasted 7 months on average. No exercise treats Köhler's disease: the plan on this page is about getting back to normal play once the pain allows.

Sources 5, 13

Surgery: very rareMixed evidence

One hospital reported an operation to relieve pressure in the bone in 3 children who were no better after more than 3 months of non-surgical care. That's a single report: a large children's hospital says no orthopaedic surgery consultation or treatment is needed.

Sources 19, 5

How much pain is OK while you exercise?

Comfort and the limp lead (editorial, as in our irritable hip guide)

No Köhler's source gives a pain rule: they say rest, pain relief and stopping or changing the activities that cause pain. So this rule is editorial, the same one our irritable hip guide uses.

While it's sore, let your child rest in whatever position is comfortable, with children's painkillers; no exercises are needed. Coming back to play, the limp and the pain are the guide: if a game brings the limp back or makes the foot sore, stop and go back to quieter play for a day or two. In a cast or boot, do only what the clinician allows.

Young children can't rate pain reliably on a 0 to 10 scale, which is why the limp is the better guide (our reasoning). A high temperature, a child who seems unwell, not putting any weight on the leg, pain at night, or pain that's getting worse isn't covered by the rule: see the warning signs.

Sources 5, 9

The exercise plan: 3 stages

Start at the first stage. Each move opens a full guide with a 3D demo.

Stage 1

Rest and comfort (the sore weeks, and while any cast or boot is on)

Rest from the activities that hurt, children's painkillers at the dose on the packet, and a cast or boot if the doctor advises one. No exercises are needed: these are optional, playful ways to keep a restless child moving with weight off the sore foot.

Breath reach demonstrated on the 3D figure

3D demoBreath reachBeginner · No equipment

Reach for the stars, sitting: 5 breaths, breathing out for longer than breathing in · The move page's dose

Harder: Slow breathing (6 breaths a minute)

3D demoDead bugBeginner · No equipment

A beetle on its back, lying down: 5 slow arm and leg reaches on each side · Editorial dose

Easier: Dead bug heel taps · Harder: Forearm plank

Glute bridge demonstrated on the 3D figure

3D demoGlute bridgeBeginner · No equipment

10 bridges, high enough for a toy car to drive under · The animal moves workout's amount. Leave it out if pressing the foot into the floor hurts

Easier: Pelvic tilt into bridge · Harder: Single-leg glute bridge

Move on when: Your child walks around the house without a limp, or with a limp that's better each day, any cast or boot is off, and the clinician agrees.

Follow along: a timer, a cue and the next move, one step at a time.

Stage 2

Walking and gentle play again

Everyday walking and quiet play: bikes and scooters before running games, and swimming once any cast is off (our suggestion). No PE (physical education), trampolines or running games yet.

Standing march demonstrated on the 3D figure

3D demoStanding marchBeginner · No equipment

1 min, marching like soldiers · The animal moves workout's amount

Easier: Seated march · Harder: Standing band hip flexion

Single-leg stand demonstrated on the 3D figure

3D demoSingle-leg standBeginner · A wall

The flamingo: 20 s on each leg, near a support · The animal moves workout's amount

Easier: Tandem stance and heel-to-toe walk · Harder: Single-leg reach matrix

Tandem stance and heel-to-toe walk demonstrated on the 3D figure

3D demoTandem stance and heel-to-toe walkBeginner · A wall

Tightrope walking along a line: 3 walks of 10 steps · Editorial dose

Easier: Semi-tandem stance · Harder: Single-leg stand

Stationary cycling demonstrated on the 3D figure

3D demoStationary cyclingBeginner · Cardio machine

A gentle bike or scooter ride, 10 to 20 min · Editorial, as in our irritable hip guide

Easier: Recumbent exercise bike · Harder: Air bike intervals

Move on when: Your child has been walking and running about normally, without pain or a limp, for a week or two (editorial), and the clinician agrees.

Follow along: a timer, a cue and the next move, one step at a time.

Stage 3

Running, jumping and full play

Normal play, PE and sport. The animal moves workout is a fun way back.

Bear crawl demonstrated on the 3D figure

3D demoBear crawlIntermediate · No equipment

Across the room and back · The animal moves workout's amount (one round)

Easier: Knee hover (Pilates tabletop hover) · Harder: Spider crawl (low push-up knee drive)

3D demoCrab walkIntermediate · No equipment

Across the room and back · The animal moves workout's amount (one round)

Easier: Elastic wall bounce · Harder: Alternate-leg bounding

Ankle bounces (mini pogo) demonstrated on the 3D figure

3D demoAnkle bounces (mini pogo)Beginner · No equipment

15 bunny hops, small and quiet · The animal moves workout's amount

Harder: Pogo hops

Standing broad jump with stuck landing demonstrated on the 3D figure

3D demoStanding broad jump with stuck landingIntermediate · No equipment

4 frog leaps, freezing like a statue on landing · The animal moves workout's amount

Easier: Snapdown to athletic landing · Harder: Single-leg hop and stick

Move on when: Back to normal. If the limp comes back after a busy day, go back to stage 2 for a few days; if it keeps coming back, or a warning sign appears, see a GP.

Follow along: a timer, a cue and the next move, one step at a time.

What to change for now

Living with a walking cast or boot (written steps)

From a medical manual and a Canadian children's hospital, with our suggestions marked.

1. A walking cast or boot takes weight off the navicular and eases the pain. Crutches often aren't needed with a walking cast.
2. Check the toes each day: warm, pink and wiggling. Numb, tingling, swollen, blue or white toes, a cast that feels too tight, pain that's getting worse, or a bad smell: contact the team the same day.
3. Keep a cast dry, and don't let your child push anything inside it (our suggestion).
4. Do only what the clinician allows while it's on, and expect a check before it comes off (our suggestion).

Sources 9, 5

Back to play (written steps)

Our suggestions, following the approach in our irritable hip guide.

1. Let your child set the pace: walking first, then bikes, scooters and swimming, then running and jumping.
2. Cushioned trainers rather than flat pumps or bare feet on hard floors while the foot is sore.
3. Tell the nursery or school about the foot. PE and playground running can wait until the limp has gone.
4. If a game brings the limp back, have quieter play for a day or two. A limp that keeps coming back needs a GP.

Positions to swap, and why

Habit or position	Why it matters	Instead
Waiting it out when a limp has no obvious cause	The NHS says a limp with no obvious cause should always be checked by a GP.	A GP check, and A&E or 999 for the urgent signs.
Making a sore child walk to test the foot	Children choose the most comfortable way to move (our reasoning, as in our irritable hip guide).	Rest and quiet play while it's sore.
Bunny hops, trampolines and jumping games while the limp is there	Jumping loads the sore midfoot (our reasoning).	Bikes, scooters and swimming first.Try: Stationary cycling
Bare feet or flat pumps on hard floors while it's sore	There's less cushioning under the arch (our suggestion).	Cushioned trainers.
Expecting physiotherapy or insoles to cure it	Physiotherapy is rarely needed, and arch supports only lessened the pain in an older series.	Rest, painkillers and, if the doctor advises, a cast or boot.
Aspirin for the pain	It isn't for children under 16 unless a doctor prescribes it.	Children's ibuprofen or paracetamol at the dose on the packet.

Routines to follow

Animal moves for kids: a 15-minute active play workout

Fifteen minutes of animal moves, jumps and balance games for children, building the muscle- and bone-strengthening activity they need, with nothing to buy.

15 minBeginner16 movesA wall

More moves for this area

Questions people ask

What is Köhler's disease?

A temporary loss of blood supply to the navicular, a small bone on the inner side of the midfoot, in young children. The bone flattens, then rebuilds itself.

Who gets it?

Usually children aged about 4 to 7, sometimes from 2 to 10, and boys more often than girls. It's usually in one foot.

Why is my child limping?

Köhler's disease makes the inner side of the midfoot sore, so children limp or walk on the outer edge of the foot. But a limp has many causes, and the NHS says one with no obvious cause should always be checked by a GP.

When should I worry about my child's limp?

Call 999 or go to A&E if your child can't put any weight on the leg, has sudden hip, knee or thigh pain, the leg looks out of shape, they're unwell with a high temperature, or their symptoms get worse. See a GP about any limp you're not sure about.

Does my child need an X-ray?

Usually, yes: it shows the flattened, dense navicular and helps rule out a break. Similar changes can appear in children without pain, so the doctor reads the X-ray together with the examination.

How long does Köhler's disease last?

The pain usually settles over months, and the bone rebuilds over months to a couple of years; estimates differ between sources. Children followed into adulthood had normal or good feet.

Does my child need a cast or boot?

Not always. In older studies, a short walking cast shortened the pain, though the long-term result was the same either way, and some hospitals use a walking boot when it's very painful. Your child's doctor decides whether a cast or boot is worth it.

Does my child need physiotherapy or special insoles?

Rarely: it gets better on its own. Arch supports only lessened the pain in an older series.

Can my child go to nursery or school, and play?

Yes, with rest from what hurts while it's sore and children's painkillers if needed. Let the limp guide a gradual return to running and jumping.

Will it affect them when they're older?

Studies that followed children for over 30 years found normal or good feet. The clinic may arrange follow-up X-rays.

Is it the same as an accessory navicular or flat feet?

No. An accessory navicular is an extra bone that leaves a bump on the inner midfoot and usually starts hurting at about 10 to 15, and flat feet that don't hurt need nothing. Each has its own guide.

Can adults get Köhler's disease?

It's a childhood condition. A similar-looking problem in adults, Müller-Weiss disease, is a different condition that a specialist manages.

Related exercise guides

Other pain guides

Sources

Exercise education, not a diagnosis or treatment plan. It is written from the guidelines and studies listed above; review by a clinician is pending. If your pain follows an injury, is severe, is getting worse, or comes with any warning sign listed on this page, get it assessed. Health disclaimer.