What Is Causing a 5-Year-Old Boy’s Limp?

Authors:

Laura R. Meidl

University of Missouri - Kansas City School of Medicine in Kansas City, Missouri.

Natalie C. Stork, MD

University of Missouri - Kansas City School of Medicine and Children’s Mercy Kansas City in Kansas City, Missouri.

Julia G. Harris, MD

University of Missouri - Kansas City School of Medicine and Children’s Mercy Kansas City in Kansas City, Missouri.

Citation: Meidl LR, Stork NC, Harris JG. What is causing a 5-year-old boy's limp? Consultant for Pediatricians. 2017;e10.

An otherwise healthy 5-year-old boy presented to the pediatric rheumatology clinic for evaluation of a limp of 1 year’s duration. The patient also experienced intermittent right foot and ankle pain and transient morning stiffness lasting 60 minutes. His pain was worse with exercise, but this did not limit his activity. There was no history of trauma, and a complete review of systems was negative except for intermittent abdominal pain.

On physical examination, the boy was well appearing, and his vital signs were within normal limits. Musculoskeletal examination revealed no swelling, tenderness, erythema, warmth, pain with movement, or limited range of motion in any joints. The boy’s strength was normal and symmetric, and no tenderness was elicited with palpation of the lower extremities. He had an antalgic gait and had difficulty hopping on the right leg relative to the left, but he denied pain. Gowers sign was negative, and the rest of his examination was unremarkable.

Laboratory studies were obtained to evaluate for a chronic inflammatory process, infection, or muscular etiology and were within normal limits. A radiograph of the right foot (Figure 1) provided evidence that supported the diagnosis.

What was the cause of the boy’s limp? >>

Answer: Kӧhler disease

The radiograph revealed sclerosis and decreased height of the right navicular, consistent with Kӧhler disease (Figure 1). The patient was referred to orthopedics. Treatment options of observation versus casting were discussed with the family, and observation with 6-month follow-up radiographs was the chosen plan.

Figure 1. Radiograph of right foot with sclerosis and decreased size of the right navicular bone.

DISCUSSION

Kӧhler disease is an osteochondrosis of the tarsal navicular bone.¹ This syndrome occurs more commonly in males, with an average age of onset between 2 and 9 years.^1,2 Necrosis of the ossification center in the navicular may be caused by decreases in blood supply due to compression by the talus and cuneiform bones.² Trauma may also play a role in this disease, but the exact etiology remains unclear.²

The most common presenting complaint is medial foot pain and limp, generally worse with weight-bearing physical activity.^1,2 There may be tenderness, swelling, and/or erythema over the dorsum and/or medial aspect of the foot.^1,2 The child may walk on the lateral aspect of the affected foot.¹

Diagnosis is made by clinical examination and radiographic findings. On radiographs, the navicular may appear sclerotic, fragmented, and flattened.^1,2 Kӧhler disease is unilateral in 75% to 85% of cases,^2,3 so it is helpful to obtain radiographs of both feet for comparison.¹ It is important to note that a fragmented-appearing tarsal navicular bone in the toddler age range may be considered a normal ossification variant if the clinical picture is not consistent with Kӧhler disease.⁴ Laboratory studies are not necessary unless there is high suspicion for infection.

Kӧhler disease is self-limited and will generally resolve as the navicular bone regenerates (between 4 months to 4 years).⁵ Treatment is variable and based on symptomatic relief. Immobilization with a short-leg walking cast may decrease symptom duration.⁶ Additional treatment may include rest, ice, analgesics, and orthotics.^1,5,7 Consider referral to an orthopedic physician if diagnosis is unclear, if there is persistent pain, and/or if the patient’s family wishes to try casting.   

References:

1. Gillespie H. Osteochondroses and apophyseal injuries of the foot in the young athlete. Curr Sports Med Reps. 2010;9(5):265-268.

2. Tuthill HL, Finkelstein ER, Sanchez AM, Clifford PD, Subhawong TK, Jose J. Imaging of tarsal navicular disorders: a pictorial review. Foot Ankle Spec. 2014;7(3):218-219.

3. Stanton BK, Karlin JM, Scurran BL. Kohler’s disease. J Am Podiatr Med Assoc.. 1992;82(12):625-629.

4. Mosca VS. The Foot. In: Weinstein SL, Flynn JM, eds. Lovell & Winter’s Pediatric Orthopaedics. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2013:1491-1492.

5. Borges JL, Guille JT, Bowen JR. Kӧhler's bone disease of the tarsal navicular bone. J Pediatr Orthop. 1995;15(5):596-598.

6. Williams GA, Cowell HR. Kӧhler’s disease of the tarsal navicular. Clin Orthop Relat Res. 1981;158:53-58.

7. Ippolito E, Pollini R, Falez F. Köhler's disease of the tarsal navicular: long-term follow-up of 12 cases. J Pediatr Orthop. 1984;4(4):416-417.