Köhler’s disease II is described as an aseptic necrosis of the bone (mainly the metatarsal bone or segments II to IV). Notably, unlike Köhler’s disease I, Köhler’s disease II occurs mainly in young women girls.
What is Köhler’s disease II?
Köhler’s disease II represents aseptic bone necrosis of the 2nd metatarsal head. It primarily affects girls who are between 12 and 18 years old. The causes of the disease have not yet been adequately elucidated. The disease is also known by the synonyms Köhler-Freiberg disease, Freiberg Köhler disease, juvenile osteochondrosis of the metatarsus, or osteochondrosis of the metatarsal heads.
Causes
The reasons for the development of Köhler II disease have not yet been clarified. However, physicians assume that sometimes too tight or high-heeled shoes may very well promote the disease. However, this theory has not yet been clearly proven. Sometimes also the theory of the overloading is represented. If the bone is permanently overloaded, this is a favoring factor for Köhler II disease. Trauma, which subsequently causes a malposition of the foot, can also sometimes trigger Köhler II disease. However, these are merely theories; the cause of why Köhler’s disease I occurs has also not yet been 100 percent clarified.
Symptoms, complaints, and signs
The affected person initially complains of pain in the foot. The pain occurs predominantly when weight is placed on the foot. However, parents and medical professionals may not notice any external injuries or changes; sometimes the only indication is swelling in the affected region. It is possible for the swelling to occur in the anterior region as well; the swelling becomes more severe if weight continues to be placed on the foot, even though it is causing pain. Affected individuals state that rolling movements cause pain; in the advanced stage of Köhler II disease, the classic painful limping occurs, which subsequently leads to a protective posture or a walking gait.
Diagnosis and course of the disease
If Köhler II disease is suspected, the physician must perform various examinations so that the suspected diagnosis can be confirmed. To do this, an x-ray of the foot is taken. The foot is x-rayed once from the side and then from above. While in the case of Köhler’s disease I a narrowing and compression of the navicular bone is visible, in the case of Köhler’s disease II the doctor recognizes a flattening and also a shortening of the metatarsal bone. If Köhler’s disease II is already in an advanced stage, the physician can recognize any changes in the so-called metatarsophalangeal joint. This change is also responsible for the severe pain when walking or rolling. It is important that – if the first changes in the metatarsophalangeal joint are already recognizable – therapies are carried out here so that further damage can be prevented. Only in this way can the patient be spared any permanent damage. The course of the disease depends above all on whether and how quickly a so-called revascularization of the bone takes place. For this reason, it is advantageous if the diagnosis is made at an earlier stage. Surgery is usually necessary; this is also because Köhler’s disease II is usually diagnosed relatively late. In many cases, the damage cannot be repaired in such a way that the original condition is achieved, so that the patient experiences mild discomfort for the rest of his life. In exceptional cases, the sole of the foot must be stiffened, which sometimes means restrictions in mobility.
Complications
In most cases, Koehler II disease primarily causes severe pain and other unpleasant discomfort in the feet. The pain may be burning or stabbing and may lead to sleep disturbances, especially at night. It is not uncommon for sleep complaints to lead to irritability in the patient and can significantly reduce the ability to cope with stress. Those affected feel tired and weary as a result of the disease and usually do not take an active part in life. The pain occurs especially when weight is placed on the feet, resulting in significant restrictions and discomfort during movement. Children can no longer participate in sports and there is a disturbance of development due to Köhler’s disease II.Not infrequently, there is also severe swelling of the foot, which makes the patient’s everyday life much more difficult. There are no particular complications in the treatment of Köhler’s disease II. The symptoms can be relatively well limited and reduced either by surgical intervention or by various therapies. As a rule, however, the affected person is no longer allowed to put much weight on his or her foot. However, life expectancy is not reduced by this disease.
When should one go to the doctor?
Girls between the ages of twelve and eighteen are the primary sufferers of Köhler II disease. If health changes or irregularities occur in those affected in this risk group, a visit to the doctor should be made. Pain in the foot, visual abnormalities of the foot or toes, and a change in locomotion should be examined by a doctor. The use of pain medication should be completely avoided until consultation with the treating physician. It is characteristic of the disease that often no external injuries can be detected. Nevertheless, swellings or slight thickenings are signs of a health impairment. A visit to the doctor is advisable as soon as physical performance is reduced or sporting activities can no longer be performed as usual. If the person affected adopts a relieving posture due to the complaints, if the body becomes generally crooked or if a limp develops, a doctor is needed. If, in addition to the physical symptoms, emotional or mental abnormalities occur, a visit to the doctor is recommended. Although the affected person is going through puberty, withdrawal from social life, behavioral changes or mood swings may also be indications of an additional health disorder that should be investigated and clarified.
Treatment and therapy
For Koehler II disease, the medical professional has two treatment options: conservative and surgical. If the physician decides on conservative therapy, attention is paid primarily to promoting blood circulation and also relieving pressure on the foot. If Koehler’s disease II is detected at an early stage or if there are only minor symptoms and the complaints are so minor that there are no actual restrictions, a ban on sports and immobilization of the foot (e.g. by means of relieving bandages) can be positive. Sometimes the physician may also apply a lower leg cast, which is removed after six weeks. Other options available as part of conservative therapy include insole fittings or physiotherapeutic measures. Methods that promote blood circulation, such as the application of certain ointments, can also provide relief from the symptoms and also direct treatment of Köhler’s disease II. However, if the conservative therapy is unsuccessful or if Köhler’s disease II was only diagnosed at an advanced stage, the physician must consider surgical treatment. Only a few years ago, drilling was performed; today, medicine knows that that surgical technique did not produce convincing results. If there is a minor wear and tear of the joint, a joint toilet is mainly used. If there is a degenerative change in the upper half of the metatarsal head, a dorsal wedge osteotomy with fixation is performed. That method has stood its ground and is preferably used when the physician believes that only surgery can actually improve the patient’s quality of life.
Outlook and prognosis
Köhler II disease is usually diagnosed at a late stage, which entails low prospects of cure. Affected individuals must therefore cope with limitations. Surgery usually takes place, but this does not allow doctors to restore the original condition. The prognosis is therefore mixed. Certain types of sports and permanent stress are to be avoided afterwards. On the other hand, Köhler’s disease II does not result in a shortened lifespan. The disease occurs mainly in girls. According to statistical surveys, there are four female patients for every male patient. The greatest risk for symptoms is between the ages of 12 and 18. If treatment is refused, osteoarthritis regularly develops in adulthood. Pain on exertion, but also at rest, is a daily occurrence.Many patients have to use aids such as insoles in order to realize a pain-free motion sequence. The best prospects arise insofar as Köhler’s disease II is diagnosed before the development of arthrosis. Stiffenings cannot be repaired in every case. Conservative procedures are generally to be preferred. They allow the best treatment success in the early stages without surgical intervention.
Prevention
Due to the fact that no causes are known so far, no preventive measures can be taken so that Köhler II disease can be prevented. It is advisable that, if the first signs already suggest that Köhler II disease may be involved, a physician should be contacted immediately. The earlier the diagnosis is made, the higher the chances of a positive course of the disease and a good prognosis.
Follow-up
After completing therapy, patients are relied upon to have their feet examined regularly. An orthopedic surgeon checks for relief of the metatarsal heads by palpating the metatarsus (palpation) and using imaging techniques such as an x-ray. If the disease has caused the bones to soften, the doctor also checks to see if there is any consolidation in the bone structure after treatment. The doctor may also do a blood count to detect any signs of bacteria. In most cases, however, this step is omitted. It is much more important to regularly check whether a prescribed soft padding insert or a shoe fitting in the form of a butterfly roll still provides sufficient relief. Since the soft padding compresses over time under permanent stress, patients with Köhler II disease regularly require new insoles or a new soft padding for their shoes. If the padding is too worn, there is a risk that the metatarsal heads will again be subjected to excessive stress. This can lead to recurrence of the disease despite completed therapy. To permanently improve circulation to the feet, patients are also often given a series of small home exercises to help them move their feet and relieve stress. This is an additional way to improve foot health.
Here’s what you can do yourself
In the case of Köhler II disease, the main focus for those affected is to provide relief for the foot. This can be helped by a shoe fitting called a “butterfly roll,” in which the area under the painful metatarsal bones is padded very softly. This means there is no pressure pain when walking and the feet can roll more easily. Soft cushion insoles for shoes can also help relieve pressure. To promote blood circulation to the foot bones, foot exercises are very important. Massage devices such as the hedgehog ball are popular for stimulating circulation through small pressure points while exercising the muscles under the bones. Patients can do small exercises in the comfort of their own homes, as they require little time or effort. Foot baths and curd compresses can also help. Most important, however, is that sufferers do not put unnecessary stress on their feet. Sports or permanent standing activities should be avoided until the blood circulation to the bones has improved. For women, it is also important not to wear high-heeled shoes, but rather shoes with flat heels. In addition, feet should be elevated more often or relieved by sitting down for a short time to prevent worsening of Koehler II disease.