Koehler II Disease

Aseptic necrosis of the bone (predominantly the metatarsal bone or segments II to IV) is described as Köhler II disease. Above all, Köhler II disease, in contrast to Köhler I disease, occurs mainly in young women and girls.

Koehler II Disease

What is Koehler II disease?

Köhler II disease represents aseptic bone necrosis of the 2nd metatarsal head.

Girls between the ages of 12 and 18 are particularly affected. See homethodology for Cardiogenic Shock Overview.

The causes of the disease have not yet been sufficiently clarified.

The disease is also known under the synonyms Morbus Köhler-Freiberg, Morbus Freiberg Köhler, juvenile osteochondrosis of the metatarsus or osteochondrosis of the metatarsal heads.


The reasons for Köhler II disease have not yet been clarified. However, doctors assume that shoes that are sometimes too tight or high-heeled can very well promote the disease. However, this theory has not yet been clearly proven. Sometimes the theory of overloading is also advocated.

If the bone is permanently overloaded, this represents a favorable factor for Morbus Köhler II. Trauma, which subsequently causes a malposition of the foot, can sometimes trigger Morbus Köhler II. However, these are only theories; the cause of Köhler I disease has not yet been 100 percent clarified.

Symptoms, Ailments & Signs

The patient initially complains of pain in the foot. The pain occurs mainly when the foot is loaded. However, parents and medical professionals cannot perceive external injuries or changes; sometimes the only clue is swelling in the affected area.

It is possible that the swelling also occurs in the front area; the swelling increases if you continue to put weight on the foot even though it is causing pain. Those affected state that rolling movements cause pain; In the advanced stage of Köhler II disease, the classic painful limping occurs, which subsequently leads to a relaxed posture or a gentle walk.

Diagnosis & course of disease

If Köhler II disease is suspected, the doctor must carry out various examinations so that the suspected diagnosis can be secured. An X-ray of the foot is taken for this purpose. The foot is X-rayed once from the side and then from above. While a narrowing and compression of the scaphoid is visible in Köhler I disease, the doctor sees a flattening and shortening of the metatarsal bone in Köhler II disease.

If Köhler II disease is already in an advanced stage, the doctor can detect any changes in the so-called metatarsophalangeal joint. This change subsequently also causes severe pain when walking or rolling. It is important that – if the first changes in the metatarsophalangeal joint are already recognizable – therapy is carried out here so that further damage can be prevented.

This is the only way the patient can 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. Operations are usually required; This is also because Köhler II disease 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 feels mild discomfort for the rest of his life. In exceptional cases, the sole of the foot has to be stiffened, which sometimes means restrictions in mobility.


In most cases, Köhler II disease primarily leads to severe pain and other unpleasant symptoms in the feet. The pain can be burning or stabbing and lead to sleep disturbances, especially at night. It is not uncommon for sleep disorders to lead to irritability in the patient and can significantly reduce resilience.

Those affected feel tired and exhausted by the disease and usually do not actively participate in life. The pain occurs especially when the feet are put under strain, so that there are significant restrictions and complaints when moving. Children can no longer practice sports and Köhler II disease leads to a developmental disorder. It is not uncommon for severe swelling to occur on the foot, which makes the patient’s everyday life significantly more difficult.

There are no particular complications in the treatment of Köhler II disease. The symptoms can be limited and reduced relatively well either by surgery or by various therapies. As a rule, however, the affected person is no longer allowed to put too much weight on his foot. However, life expectancy is not reduced by this disease.

When should you go to the doctor?

Girls between the ages of twelve and eighteen tend to develop Köhler II disease. If those affected in this risk group experience health changes or irregularities, they should see a doctor. Pain in the foot, visual abnormalities in the foot or toes and a change in locomotion must be examined by a doctor. You should completely refrain from taking any pain medication until you have consulted your doctor. It is characteristic of the disease that often no injuries can be identified externally. Nevertheless, swelling or slight thickening are signs of health problems.

A visit to the doctor is advisable as soon as there is reduced physical performance or sporting activities can no longer be carried out as usual. If the affected person adopts a relieving posture due to the symptoms, if there is an overall crooked posture of the body or if a limp occurs, a doctor is needed.

If, in addition to the physical symptoms, emotional or psychological abnormalities occur, a doctor’s visit is recommended. Although the affected person is going through puberty, withdrawal from social life, changes in behavior or mood swings can also be indicators of an additional health disorder that should be investigated and clarified.

Treatment & Therapy

Doctors have two treatment options for Köhler II disease: conservative and surgical. If the physician opts for conservative therapy, attention is primarily paid to promoting blood circulation and also relieving the foot.

If Köhler II disease is detected in an early stage or if there are only minor symptoms and the symptoms are so minor that there are no actual restrictions, a ban on sports and immobilisation of the foot (e.g. with relieving bandages) can be positive. Sometimes the doctor can also put on a lower leg cast, which is removed after six weeks.

Other options that are available as part of conservative therapy are insoles or physiotherapeutic measures. Methods that promote circulation, such as applying certain ointments, can also alleviate the symptoms and also provide direct treatment for Köhler II disease.

However, if conservative therapy is unsuccessful or if Köhler II disease was only diagnosed at an advanced stage, the doctor must consider surgical treatment. Drilling was carried out just a few years ago; Today, medicine knows that that surgical technique did not bring convincing results.

If there is little joint wear, an articulated toilet is usually 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 proven itself and is preferably used when the physician is of the opinion that only an operation can actually improve the patient’s quality of life.

Outlook & Forecast

Köhler II disease is usually diagnosed at a late stage, which means that the chances of recovery are low. Affected people must therefore come to terms with restrictions. As a rule, an operation takes place, which means that doctors cannot restore the original condition. The prognosis is therefore mixed. Certain types of sports and permanent stress should then be avoided. However, Köhler II disease does not result in a reduction in life expectancy.

The disease occurs mainly in girls. According to statistical surveys, there are four female patients for every male patient. The greatest risk for complaints is between the ages of 12 and 18. If treatment is refused, arthrosis regularly develops in adulthood. Pain during exertion, but also when resting, is present every day. Many patients have to use aids such as insoles in order to be able to move freely without any problems.

The best prospects arise if Köhler II disease is diagnosed before arthrosis develops. Stiffening cannot always be remedied. Conservative methods are always to be preferred. They allow the best treatment success in the early stages without surgical intervention.


Due to the fact that no causes are known so far, no preventive measures can be taken to prevent Köhler II disease. It is advisable that if the first signs suggest that it could be Köhler II disease, a doctor is contacted immediately. The earlier the diagnosis is made, the higher the chances of a positive course of the disease and a good prognosis.


After completing therapy, patients are dependent on having their feet examined regularly. An orthopaedist checks the metatarsal (palpation) and imaging methods such as an X-ray to determine whether the metatarsal heads are relieved. If the disease has caused the bones to soften, the doctor will also check whether the bone structure has hardened after the treatment.

The doctor may also do a blood test to check for any signs of bacteria. In most cases, however, this step is omitted. It is much more important that it is regularly checked whether a prescribed soft padding or a shoe adjustment in the form of a butterfly roll still offers sufficient relief.

Since the soft padding compresses over time under constant stress, patients with Köhler II disease regularly need new insoles or new soft padding for their shoes. If the pad is too worn, there is a risk that the metatarsal heads will be put under excessive stress again. This can lead to a recurrence of the disease despite a completed therapy.

In order to permanently improve the blood circulation in the feet, patients are often given a series of small exercises to do at home so that they can move and relieve their feet. In this way, the health of the feet can be further improved.

You can do that yourself

In the case of Köhler II disease, the priority for those affected is to relieve the foot. A shoe adjustment, called “butterfly roll”, can help with this, in which the area under the painful metatarsal bones is very softly padded. As a result, there is no pressure pain when walking and the feet can roll off more easily. Soft padding insoles for the shoes can also contribute to the relief.

Foot exercises are very important to promote blood circulation in the bones of the feet. Massage devices such as the hedgehog ball are often used to stimulate blood circulation through small pressure points and at the same time to train the muscles under the bones. Patients can do small exercises in the comfort of their own homes, as they require little time and little effort. Foot baths and quark wraps can also help.

The most important thing, however, is that those affected do not put unnecessary strain on their feet. Sport or prolonged standing activities should be avoided until blood flow to the bones has improved. Women are also not allowed to wear high-heeled shoes, but rather use shoes with flat heels. In addition, the feet should be put up more often or relieved by sitting down for a short time in order to prevent Köhler II disease from getting worse.