Proximal Tibiofibular Dysfunction

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Proximal Tibiofibular Dysfunction

Mechanisms of injury for the proximal tibiofibular joint include direct impact trauma and forces arising out of twisting the lower leg or bending moments of the tibia. Aggravating factors for proximal tibiofibular joint sprain include injuries leading to dorsiflexion and eversion of the ankle, walking (particularly on uneven ground), and squatting. Some authors refer to biceps femoris hypertonicity as an associated finding which could cause a disturbance in the biomechanics of the pelvis and, as a result, leads to low back pain. The potential for irritation of the common peroneal nerve as it passes behind the swollen joint has also been suggested.

The proximal tibiofibular joint is described as a sliding synovial joint. In approximately 10% of cases, the joint capsule communicates with the tibiofemoral joint. Anatomical studies have revealed significant variations in the angle of the inclination of the proximal tibiofibular joint. Ogden classified the joint into two types as follows:

“The first type will be defined as horizontal. The fibular articular surface was usually planar (although it was slightly concave in some cases) and circular. The tibular surface articulated with a similarly planar, circular surface of the tibia. These articular surfaces were under and behind a projection of the lateral edge of the tibia) … The second type of proximal tibiofibular joint will be defined as oblique. The articular surfaces in this type were much more variable in surface area, configuration and inclination  . . .  The transition zone was chosen arbitrarily at 20°. The obliquity ranged all the way to 76°.”

Image Source: Ogden JA. The anatomy and function of the proximal tibiofibular joint. Clinical Orthopaedics and Related Research. 1974, No 101, p. 186-191.

With respect to the function of this joint, Ogden and other authors have noted that the fibula externally rotates with ankle dorsiflexion and that the fibular head slides forward with knee flexion (likely to be due to relaxation of the lateral collateral ligament and biceps femoris) and slides backward with knee extension.

Cause

• Direct impact injury to the lateral knee
• Indirect injury caused by excessive loading of the ankle or knee
• Ligamentous instability

• Lateral knee pain (which may radiate distally if the common peroneal nerve is also involved)
• Pain aggravation with knee and ankle movement (particularly ankle dorsiflexion)
• Pain relieved by rest

• Pain on palpation of the proximal tibiofibular joint or fibular head
• Local swelling in the region of the proximal tibiofibular joint
• Reduced fibular head motion (proximal tibiofibular joint dysfunction)
• Tightness in the hamstring muscles (particularly in the biceps femoris)
• Reduced knee extension caused by tightness in the hamstring muscles

Examples of red flags in patients presenting with knee pain:

• Severe pain
• Inability to bear weight
• Moderate to severe swelling
• Extensive bruising
• Deformity
• Severe tenderness on palpation or severe pain with any examination procedure

If any red flags are identified during history taking and clinical examination, referral for urgent medical evaluation and further investigation is warranted.

Joint Dysfunction

• We recommend using an instrument-assisted procedure to avoid or minimize further strain to the joint capsule and ligaments. Others may advocate manual manipulation using a high-velocity short amplitude thrust or mobilization.
• When injuries result in tibiofibular joint dysfunction, it may irritate the common peroneal nerve as it passes behind the joint. As such, manipulative methods for treating tibiofibular joint dysfunction should be carefully considered in order to avoid nerve irritation.

Common Peroneal Nerve Injury

Common peroneal neuropathy is the most frequently encountered mononeuropathy in the lower limbs and ranks as the third most common focal neuropathy overall. It follows median neuropathy (carpal tunnel syndrome) and ulnar neuropathy in terms of prevalence. The most typical clinical presentation is a weakness of ankle dorsiflexion, leading to the characteristic foot drop, which can manifest suddenly or gradually over a period of days to weeks. Another common symptom is stumbling or catching the toes while walking. Additionally, individuals may experience numbness or paresthesia along the lateral leg, dorsal foot, and/or the first toe webspace. While pain may be evident in traumatic cases, its presence is not consistent across all instances.

Lateral Knee Pain Differential Diagnosis 

In the adult age group, the differential diagnosis of lateral knee pain includes conditions such as:

• Proximal tibiofibular dysfunction
• Lateral collateral ligament injuries
• Lateral meniscal tears
• Iliotibial band Syndrome
• Vastus lateralis myofascial pain syndrome
• Popliteus tendinopathy
• Biceps femoris tendinopathy
• Proximal fibular fracture