Description of Proximal Tibiofibular Joint Pain
An injury to the proximal tibiofibular joint is rather rare, but can be debilitating in patients who have symptoms.
The proximal tibiofibular joint is located between the lateral tibial plateau of the tibia, and the head of the fibula. Typically, the proximal tibiofibular joint is injured in a fall when the ankle is plantar-flexed, with the stress being brought through the fibula, will cause the proximal fibula to sublux (partial dislocation) out of place over the lateral aspect of the knee joint. In other circumstances, significant trauma or a motor vehicle accident can cause a disruption of the proximal tibiofibular joint. In most circumstances, it is the posterior proximal tibiofibular joint ligament that is injured. This results in the fibula rotating away from the tibia during deep squatting.
Symptoms of an Injured Proximal Tibiofibular Joint:
- Instability of the joint, especially during deep squatting
- Visible bony deformity
- Concurrent irritation of the common peroneal nerve, because the common peroneal nerve crosses the lateral aspect of the fibular neck within 2-3 cm of the lateral aspect of the fibular head
The diagnosis of proximal tibiofibular joint instability is almost always based on a thorough clinical exam. In acute cases, it may be difficult to make the patient relax sufficiently to be able to examine for proximal tibiofibular joint instability, but usually having the knee flexed to 90 degrees and trying to perform an anterolateral subluxation maneuver of the proximal tibiofibular joint is sufficient to confirm this diagnosis. In chronic injuries, the instability may appear obvious when the patient performs a maximal squat.
It is important to compare the injured side to the normal contralateral side because some patients may have physiologic laxity of this joint. In more chronic cases, we have the patient squat down, which can often demonstrate that the proximal tibiofibular joint is being subluxed. Concurrent with this, we will perform a Tinel’s test by percussing over the common peroneal nerve to confirm the presence of dysesthesias or “zingers,” which translate down the leg.
Are you experiencing proximal tibiofibular joint instability?
There are two ways to initiate a consultation with Dr. LaPrade:
You can provide current X-rays and/or MRIs for a clinical case review with Dr. LaPrade.
You can schedule an office consultation with Dr. LaPrade.
(Please keep reading below for more information on this condition.)
Treatment of Proximal Tibiofibular Joint Instability
The treatment of proximal tibiofibular joint instability usually depends upon whether it is an acute or chronic injury. In acute cases, we have found that immobilization in a brace in full extension for 3 weeks is often very effective to allow the posterior proximal tibiofibular joint ligament tear to scar in sufficiently such that there is no instability. However, in chronic cases, immobilization would not be sufficient to achieve this goal. In cases where the symptoms of proximal tibiofibular joint instability are difficult to discern, especially for chronic cases, we have found that taping of the proximal tibiofibular joint is helpful to confirm the diagnosis. In order to best treat this pathology, Dr. LaPrade and his team have developed an anatomic proximal posterior tibiofibular joint reconstruction procedure. We have found it to be very effective at restoring stability to this joint and not resulting in joint overconstraint. In the past, while others have often treated this instability of this joint by fusing it, we have reported through research that a proximal posterior tibiofibular joint ligament reconstruction is easily performed, does not overconstrain the joint and has decreased the chance of leading to ankle pathology further down the line.
In addition, we frequently perform a common peroneal nerve neurolysis concurrent with the ligament reconstruction to release the scar tissue around the common peroneal nerve so that any further nerve irritation will not occur after surgery due to postoperative swelling or scar tissue entrapment.
Post-Operative Care
Patients who undergo this reconstruction are kept on crutches for 6 weeks with no to minimal weight-bearing movement, but are allowed full range of motion. After 6 weeks postoperatively, patients may start to use a stationary bike with low resistance. We anticipate that our patients will return back to full activities about 4-5 months after surgery, following the rehabilitation program.
Proximal Tibiofibular Joint Instability FAQ
1. What type of taping is used for proximal tibiofibular joint instability?
A more definitive way to validate a diagnosis of proximal tibiofibular joint instability is with a taping program of the joint. Taping of the proximal tibiofibular joint, in a reverse direction to pull it away from the tendency to anterolateral subluxation, can be very effective at obtaining a validated clinical response in a patient who has injuries to this joint.
2. What is instability of the proximal tibiofibular joint?
Instability of the proximal tibiofibular joint occurs when the ligaments which provide stability to this joint are injured. Because the joint is relatively inherently stable because of its bony anatomy when the knee is out straight, most cases of proximal tibiofibular joint instability occur when the knee is bent.
3. Are there any exercises for proximal tibiofibular joint instability?
There are no specific exercises for proximal tibiofibular joint instability. This is because there are no muscles that can control the joint for most activities of daily living. Whereas the short and long heads of the biceps do attach the fibular head, they aren’t in a force vector position well enough to be able to hold the joint stable when one performs deep flexion activities or any rotational activities with the knee bent that involve the proximal tibiofibular joint.
4. What is the treatment of proximal tibiofibular joint instability?
The treatment of proximal tibiofibular joint instability depends upon the time of presentation. If one obtains the diagnosis soon after injury (acutely), immobilization of the knee in extension for a few weeks to try to get the posterior injured ligaments to heal is reasonable. If one has a chronic proximal tibiofibular joint injury, we prefer to trial taping to validate that the symptoms of the proximal tibiofibular joint injury are improved with the taping program. This helps us to confirm that the patient does have instability of the proximal tibiofibular joint which may require surgery.
5. What is the surgical treatment for proximal tibiofibular joint instability?
The surgical treatment for proximal tibiofibular joint instability most often consists of an anatomic reconstruction of the torn ligaments. The vast majority of the time, the torn ligaments are the posterior proximal tibiofibular joint ligaments, so a graft which is placed in the anatomic position to restore these ligaments has been proven to be successful. In general, reaming a tunnel from front to back (anterior to posterior) through the fibular head and having it exit where the proximal tibiofibular joint posterior ligaments attach, and then drilling another tunnel from front to back on the tibia and which exits posteriorly at the attachment site of the proximal posterior tibiofibular joint ligaments, is the desired location for an anatomic-based reconstruction graft. Most commonly, hamstring allografts and autografts are used to reconstruct the proximal tibiofibular joint anatomically. In general, we prefer an autograft (using one’s own tissues) because it will heal in faster than an allograft (cadaver graft).
6. What is the postoperative rehabilitation program for proximal tibiofibular joint instability?
In order to ensure that the ligament heals without having it stretch out, it is recommended that the patients be non-weight or toe-touch weight bearing for the first six weeks to ensure that the joint is not overloaded to allow the reconstruction graft to start to heal in the tunnels. In addition, patients should avoid any deep squatting, or squatting and twisting, because this puts a significant amount of stress on this joint, for the first four months postoperatively.
We advise that patients initiate a program of weaning off the crutches at the six week point and starting the use of a stationary bike to regain the strength of their quadriceps mechanism. Most patients are cleared to begin full activities between four to six months postoperatively, assuming they have adequate restoration of proximal tibiofibular joint stability, pain relief, and return of strength, agility and endurance.
