Knee
Tibiofibular Joint Instability
What is the proximal tibiofibular joint?
The proximal tibiofibular joint is located between the lateral tibial plateau of the tibia (shinbone), and the head of the fibula (small long bone on the outside of the leg).
What causes a proximal tibiofibular joint injury?
Classically, the proximal tibiofibular joint is injured in a fall when the foot is downwards (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.
What are the symptoms of proximal tibiofibular instability?
The symptoms of a proximal tibiofibular instability can vary depending on the severity of the injury, but common signs and symptoms include:
- Pain: Pain around the knee is a primary symptom. The intensity of the pain may vary, but it is typically aggravated by movement or putting weight on the affected leg or when rotating the leg.
- Instability: This can be perceived as motion or true dislocation of the fibular head on the tibia.
- Deformity: In more severe cases the fibular head can be dislocated an observed through the skin.
- Crepitus: Some individuals may experience a grating or crunching sensation (crepitus) when osteoarthritis has developed.
How do you diagnose a proximal tibiofibular instability?
The combination of a detailed history, comprehensive physical examination, x-rays, and possibly an MRI is the key to a successful diagnosis of a proximal tibiofibular instability. Dr. Bryan Penalosa and his team will complete a thorough exam to evaluate your range of motion, stability, and points of tenderness to palpation. Specifically, in acute cases, it is sometimes challenging 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 always important to perform the exam on both legs to ensure that there is a significant difference from one side to the other. 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. X-rays will be obtained to allow Dr. Bryan Penalosa to assess the position of the fibular head. An MRI may be ordered to observe the anterior and posterior ligamentous complexes.
Tibiofibular Joint Instability Non-Surgical Treatment
Can proximal tibiofibular joint instability be treated without surgery?
The proximal tibiofibular joint instability without surgery depends on the severity and specific characteristics of the injury. In some cases, especially with acute or less severe chronic cases, non-surgical or conservative approaches may be considered.
For patients who are candidates for non-operative treatment, the focus of care will be on reducing pain, inflammation, while also improving overall stability and function of the proximal tibiofibular joint.
Rest and Immobilization:
During the initial period after the injury, it is essential to rest the knee and avoid activities that worsen the pain. In acute cases, immobilization in a brace in full extension for 3 weeks is often very effective in allowing the posterior proximal tibiofibular joint ligament tear to scar in sufficiently such that there is no instability.
Oral Anti-Inflammatories, Ice, and Compression:
Oral anti-inflammatory and pain-relieving medications, such as Meloxicam, Naproxen, Advil, or Ibuprofen, may help to manage the pain and reduce inflammation of the knee. Applying ice packs and compression to the knee can also help reduce swelling and inflammation. Remember to use a cloth or towel between the ice pack and your skin to avoid frostbite.
Physical Therapy:
A structured physical therapy program can be beneficial for strengthening the muscles around the knee and improving overall joint stability. A physical therapist can guide you through exercises that focus on the quadriceps, hamstrings, and calf muscles to provide this additional support to the knee. Additionally, proprioceptive training can enhance knee stability. Proprioception is the body’s ability to sense joint position and movement, and improved proprioception can help with knee stability and control during activities. It is important to complete any home exercises that your physical therapist provides to you in order to optimize your recovery.
Intra-Articular Knee Injections:
The goal of an intra-articular injection is to manage pain and inflammation of the tibiofibular joint when arthritis has settled.
Tibiofibular Joint Instability Surgical Treatment
What are the surgical options for a tibial plateau fracture?
Surgical intervention is often necessary for more severe proximal tibiofibular joint instability cases stabilize the joint. If surgery is needed, it is best to proceed as soon as possible following the injury. The specific surgical approach depends on the characteristics of the injury (anterior vs posterior or both).
Dr. Chahla and other researchers have developed techniques to restore stability to this joint without over constraining the joint. 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, replicating the native anatomy and biomechanics 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.
Recovery from Proximal Tibiofibular Reconstruction
What is the expected recovery from a proximal tibiofibular reconstruction?
Your recovery from a tibial plateau ORIF will begin the first day after your operation. Immediate physical therapy intervention allows for optimal recovery of one’s range of motion and muscle re-activation. Subsequent phases of post-operative rehabilitation are strategically outlined to enhance recovery and prevent future injury. Immediately following surgery, you will be non-weight bearing for 6 weeks, as the ligaments site needs to heal before weight can be applied to the operative leg. Compliance with the non-weightbearing recommendation is critical in overall success from the surgery. Additionally, 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. 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.