http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2564106/
(2006)
Proximal tibiofibular dislocation
Four injury patterns have been described.3 Subluxation occurs in preadolescent girls and is usually atraumatic.4 Anterolateral dislocation is the commonest injury pattern, accounting for 85% of dislocations. It is usually described after a fall with the knee flexed, the ankle inverted, and foot plantar flexed. Posteromedial dislocation occurs in 10%. The mechanism is usually direct trauma, such as a blow from the bumper of a car or banging the knee against a gate post while horse riding. This is associated with a transient common peroneal nerve injury. Superior dislocation occurs in approximately 2% and is most often associated with high energy ankle injuries and also common peroneal injury.
Diagnosis is largely clinical, relying on suspicion for the injury.1 The findings on examination may be quite subtle, and are easily missed.2 Clinical features may include: lateral knee pain aggravated by pressure over the fibular head, limited knee extension, crepitus, visual deformity, and locking or popping.4,5 Ankle movement may exacerbate knee pain.4 There may be transient peroneal nerve palsy, especially with posterior or superior dislocations.4
Ankle movement may exacerbate knee pain... and visa versa...
http://www.wheelessonline.com/ortho/proximal_tibiofibular_joint_injuries
(On website)
anterolateral dislocation
- fall on a flexed knee with the foot inverted and plantarflexed
- flexion leads to LCL laxity, predisposing to lateral dislocation
- peroneal muscles, EHL and EDL pull the proximal fibula anteriorly
- most common pattern of proximal tibiofibular dislocation (>85%)
- lateral knee pain, swelling, and prominence of the fibular head
- ankle motion exacerbates knee pain
- may be unable to bear weight secondary to pain
Ankle motion exacerbates knee pain, but perhaps more in my case, knee movement exacerbates ankle pain.
http://www.ajronline.org/doi/pdf/10.2214/AJR.06.0627
(2006)
Proximal Tibiofibular Joint: An Often-Forgotten Cause
of Lateral Knee Pain
The proximal tibiofibular joint is often injured by direct trauma. However, indirect forces causing varus strain, hyperflexion, or hyperextension can also lead to significant injuries, including fracture, dislocation, ligament strains (Fig. 8) and tears, and injury to the neurovascular bundle. The popliteus tendon, lying
in close proximity to the proximal tibiofibular joint, should be carefully assessed for either an isolated tear (Fig. 9) or involvement in a more complex posterolateral corner injury.
Fig
Diagram of the extensor digitorum longus muscle used to bend the four small toes upwards. Also to assist in bending the foot at the ankle up toward the body, taken from http://thewellnessdigest.com/extensor-digitorum-longus-pain-in-the-top-of-the-foot/
Fig
Diagrams of the types of proximal tibiofibular joint dislocation (arrows): A, anterolateral dislocation; B, posteromedial dislocation; C, superior dislocation, taken from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3445190/
Proximal Tibiofibular Joint
Damage to the proximal tibiofibular joint is easy to miss. Diagnosis is often based on history, so it is very important that the events leading up to the injury are noted.
Diagnosis
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2564106/
(2006)
Diagnosis is largely clinical, relying on suspicion for the injury.1 The findings on examination may be quite subtle, and are easily missed.2 Clinical features may include: lateral knee pain aggravated by pressure over the fibular head, limited knee extension, crepitus, visual deformity, and locking or popping.4,5 Ankle movement may exacerbate knee pain.4 There may be transient peroneal nerve palsy, especially with posterior or superior dislocations.4
AND knee movement may exacerbate ankle pain... ?
Damage and symptoms
http://www.sportsinjurybulletin.com/archive/tibiofibular-joint-damage#
(On website)
Anatomy of the tibiofibular joint
The two long bones of the lower leg, the tibia (shin bone) and the fibula (outer leg bone) are bridged together at three distinct regions:
* the tibiofibular articulation at the knee
* the tibiofibular syndesmosis at the ankle
* a thin fibrous tissue along the length of the two bones, known as the interosseous membrane (1).
These connections enable the two bones to work together to coordinate ankle and knee movements.
The tibiofibular articulation at the top of the bones (connecting the head of fibula and lateral condyle of tibia) is an ‘arthrodial’ or ‘plane-type’ joint which allows only slight gliding movement between the two surfaces. The contiguous surfaces of the bones are covered with cartilage and are connected with an articular capsule. This is reinforced by two or three broad, flat bands of ligament (anterior superior ligament) in front and a single thick band of ligament (posterior superior ligament) behind. Both ligaments pass obliquely upwards from the head of the fibula to the lateral condyle of the tibia. The tendon of the popliteus muscle, which plays a significant role in posterolateral knee stability, lies close to the posterior superior ligament. An injury to this region may therefore involve both these structures.
A synovial membrane, similar to that found inside the knee joint lines the inner surface of the capsule of the proximal tibiofibular joint. In 10% of the population, this synovial space is continuous with that of the knee joint. The common peroneal nerve winds about the neck of the fibula close to the lower edge of the joint, where it is vulnerable to injury. Such an injury may lead to foot drop and loss of sensation in parts of the leg and feet.
10% where the proximal tibiofibular joint is contiguous with the knee joint... Can their PTFJ dislocate...??? Or not...???
A complex play of muscles and ligaments
The nature of the traumatic event dictates the way in which the proximal tibiofibular joint will dislocate. Although there are three main reported types of dislocation, the usual one in sporting contexts is anterolateral. It occurs as a result of a complex interplay of sudden abnormal movements in the muscles controlling the ankle and knee, typically following a sudden inversion and plantar flexion of the foot, together with simultaneous knee flexion and twisting ofthe body.
In a flexed knee the biceps femoris tendon and lateral collateral ligaments are relaxed. This, along with the external rotational torque of the tibia on the foot during twisting of the body, springs the head of the fibula out laterally. At this point a violent contraction of the peroneal muscles, the extensor digitorum longus and the extensor hallucis longus (caused by sudden inversion and plantar flexion of the foot), pulls the fibula forward.
NOTE: The use of the phase 'a violent contraction' may be suggestive of the 'violent, violent, violent pain' that I had whilst jogging.
In a flexed knee the biceps femoris tendon and lateral collateral ligaments are relaxed... as is the popliteus tendon.
Signs and symptoms
It is easy to miss this injury, as the findings on examination may be subtle. Diagnosis is often based on history of presentation and a strong clinical suspicion. Clinical features may include:
* outer-knee pain which is aggravated by pressure over the fibular head
* limited knee extension
* crepitus (grinding) on knee movement
* pain on weight bearing
* visible deformity
* locking or popping.
Ankle movement may exacerbate the knee pain. There may be temporary peroneal nerve palsy, presenting as pins and needles or numbness on the outer side of the leg (although this symptom is less likely in the anterolateral form of dislocation associated with athletic trauma).
The treatment options also vary with the pattern of dislocation. In acute anterior dislocation, the joint is treated with closed reduction and immobilisation of the knee in extension for two or three weeks.
In cases of chronic instability, a more complicated surgical process is advocated, involving resection of fibular head, reduction and temporary internal fixation, arthrodesis and tendon reconstruction(7-9).
Unrecognised dislocations often present with peroneal nerve symptoms such as pins and needles in the leg or feet, or weakness of foot movements. Failed conservative management may bring about chronic knee pain and ankle pain. This may also follow arthrodesis(10) of the joint. Resection of the fibular head is believed to affect knee stability and gait.
NOTE: Definition...
http://medical-dictionary.thefreedictionary.com/arthrodesis
ar·throd·e·sis (är-thrd-ss, ärthr-dss)
n.
The surgical fixation of a joint to promote bone fusion. Also calledartificial ankylosis, syndesis.
Mechanism of anterolateral dislocation
This describes how I believe my injury occurred:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2397423/
(2008)
Dislocation of the fibular head in an unusual sports injury: a case report
The mechanism of the anterolateral dislocation is inversion and plantar flexion of the ankle that causes tension in the peroneal muscles, extensor digitorum longus and extensor hallucis longus and thus applies a forward dislocating force on the proximal fibula. Flexion of the knee relaxes the biceps tendon and the fibular collateral ligament. Twisting of the body at this point is transmitted along the femur to the tibia, which causes an external rotatory torque of the tibia. Rotatory torque of the tibia along with relaxation of the biceps tendon and collateral ligament causes the fibula to displace laterally while the tensed muscles pull it anteriorly.
This description seems to cover most things, and even includes issues with the extensor digitorum longus which is responsible for extending the small toes which clearly isn't working properly in my right foot.
Rotatory torque of the tibia along with relaxation of the biceps tendon and collateral ligament causes the fibula to displace laterally while the tensed muscles pull it anteriorly... Note that as the biceps femoris is relaxing because of flexion of the knee, then shouldn't the popliteus structures do likewise...???
?????????????????????????????????
I did have a panic just then... Looking at the diagrams of the types of proximal tibiofibular joint dislocation, I was under the impression that the anterolateral dislocation was 'B', where the fibular head did not appear to stick out too far from the tibia. But that is the posteromedial dislocation... 'A' is the anterolateral dislocation...
This is worrying, because I was also going to mount a case to explain why my injury might have been overlooked... As I sit with my knees bent at 90 degrees and look at my knees, and feel the fibular head on each knee simultaneously, it feels to me like the good, left fibular head protrudes more than the bad, right one...!!! But then it is over 8½ years since the injury occurred and I have put on such a lot of weight due to inactivity... and the diagram shows sketches/drawings at different angles which may not be completely accurate.
I cannot change my mind because ALL the evidence supports an anterolateral dislocation, even the fact that these constitute 85% of all PTFJ dislocations. I've got to play the percentages... BUT BARE THIS IN MIND...!!!
?????????????????????????????????
http://drrobertlaprademd.com/proximal-tibiofibular-ligament-instability
(On website)
DESCRIPTION OF PROXIMAL TIBIOFIBULAR JOINT PAIN
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.
If the posterior proximal tibiofibular joint ligament is more likely to be injured than the anterior ligament, then why isn't the popliteus system helping out...??? Perhaps it can't...!!!
Squats are a problem for me
I have over the years been given physiotherapy exercises to do learning against a wall and 'squatting', and I can do them. But my good, left leg is helping out/covering for its wounded contralateral partner. When I attempted to ensure that the bad, right leg was doing more of its fair share of work, I had a violent pain around the head of the right fibular. I only ever tried this once... too scared!
NOTE: Definition...
http://medical-dictionary.thefreedictionary.com/dysesthesia
dysesthesia [dis″es-the´zhah]
1. impairment of any sense, especially of the sense of touch.
2. a painful, persistent sensation induced by a gentle touch of the skin.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2564106/
(2006)
Proximal tibiofibular dislocation
Four injury patterns have been described.3 Subluxation occurs in preadolescent girls and is usually atraumatic.4 Anterolateral dislocation is the commonest injury pattern, accounting for 85% of dislocations. It is usually described after a fall with the knee flexed, the ankle inverted, and foot plantar flexed. Posteromedial dislocation occurs in 10%. The mechanism is usually direct trauma, such as a blow from the bumper of a car or banging the knee against a gate post while horse riding. This is associated with a transient common peroneal nerve injury. Superior dislocation occurs in approximately 2% and is most often associated with high energy ankle injuries and also common peroneal injury.
Diagnosis is largely clinical, relying on suspicion for the injury.1 The findings on examination may be quite subtle, and are easily missed.2 Clinical features may include: lateral knee pain aggravated by pressure over the fibular head, limited knee extension, crepitus, visual deformity, and locking or popping.4,5 Ankle movement may exacerbate knee pain.4 There may be transient peroneal nerve palsy, especially with posterior or superior dislocations.4
Ankle movement may exacerbate knee pain... and visa versa...???
http://www.drsarahsimison.com/biomechanics-blog/fibular-head-and-associated-lateral-knee-pain
(On website)
Actions of the fibula relate to upper leg and down to the foot
... one thing stands out - the lateral hamstring (biceps femoris) is the only upper leg muscle that attaches to the fibula. However it is a large muscle and a prime mover for knee flexion. Interestingly, since the long head of the biceps femoris also attaches to the pelvis it is also a hip extensor. This muscle acts best as a hip extensor when the knee is flexed, and as a knee flexor when the hip is flexed. It is inefficient at producing both movements simultaneously. ???????????
Interestingly the fibula is also the origin for many of the muslces that insert into the toes. This makes it an integral portion of both the lateral kinetic chain as well as the chains that run through the deeper sections of the front of the body. It plays an important role in transmitting forces from the knee to the ankle.
It seems to me that the fibular is exerting forces from the knee to my ankle producing pain in my ankle, and the biceps femoris attaches to the fibula and to the pelvis, producing pain in my groin.
I am guessing that the reverse it also true: the fibular is exerting forces from the ankle to my knee producing pain in my knee.
eot
sot
Anatomic reconstruction of chronic symptomatic anterolateral proximal tibiofibular joint instability.
The most important finding of the present study was that an anatomic reconstruction of the proximal tibiofibular joint restored stability for patients with chronic, symptomatic proximal tibiofibular joint anterolateral subluxation. The proximal tibiofibular joint is stabilized by both its anterior and posterior ligamentous attachments [7, 10]. The anterior aspect of the proximal tibiofibular joint consists of two to three flat ligamentous bands and is reinforced by the biceps femoris tendon, which makes it stronger and less likely to tear than the posterior ligament, which exists as only a single band [1, 16]. Subluxation of this joint is rare and primarily reported in case studies. When reported, the most common dislocation is anterolateral with disruption of the posterior capsular ligaments commonly caused by a fall onto a hyperflexed knee with a plantar flexed foot [3, 4, 7, 8, 10]. Patients with this pathology commonly present with lateral knee pain during deep flexion, common peroneal nerve symptoms, and anterior translation of the fibula on physical exam [7, 8, 11, 12]. This was the mechanism of injury, presenting symptoms, and disrupted ligament for both patients presented in this report.
Acute injuries may be treated conservatively with activity modification, physical therapy, supportive straps, and immobilization. However, patients with chronic pain and instability may require surgical intervention. Previ- ously reported surgical interventions include arthrodesis, fibular head resection, reconstruction of the proximal tibi- ofibular joint with a portion of the biceps femoris tendon, iliotibial band, and temporary fixation of the fibular head [2, 3, 6, 17]. To this point, the ideal treatment for patients requiring surgical intervention has not been well defined. In fact, some of these interventions have been reported to cause pain and instability of the lateral knee and ankle joint and are not recommended in children and athletes [4, 8, 9, 11]. A new anatomic reconstruction technique for chronic anterolateral proximal tibiofibular instability utilizing an autogenous semitendinosus tendon was presented. These patients had posterior proximal tibiofibular ligament dis- ruption leading to anterolateral fibular subluxation that was eliminated by an anatomic reconstruction. Both patients returned to normal activity, with satisfactory knee function and improved IKDC subjective knee and Cincinnati Knee Survey scores. Moreover, there were no post-operative or long-term complications related to this procedure.
Tibiofibular Hypomobility
As I read sections of this article, I am wincing and wrenching in agony because it is very similar to my injury in many ways, and so very different in other ways.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2953316/
(2009)
Treatment of Lateral Knee Pain by Addressing Tibiofibular Hypomobility in a Recreational Runner
Abstract
Background
Altered joint arthrokinematics can affect structures distal and proximal to the site of dysfunction. Hypomobility of the proximal tibiofibular joint may limit ankle dorsiflexion and indirectly alter stresses about the knee.
Objectives
To examine the effect of addressing hypomobility of the proximal tibiofibular joint in an individual with lateral knee pain.
Case Description
A 24 year old female recreational runner presented with a three month history of right lateral knee pain. Limited right ankle dorsiflexion was noted and determined to be related to decreased mobility of the proximal tibiofibular joint, as well as, the talocrural and distal tibiofibular joints. Functional movement deficits were noted during the squat test and step down test. Treatment was performed three times over the course of two weeks which included proximal tibiofibular joint manipulation and an exercise program consisting of hip strengthening, balance, and gastrocnemius/soleus muscle complex stretching.
Outcomes
Immediately following intervention, improvements were noted for ankle dorsiflexion, squat test, and step down test. One week following the initial intervention the patient reported she was able to run pain free.
Discussion
Addressing impairments distant to the site of dysfunction, such as the proximal tibiofibular joint, may be indicated in individuals with lateral knee pain.
INTRODUCTION
The knee joint is the most commonly injured joint for runners and typical injuries include patellofemoral pain, iliotibial band syndrome, meniscus lesions, and patellar tendinopathy.1Knee pain about the lateral aspect of the knee is less commonly described and primarily thought to be related to iliotibial band syndrome2 or a lateral meniscus lesion.3 In the absence of these two conditions, other less common presentations could be lateral plica, fabella syndrome, biceps tendinosis, or popliteus tendinosis. A thorough examination of the local structures as well as distant sites may be helpful in the differential diagnosis of lateral knee pain.
An adjacent structure which may contribute to lateral knee pain is the proximal tibiofibular joint.4–6 Previous authors5, 6 have suggested that hypermobility of the proximal tibiofibular joint may be a source of lateral knee pain. During ankle dorsiflexion, torsional stress is placed through the proximal tibiofibular joint, via external rotation and anterior glide of the fibula.6 Decreased mobility of the proximal tibiofibular joint may subsequently limit ankle dorsiflexion range of motion (ROM). Ankle dorsiflexion restrictions have been previously associated with anterior knee pain7, 8 and are thought to be due to gastrocnemius/soleus tightness or talocrural joint hypo-mobility. No study has discussed the potential for hypomobility of the proximal tibiofibular joint and the contribution to lower extremity dysfunction. The purpose of this case report was to examine the effect of addressing hypomobility of the proximal tibiofibular joint in an individual with lateral knee pain.
So similar, but very different:
Age... this patient was 24 years of age; I was 55 when the injury occurred in 2006, and am a tad older now,
Mobility... this patient is still running albeit with pain... I could then, and can now, barely walk... let alone run...
New reduction technique
(2014)
http://www.europeanreview.org/wp/wp-content/uploads/93-95.pdf
A new technique of reduction for isolated proximal tibiofibular joint dislocation: a case report.
Abstract Isolated proximal tibiofibular joint dislocation (PTFD) is associated with a severe twisting, inversion and plantar flexion of the foot, simultaneously with knee flexion and external rotation of the leg1,2; it may also occur following direct high energy trauma to the knee1,3,4.
Dislocation of the proximal end of the fibula is not always an isolated injury, as it is usually described. According to the literature, it may be associated with tibial fractures, femoral-shaft or head fracture, dislocation of the knee, fibular fracture and anterior fracture-dislocation of the distal femoral epiphysis.
The patient usually present with pain along the lateral side of the knee and leg. This could be elicited by direct pressure over the fibular head (pushing it either forward or medially).
Antero-posterior radiographs of the knee usually show the proximal fibula and tibia overlain5. In the majority of the cases, comparison between anterior and lateral radiographs on the two knees helps to confirm the diagnosis of fibular head dislocation6. Computed Tomography scan (CT scan) is indicated for better assessment of the joint and in case of diagnostic doubts7-9...
Patient was placed in supine position; she was asked to flex her knee more than 90 degree while the surgeon was applying a counterforce to the heel using his palm (Figure 2). Simultaneously, a gentle direct pressure was applied to the fibular head to move it to the apex of the lateral tibial ridge. Complete range of motion and pain relief was observed immediately following this maneuver. CT scan confirmed the correct repositioning of the fibular head (Figure 3); the knee was immobilized in slight flexion position for three weeks.
QUESTIONS: It seems to me that:
-
anterolateral tibiofibular dislocations might not ever be entirely isolated... subluxation of many tendons and ligaments...???
-
need to avoid lax, snapping tendons of the biceps femoris and popliteus and/or the popliteofibular ligament, and also the peroneal nerve structures,
-
do lateral meniscus tears negate this as an isolated dislocation, or are they a consequence of the dislocation...???
-
etc.
Neuropathy
http://www.ncbi.nlm.nih.gov/pubmed/21600446
(2011)
Peripheral nerve entrapments of the lower leg, ankle, and foot.
https://depts.washington.edu/neurolog/images/emg-resources/Fibular_Peroneal_Neuropathy.pdf
Acute or chronic exertional compartment syndrome may also result in foot drop and
should be considered, particularly in athletes with intermittent complaints.36 Superficial fibular nerve injuries at the ankle have been described in soccer players.34 Due to excursion of superficial nerve with inversion, injury may be seen in association with ankle inversion sprains.37,38 Nerve abnormalities may also occur at the fibular head in the setting of ankle sprains due to traction of the nerve at the posterolateral knee because the patient’s foot is forced into plantar flexion and inversion.39
I have lateral knee pain that includes sharp, pulling feelings that I think may well be caused by the displaced the peroneal nerve...???
So it seems to me that an anteolateral dislocation of the proximal tibiofibular joint may incorporate many others conditions including those of mimickers of the lateral meniscus. This does suggest to me that Closed Re.... needs to be conducted with great regard to nerves, tendons, ligaments and muscles that may not be where they should be...
(2013)
The anterolateral ligament connects the thigh bone to the shinbone.
Fig
Photograph showing the anteriolateral ligament connecting the thigh bone to the shinbone in the knee of a cadaver, taken from: