Proximal Tibiofibular Joint Instability?

[petridish]

Hi folks,

New poster here.  First, my name's Pete, I live in southern Maine.  I'm 35, and love to surf, mountain bike, backcountry ski, and hike (I feel like I'm doing an AA intro!)

Second, I've tried several different searches on the boards, and have found nothing.  Hopefully I'll find someone with a similar experience, or any info, or my posting this will be helpful to someone else.

I've been diagnosed with instability of the proximal tibiofibular joint - where the fibular head is, below the lateral knee joint.  This happened playing ice hockey in Feb 2007.  I damaged the internal knee ligaments that hold my fibula to the tibia, and also the biceps femoris tendon where it attaches to the fibular head.  I luckily did spare my ACL and meniscus according to exam and MRI.

Now my fibular head migrates too far anterolaterally during activity, which causes pain, snapping, and irritates my biceps femoris, and my peroneal nerve, leading to lateral knee, shin (peroneal muscles), and ankle pins and needles and pain.  The doctor can actually sublux the fibula out of place during exam, which is very painful, and reproduces my symptoms.

I am 35, and a very active individual, and all activities that require repetitive leg or ankle flexion, from hiking, long walking, standing, to the sports I love to do including cycling and skiing, cause pain.

I'm currently undergoing rehab to strengthen the rest of the leg, the peroneal muscle group, and also am trying deep tissue massage and lymph node work to deal with the symptoms.  I also wear a Chopat strap around this portion of the knee to help stabilize the joint - it helps to an extent.

It's taken some time to get this diagnosis down.  This apparently is not a very common injury.  I visited the head of Sports Medicine at Lahey Center in MA, and also the team doctor for the New England Revolution/New England Patriots at Mass. General Hospital in Boston, MA.  The MGH doc has only seen 3 of these injuries over the past 30 years of orthopaedics!

I was basically given 3 options:

1) live with it until I can't do anything, then deal with it surgically (I'm nearing that!)
2) pin the fibula to the tibia with a screw
3) undergo ligamentous reconstruction of the ligaments that hold the fibula to the tibia with either an auto or allograft (likely an allograft).

Problem is, what I've found is that since the injury is uncommon, very few docs are experienced in doing either #2, or #3 (i.e., the MA General Sports Medicine guy has only seen this 3 times in 30 years!).  I'm hesitant to have it pinned, since literature I've reviewed shows that in athletes, the lack of rotation of the joint leads to ankle pain and instability down the line. 

From a reconstruction standpoint, I have yet to find a surgeon who has actually done a number of these procedures that I have read about in the literature - tightening the joint with an auto or allograft that connects from the tibia, through a hole in the fibula, and back to the tibia.  This supposedly replicates natural functionality of the joint, with the inherent stability returned, but the lateral rotation forces that a pin would diminish remains, thus avoiding ankle issues.

I was wondering if anyone has had this problem, if you've had anything surgically done, and what the outcome has been. 

Also, any advice for finding a surgeon that might specialize - or at least has done - a number of these surgeries in the US?

Thanks all.

Peter




 

[petridish]

You're definitely in time!  I have done nothing except get a cortizone injection, and continue with rehabilitation.  I see you contacted me via email too, so let's continue with that.  Thanks!  - pete

[aking1]

Hi,

I read your article with interest and desperation,
I too have been suffering from the symptoms you mention for exactly a year, i ski and mountain bike(although have been unable to do the latter for some time because of the injury).
when i squat with my feet apart and pointing forward i get an audible and visible click as my tendon passes over my fibular head, this went unnoticed by two physios and 1 knee surgeon who dismissed the clicking as a sign of getting older(i'm 33!)
It has gradually gotten worse over the last few months to the point where i have pins and needles running down to my foot.

How has the cortisone injection worked?

i work ski-guiding in the winter and am quite concerned that i will not be able to do so this year.

I am also loathe to have any sort of surgical procedure as this is such an uncommon injury.
I ve had chiro, and three courses of physio for itb syndrome. the chiro(who by the way was the only one to examine me further than the usual tests)has suggested visiting another specialist....

What is prolotherapy and where could i get it?(in north west u.k.)

[petridish]

Hi,
The cortizone injection seems to have worked a bit - but mostly, activity modification (unfortunately) has been doing some good.  I haven't cycled or run nearly as much as I did prior to the injury.  I can't run for more than 10 minutes or so, but can fight through a good MTB ride.  A chopat strap helps, but isn't a magic bullet, at least not for me.  I haven't really tried skiing yet this year, but will see how that goes shortly.  I backcountry ski as well, and that in the past has not been kind to the knee.

There have been several papers on tib-fib joint reconstruction using allo/auto graft, which has been successful since it mimics natural knee mobility, and does not use a pin to fuse the joint (which passes the problem down to the tib/fib joint at the ankle).  Google this and you'll find some folks in the US that have done it.

Right now I am sticking with the status quo, but if things really flare up this year during ski season, will consider doing something.

Cheers
Pete

[aking1]

any improvement with the knee pete?

[petridish]

any improvement with the knee pete?

Nope - still dealing with it.  Still working on strengthening, but it still gets very irritated during any repetitive activity.  Might look into trying prolotherapy - hard to find around here (Maine, USA).  Surgically, I have been offered little aside from permanent fixation, which I am going to avoid at this point.  It is not a common injury.

Your story sounds familiar.  I also get ITB irritation, but mostly biceps femoris (outer lateral hamstring) and peroneal nerve irritation and pain, because the hamstring attaches to the fibular head.  So too much fibular head movement = strain on the biceps femoris, which causes the ITB to work harder to stabilize the leg.

[jere1572]

Hi  have   been through almost everything for tibiofibular joint problems.  Started out with 4 different docs just to diagnose the problem.  The first doc that figured out what it was did offer prolotheropy.  I tryed the prolotheropy  did not work.   Had various tests mri ct scan xray.  Went to see a doc in michigan DR Sekia.  Found some resarch work he did on the tibifibular joint.  He diagnosed me with arthritis of the tibfibular joint.  At this point i am not sure i wanna go with the arthodisis but seems like the only option.  Oh by the way i am 24 years old and have been dealing with this since i was 21.  I found aleve works the best for the pain.  Makes it almost better haha.  I will be seeing another doctor this week to see what he says.  Allong with the arthritis i also have bone spurs.  But i would recomend prolotheropy as quick as possible.  The longer you let it go i think the more chances of it getting arthritis.

[CaliforniaJL]

Certain knee-lock symptoms may not be meniscus-related, but rather the fibular head dislocating out of joint. I've attached to this post a medical paper from Drs. Kuhn and Sekiya describing the issue.

Unfortunately, many orthopedic surgeons are still doing thousands of unnecessary meniscus surgeries every year. I had meniscus surgery for my knee lock, and it did absolutely nothing. This was years before I discovered Kuhn's description of fibular lock. Worthless meniscus surgery has become an epidemic, as Mercola summarizes: http://fitness.mercola.com/sites/fitness/archive/2013/04/05/unnecessary-knee-surgery.aspx

Also unfortunate is that, according to Kuhn, knee-lock caused by fibular instability is generally not curable by surgery. We just need to learn how to live with it and be conscious of avoiding situations that would cause a lock-up. I've also found that leg press and curl exercises seem to help by strengthening the muscles. Also see this lengthy knee-lock thread started in 2008 with nearly 200 comments: http://forums.bettermedicine.com/showthread.php/28197-knee-lock-s-up-anyone-else (EDIT Oct 2014: looks like the 200+ comments have been deleted. I've just started a new knee-lock conversation here: www.kneelock.com)

Of course, there are some with a true meniscus tear (etc.) that is causing a form of knee lock. I think the difference is that, when a meniscus shim unlocks, there is no massive "thunk" of a joint or bone falling back into place.

Since 2008, I have been contacted by 50+ people, all with the identical symptoms, many of which had ineffective meniscus surgery. And in virtually all cases, their ortho doc's were not aware of the medical condition known as "instability of the proximal tibiofibular joint." Educate your doctors.

[drmark]

I have done a number of proximal tib/fib joint stabilizations.  They are more common that believed.  Its just that most docs don't understand the diagnosis, so they can make it.  As on the the Father's of American Orthopaedic Sports Medicine, Dr. Jack Houghston, of Blessed Memory said, "You might not have seen it, but it's seen you"!

A common distractor, also rarely, but easily diagnosed is excessive external torsion.  The patient who I have seen both in, found the knee and limb function was signifigantly improved when that was corrected into the normal range, so now I CT all proximal tib/fib joint patients to determine if they have excessive (>35 degrees) of external tibial torsion.

[anniemac1313]

Peter,

I know it's been quite a few years since you originally posted about your knee pain, but since I am in Maine also, I was wondering if you received any relief or have any docs to recommend in the area?  I've gone to several doctors, PTs, chiropractors, etc. with no success.  Just wondering if you ever got surgery or if you found a better alternative?

Thanks!

Annie

[CaliforniaJL]

Hi Annie,

The bettermedicine.com conversation, with over 200 important knee-lock comments, has been deleted. I've started a website for knee lock conversation. Anyone who experiences knee lock, please join the conversation. www.kneelock.com

[stefanushendri]

Pete,

Did you injure your Antero Lateral Ligament (ALL)?
Because I injure that Ligament and I experience similar symptoms as yours with peroneal nerve tingling and snapping or clicking sound.
Thank you.

[The KNEEguru]

This is an old post but I was referred to it recently, and found it interesting. I often get a painful and tender tibiofibular joint that seems at those times to have a small bursa palpable. I notice it when I sit working at the computer in bed with my leg crossed over the other in a figure-of-4. When I was a child I sprained my ankle on that side quite badly several times, and it was always just treated conservatively so I assume the ankle was never properly stabilised. I wonder if they are related, since a bad pull at the ankle is likely to affect the tibia at its promixal end?

[tregearwill]

Hi Pete,

I've recently battled from numerous false diagnosis to finally (I hope) to have a definitive one i.e proximal tibiofibular joint instability.

Given the length of years its been since your last post, did you go through with surgery or grit and bear? In either case what was the outcome?

I can handle the pain/swelling derived from this injury, can (just) participate in most exercises I enjoy (cycling/hiking- have given up on basketball) though they obviously aren't as enjoyable as previous. However, my concern is the lon-term effects of this continued participation alongside conservative treatment.

Many Thanks

[Volleyball08]

. I just had proximal tib/fib stabilization surgery. 7 weeks post op. My dr put 2 tightropes proximally and one tightrope in my ankle. The tightropes allow some give so better than a screw.. My Dr was Christopher Main in Macon Missouri. He is awesome and knows so much about this issue! He actually created this procedure and is on the Arthrex website for tightropes in a video doing the surgery.  So far some major symptoms have improved but I wasn’t able to walk for 3 years so the rehab journey will be long.