Tibiofibular Pain Syndrome – The Clinical Syndrome
Tibiofibular joint pain is most often the result of arthritis of the joint. Osteoarthritis of the joint is the most common form of arthritis that results in tibiofibular joint pain. Rheumatoid arthritis and posttraumatic arthritis also are common causes of tibiofibular pain secondary to arthritis.
The tibiofibular joint is frequently damaged from falls with the foot fully medially rotated and the knee flexed, and such trauma frequently results in posttraumatic arthritis. If the trauma is severe enough, dislocation of the tibiofibular joint may occur. Less common causes of arthritis-induced tibiofibular pain include collagen-vascular diseases, infection, villonodular synovitis, and Lyme disease.
In addition to arthritis, the tibiofibular joint is susceptible to the development of tendinitis, bursitis, and disruption of the ligaments, cartilage, and tendons, all of which may cause pain and functional disability.
Most patients with tibiofibular pain secondary to osteoarthritis and posttraumatic arthritis report pain localized around the tibiofibular joint and the lateral aspect of the knee. Activity, especially involving flexion and medial rotation of the knee, makes the pain worse; rest and heat provide some relief. The pain is constant and characterized as aching. The pain may interfere with sleep.
What are the Symptoms of Tibiofibular Pain Syndrome
Examination of the knee in patients with tibiofibular joint pain reveals tenderness to palpation of the lateral aspect of the knee. Some patients report a grating or popping sensation with use of the joint, and crepitus may be present on physical examination. In addition to the previously mentioned pain, patients with arthritis of the tibiofibular joint often experience a gradual decrease in functional ability with decreasing tibiofibular joint range of motion, making simple everyday tasks such as walking, climbing stairs, and getting in and out of an automobile difficult.
Morning stiffness and stiffness after sitting for prolonged periods are commonly reported by patients with arthritis of the tibiofibular joint.
With continued disuse, muscle weakness and wasting may occur, and loss of support from the muscles and ligaments eventually makes the tibiofibular joint unstable. This instability is most evident when the patient attempts to walk on uneven surfaces or climb stairs.
How is Tibiofibular Pain Syndrome diagnosed?
Plain radiographs of the knee are indicated in all patients with tibiofibular joint pain. Based on the patient’s clinical presentation, additional tests, including complete blood cell count, erythrocyte sedimentation rate, and antinuclear antibody testing, may be indicated.
Magnetic resonance imaging (MRI) and ultrasound imaging of the tibiofibular joint is indicated if aseptic necrosis or occult mass or tumor is suspected and to help confirm the diagnosis. Bone scan may be useful to identify occult stress fractures involving the joint, especially if trauma has occurred.
Differential Diagnosis
The tibiofibular joint is susceptible to the development of arthritis from a variety of conditions that have in common the ability to damage the joint cartilage. Acute infectious arthritis usually is accompanied by significant systemic symptoms, including fever and malaise, and should be easily recognized by an astute clinician and treated appropriately with culture and antibiotics, rather than with injection therapy. The collagen-vascular diseases generally manifest as a polyarthropathy rather than a monarthropathy limited to the tibiofibular joint, although tibiofibular pain secondary to collagen-vascular disease responds well to the intra-articular injection technique described subsequently. Lumbar radiculopathy may mimic the pain and disability associated with arthritis of the tibiofibular joint. In patients with lumbar radiculopathy, the knee examination should be negative. Entrapment neuropathies, such as meralgia paresthetica, and bursitis of the knee also may confuse the diagnosis; both may coexist with arthritis of the tibiofibular joint. Primary and metastatic tumors of the femur and spine also may manifest clinically in a manner analogous to arthritis of the knee.
Treatment
Initial treatment of the pain and functional disability associated with arthritis of the knee should include a combination of nonsteroidal antiinflammatory drugs (NSAIDs) or cyclooxygenase-2 (COX-2) inhibitors and physical therapy. Local application of heat and cold may be beneficial. For patients who do not respond to these treatment modalities, an intra-articular injection of a local anesthetic and steroid may be a reasonable next step. Ultrasound guidance may improve the accuracy of needle placement and decrease the incidence of needle-related complications.
Complications and Pitfalls
Failure to identify primary or metastatic tumor of the knee or spine that is responsible for the patient’s pain may yield disastrous results. The major complication of intra-articular injection of the knee is infection. This complication should be exceedingly rare if strict aseptic technique is followed. Approximately 25% of patients report a transient increase in pain after intra-articular injection of the knee joint; patients should be warned of this possibility.
Clinical Pearls
Coexistent bursitis and tendinitis may contribute to tibiofibular pain and may require additional treatment with more localized injection of a local anesthetic and depot steroid. Injection of the tibiofibular joint is extremely effective in the treatment of pain secondary to the previously mentioned causes of arthritis of the knee joint.
This technique is a safe procedure if careful attention is paid to the clinically relevant anatomy in the areas to be injected. Care must be taken to use sterile technique to avoid infection and universal precautions to avoid risk to the operator. The use of physical modalities, including local heat and gentle range-of-motion exercises, should be introduced several days after the patient undergoes this injection technique for knee pain. Vigorous exercises should be avoided because they would exacerbate the symptoms.
