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Proximal Tibiofibular Joint: An Often-Forgotten Cause of Lateral Knee Pain

¹ All authors: Department of Radiology, University of British Columbia and University of British Columbia Hospital, 2211 Wesbrook Mall, Vancouver, BC V6T 2B5, Canada.

View larger version (54K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A —Normal anatomy of proximal tibiofibular joint as shown on coronal and transverse cross-sectional drawings. Common peroneal nerve (arrow) curves around fibular head and divides into superficial and deep components.

View larger version (43K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B —Normal anatomy of proximal tibiofibular joint as shown on coronal and transverse cross-sectional drawings. Anterosuperior and posterosuperior tibiofibular ligaments are shown (arrows), which strengthen fibrous capsule of proximal tibiofibular joint.

View larger version (162K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A —Normal MRI anatomy of proximal tibiofibular joint in 31-year-old woman. Axial fast spin-echo proton density-weighted fat-saturated image shows anterior and posterior proximal tibiofibular ligaments as low-signal-intensity bands (arrows).

View larger version (143K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B —Normal MRI anatomy of proximal tibiofibular joint in 31-year-old woman. Axial fast spin-echo T1-weighted image shows intermediate-signal-intensity common peroneal nerve as it courses around fibular head (arrow).

View larger version (111K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3 —Osteoarthritis in 56-year-old man with recent knee trauma. Transverse CT images of knee show osteophytosis (arrow). Acute lateral tibial plateau fracture is present.

View larger version (122K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4A —Fibular head osteochondroma in 27-year-old woman with lateral knee swelling for 5 months. Anteroposterior radiograph of knee shows well-defined bone protuberance arising from medial aspect of fibular head (arrow).

View larger version (105K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4B —Fibular head osteochondroma in 27-year-old woman with lateral knee swelling for 5 months. Axial CT image shows exostosis arising from posteromedial fibular head (arrow) and protruding into proximal tibiofibular joint. This was subsequently resected and diagnosis was pathologically determined.

View larger version (132K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5A —Osteoblastoma in 19-year-old man who presented with 4-month history of lateral knee pain. Transverse CT image shows expansile, osteolytic lesion (arrow) with minimal osteoid matrix in fibular head. Lesion protrudes toward posterior tibia.

View larger version (79K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5B —Osteoblastoma in 19-year-old man who presented with 4-month history of lateral knee pain. Anterior and posterior whole-body bone scintigraphy image shows solitary lesion in fibular head and prominent radionuclide uptake.

View larger version (115K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5C —Osteoblastoma in 19-year-old man who presented with 4-month history of lateral knee pain. Anteroposterior radiograph after resection of tumor and bone grafting.

View larger version (106K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6A —Osteosarcoma in 19-year-old woman presenting with lateral knee pain and palpable mass. Anteroposterior radiograph shows mixed lytic and sclerotic lesion of right fibular head and periosteal reaction on medial fibular neck and shaft.

View larger version (101K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6B —Osteosarcoma in 19-year-old woman presenting with lateral knee pain and palpable mass. Coronal STIR MR image shows irregular, high-signal-intensity, lobulated mass involving proximal fibula. Cortex is breached and mass extends into proximal tibiofibular joint. Associated soft-tissue mass is present.

View larger version (103K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6C —Osteosarcoma in 19-year-old woman presenting with lateral knee pain and palpable mass. Sagittal T1-weighted MR image shows mass is primarily isointense to muscle. Patient underwent resection of proximal fibula.

View larger version (123K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7A —Common peroneal nerve schwannoma in 45-year-old man with drop foot. Transverse T1-weighted MR image with gadolinium and fat saturation shows well-delineated, homogeneously enhancing mass centered on common peroneal nerve and adjacent to fibular neck, where it branches into its superficial and deep components.

View larger version (109K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7B —Common peroneal nerve schwannoma in 45-year-old man with drop foot. Coronal (B) and sagittal (C) T2-weighted STIR MR images show mass is hyperintense and well defined.

View larger version (84K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7C —Common peroneal nerve schwannoma in 45-year-old man with drop foot. Coronal (B) and sagittal (C) T2-weighted STIR MR images show mass is hyperintense and well defined.

View larger version (108K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8A —Anterior tibiofibular ligament strain in 23-year-old woman with acute hyperflexion injury. Contiguous transverse fast spin-echo T2-weighted fat-suppressed MR images show high signal intensity surrounding anterior tibiofibular ligament (arrow, A) consistent with partial tear, fibular head bone marrow edema (arrow, B), and small amount of fluid (high signal) in proximal tibiofibular joint.

View larger version (117K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8B —Anterior tibiofibular ligament strain in 23-year-old woman with acute hyperflexion injury. Contiguous transverse fast spin-echo T2-weighted fat-suppressed MR images show high signal intensity surrounding anterior tibiofibular ligament (arrow, A) consistent with partial tear, fibular head bone marrow edema (arrow, B), and small amount of fluid (high signal) in proximal tibiofibular joint.

View larger version (153K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8C —Anterior tibiofibular ligament strain in 23-year-old woman with acute hyperflexion injury. Coronal STIR MR image shows bone marrow edema in fibular head.

View larger version (130K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9A —Popliteus tendon rupture in 55-year-old man after hyperextension injury. Transverse fast spin-echo proton density-weighted fat-saturated MR image shows popliteus tendon is ruptured and retracted from its femoral attachment. High-signal-intensity fluid surrounds torn tendon (arrow).

View larger version (165K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9B —Popliteus tendon rupture in 55-year-old man after hyperextension injury. Sagittal T2*-weighted gradient echo (B) and coronal fast spin-echo T2-weighted fat-saturated (C) images show same findings (arrows) as in A.

View larger version (133K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9C —Popliteus tendon rupture in 55-year-old man after hyperextension injury. Sagittal T2*-weighted gradient echo (B) and coronal fast spin-echo T2-weighted fat-saturated (C) images show same findings (arrows) as in A.

View larger version (157K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10A —Posterolateral corner injury in 32-year-old man after motor vehicle accident. Coronal fast spin-echo T2-weighted fat-saturated MR image shows bone marrow edema in fibular head (arrow) secondary to avulsion of arcuate complex.

View larger version (124K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10B —Posterolateral corner injury in 32-year-old man after motor vehicle accident. Sagittal fast spin-echo T2-weighted MR image shows accompanying tear of mid portion of anterior cruciate ligament (ACL). A high-signal-intensity mass (arrow), representing focal hemorrhage, disrupts normally low-signal-intensity ACL fibers.

View larger version (110K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11A —Popliteus tendon ganglion in 32-year-old man. Oblique sagittal fast spin-echo T2-weighted MR image shows well-defined, lobulated, elongated, high-signal-intensity mass (arrow). Mass is associated with popliteus tendon just posterior to tibia.

View larger version (120K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11B —Popliteus tendon ganglion in 32-year-old man. Transverse fast spin-echo proton density-weighted fat-saturated (B) and coronal fast spin-echo T2-weighted fat-saturated (C) MR images show markedly hyperintense mass related to popliteus tendon.

View larger version (122K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11C —Popliteus tendon ganglion in 32-year-old man. Transverse fast spin-echo proton density-weighted fat-saturated (B) and coronal fast spin-echo T2-weighted fat-saturated (C) MR images show markedly hyperintense mass related to popliteus tendon.

View larger version (160K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12A —Pigmented villonodular synovitis in 36-year-old woman with progressive knee swelling and discomfort. (Figures 12A and 12C reprinted with permission from Ryan RS, Louis L, O'Connell JX, et al. Pigmented villonodular synovitis of proximal tibiofibular joint. Australas Radiol 2004; 48:520-522 [8].) Transverse T1-weighted MR image of knee shows lobulated foci of low signal intensity in and around proximal tibiofibular joint and in fibular head.

View larger version (104K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12B —Pigmented villonodular synovitis in 36-year-old woman with progressive knee swelling and discomfort. (Figures 12A and 12C reprinted with permission from Ryan RS, Louis L, O'Connell JX, et al. Pigmented villonodular synovitis of proximal tibiofibular joint. Australas Radiol 2004; 48:520-522 [8].) Coronal fast spin-echo T2-weighted with fat saturation (B) and gradient-recalled echo (C) MR images of knee show that, because of magnetic susceptibility properties of hemosiderin, blooming artifacts can occur on gradient sequences, and globular low-signal lesions become more conspicuous.

View larger version (138K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12C —Pigmented villonodular synovitis in 36-year-old woman with progressive knee swelling and discomfort. (Figures 12A and 12C reprinted with permission from Ryan RS, Louis L, O'Connell JX, et al. Pigmented villonodular synovitis of proximal tibiofibular joint. Australas Radiol 2004; 48:520-522 [8].) Coronal fast spin-echo T2-weighted with fat saturation (B) and gradient-recalled echo (C) MR images of knee show that, because of magnetic susceptibility properties of hemosiderin, blooming artifacts can occur on gradient sequences, and globular low-signal lesions become more conspicuous.

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