DOI:10.2214/AJR.06.0627
AJR 2007; 188:W359-W366
© American Roentgen Ray Society
Proximal Tibiofibular Joint: An Often-Forgotten Cause of Lateral Knee Pain
Bruce B. Forster1,
Jimmy S. Lee,
Sarah Kelly,
Mariana O'Dowd,
Peter L. Munk,
Gordon Andrews and
Lorie Marchinkow
1 All authors: Department of Radiology, University of British Columbia and
University of British Columbia Hospital, 2211 Wesbrook Mall, Vancouver, BC V6T
2B5, Canada.
Received May 10, 2006;
accepted after revision August 1, 2006.
Address correspondence to B. B. Forster
(Bruce.Forster{at}vch.ca).
WEB This is a Web exclusive article.
Abstract
OBJECTIVE. This article presents the imaging findings of proximal
tibiofibular joint disorders that can cause lateral knee pain.
CONCLUSION. The proximal tibiofibular joint is often neglected in
the evaluation of lateral knee pain. The images presented in this article
highlight the diverse disorders of this area. Because this joint is usually in
the field of view in radiography, CT, and MRI of the knee, evaluation of it
should be a part of all knee imaging assessments.
Keywords: joint • knee • musculoskeletal imaging • pain
Introduction
The proximal tibiofibular joint is a source of lateral knee pain
that is often overlooked as a result of its lack of emphasis in the literature
and text-books [1,
2] and the few reports devoted
to its disorders [2]. This
point is particularly significant in that the proximal tibiofibular joint is
usually in the field of view of most knee imaging studies.
The proximal tibiofibular joint is a synovial joint that functions in
dissipating lower leg torsional stresses and lateral tibial bending moments
and in transmitting axial loads in weight-bearing
[1]. Numerous disorders of the
proximal tibiofibular joint can present as lateral knee pain. In this article,
normal proximal tibiofibular joint anatomy and imaging characteristics of
disease entities that occur at this site are discussed. In addition, many
diseases that are not technically in the proximal tibiofibular joint but are
adjacent or related to it are also included, because lesions in these adjacent
structures can affect the proximal tibiofibular joint.
This article will emphasize osteoarthritis, neoplasms, ganglion cysts,
pigmented villonodular synovitis, and trauma. Other disorders that can affect
the proximal tibiofibular joint but are not specifically discussed include
osteoid osteoma, Maisonneuve fracture of the fibular neck, and infections.
Taken together, these examples of proximal tibiofibular joint disorders
underscore the importance of evaluation of this joint in routine knee imaging
assessments.
Normal Anatomy of the Proximal Tibiofibular Joint
The proximal tibiofibular joint is located between the lateral tibi al
condyle and the fibular head. It communicates with the knee joint in
approximately 10% of adults, although communication in up to 64% has been
reported with MR arthrography
[1]. Because the proximal
tibiofibular joint can be contiguous with the knee joint, either joint may be
affected when the joint pressure is elevated, and thus the proximal
tibiofibular joint has been construed as the "fourth compartment"
of the knee joint [1].
A fibrous capsule surrounds the proximal tibiofibular joint articulation,
and this is strengthened by anterosuperior and posterosuperior tibiofibular
ligaments (Figs. 1A,
1B and
2A,
2B). The common peroneal nerve
descends along the lateral aspect of the popliteal fossa and curves around the
anterolateral aspects of the fibular head and neck
(Fig. 1A). It passes lateral to
the anterior compartment musculature and deep in relation to the peroneus
longus musculature, where it divides into superficial and deep branches.
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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.
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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.
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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).
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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).
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Normal MRI Anatomy
The anterosuperior and posterosuperior ligaments have low signal intensity
on all imaging sequences (Fig.
2A). A small amount of fluid (high T2 signal) may normally be
present in the proximal tibiofibular joint. Nerves are low to intermediate
signal intensity on T1-weighted images
(Fig. 2B) and become slightly
higher in signal intensity on T2-weighted images.
Disorders
Osteoarthritis
Degenerative arthritis of the proximal tibiofibular joint may accompany
osteoarthritis of the knee or occur in isolation. In patients scheduled to
undergo total knee replacement arthroplasty, an unrecognized proximal
tibiofibular joint disorder may be a source of progressive lateral knee pain
and may influence clinical outcome. As with other joints, osteophytes
(Fig. 3), subchondral cysts,
subchondral sclerosis, and joint space narrowing are typical imaging
findings.
Neoplasms
Various neoplasms can affect the proximal tibiofibular joint, including
osteochondroma, osteoblastoma, osteosarcoma, and nerve sheath tumors. An
osteochondroma is a benign lesion that rarely undergoes malignant
transformation [3]. It is
usually asymptomatic and is usually discovered incidentally (Fig.
4A,
4B). In superficial regions
such as the proximal tibiofibular joint, osteochondroma can present as a
painless palpable mass or with symptoms related to nerve irritation.
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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).
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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.
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Osteoblastoma is an uncommon benign neoplasm occurring predominantly in the
axial skeleton (Fig. 5A,
5B,
5C). Approximately 35% occur
in long tubular bones, and 75% of these are in the diaphysis. Only a few cases
involving the epiphysis have been reported
[3].
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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.
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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.
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Osteosarcoma is the second most common primary bone malignancy
[3], with a peak incidence in
the second to third decades of life. Although the distal femur and the
proximal tibia are most often involved, any bone can be affected. Aggressive,
bone-forming features are usually noted on imaging (Figs.
6B and
6C).
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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.
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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.
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Schwannomas and neurofibromas make up most of the peripheral nerve sheath
tumors. Most of these are solitary, slowly growing masses; when they are
large, they can cause pain and neuropathy. Schwannomas and neurofibromas
typically show homogeneously low signal intensity on T1-weighted imaging, high
signal intensity on T2-weighted imaging (Fig.
7A,
7B,
7C), and intense enhancement
with administration of gadolinium. A target appearance may be seen when
central fibrous tissue causes T2 shortening.
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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.
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Trauma
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. 8A,
8B,
8C) and tears, and injury to
the neu-rovascular bundle. The popliteus tendon, lying in close proximity to
the proximal tibiofibular joint, should be carefully assessed for either an
isolated tear (Fig. 9A,
9B,
9C) or involvement in a more
complex posterolateral corner injury.
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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.
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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.
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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).
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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.
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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.
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Posterolateral Corner Injury
The posterolateral corner of the knee is anatomically complex and is made
up of the lateral collateral ligament, the popliteus muscle and tendon, and
the arcuate complex (arcuate, fabel-lofibular, and popliteofibular ligaments)
(see [4] for a detailed
review). The diagnosis of posterolateral corner injury should be suspected
when disruption of more than one of these structures is encountered
[4]. An avulsion fracture of
the styloid process of the fibular head
(Fig. 10A), which is the site
of insertion of the arcuate complex, has been termed the "arcuate
sign" and is an indicator of posterolateral instability
[5]. Most often, the mechanism
of injury is direct force to the anteromedial tibia with the knee in
extension. It is important to recognize a posterolateral corner injury because
the knee is unstable in extension and there is usually an accompanying
anterior or posterior cruciate ligament (PCL) tear
(Fig. 10B). Unrecognized or
untreated posterolateral instability can lead to failures of the anterior
cruciate ligament (ACL) or PCL repairs and chronic knee instability
[5,
6].
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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.
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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.
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Ganglion
A ganglion is a tumorlike, cystic lesion that arises from the joint, tendon
sheath, or muscle [7]. Those
arising near the proximal tibiofibular joint articulation are rare entities
that can be associated with compression of the common peroneal nerve (Fig.
11A,
11B,
11C).
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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.
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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.
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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.
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Pigmented Villonodular Synovitis (PVNS)
A disease of unknown cause, PVNS is characterized by synovial hypertrophy
with diffuse or focal hemosiderin deposition in the joint
[8]. It is monoarticular,
affecting the knee most frequently, and it usually occurs in adults in the
third or fourth decade. Imaging reveals large, globular areas of low T1 and T2
signal outlining the hypertrophied synovium (Fig.
12A,
12B,
12C).
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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.
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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.
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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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Conclusion
The examples of proximal tibiofibular joint disorders presented in this
article highlight the diverse disease entities that can occur at this joint.
Because the proximal tibiofibular joint is usually included in the field of
view in radiography, CT, and MRI of the knee, evaluation of it should be a
part of all imaging assessments of the knee region.
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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.
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Abstract
Introduction
