Proximal tibiofibular instability (Full Version)

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cadenz2 -> Proximal tibiofibular instability (May 4, 2008 12:05:22 AM)


I have a patient which clinically I think undergoes proximal tibiofibular anterior subluxation. 

Does anyone know what type of radiology would be required to diagnose this problem. 


bonez -> RE: Proximal tibiofibular instability (May 4, 2008 2:09:32 AM)

While I'm sure you can fell the excessive mobility, the fibula sits on the tibia and I doubt that there is a view that would seperate the articulation enough to show movement. remember that most of the mobility is a combination of Ato P and S/I glide and this would require a lateral view to see. Unless the fibular head slid completely off posteriorly on the tibia I don't know if you would see it.

cadenz2 -> RE: Proximal tibiofibular instability (May 4, 2008 7:24:36 AM)

There is excessive anterior movement of the fibula head on the tibia, so I'm presuming a lateral view might pick it up but I'm not sure.  Any thoughts?

TexasOrtho -> RE: Proximal tibiofibular instability (May 4, 2008 4:48:04 PM)

I can't see how an instability of this joint would show up on plain film without some sort of mechanical stress applied at the same time (like a talar tilt).  What are your clinical findings that would support this?

cadenz2 -> RE: Proximal tibiofibular instability (May 4, 2008 11:28:52 PM)

Patient's symptoms include:  anterolateral knee pain, lateral clicking/popping/catching, instability feeling, did have transient peroneal nerve symptoms (now settled), symptoms are predominently into knee flexion
Clinicial findings include:
  • prominent fibular head
  • increased anterior laxity
  • reproduction of clicking with anterior fibular movement
  • fibular head becomes more prominent into flexion
  • laxity with external rotation
  • tibial external rotation produces apprehension feeling
  • ACL/MCL/LCL/ITB/meniscus all ok
  • symptoms occur with walking
  • stabilisation around fibular with brace reduces symptoms

Chocco -> RE: Proximal tibiofibular instability (May 23, 2008 5:41:39 PM)

I would think that you may be able to tell if you took bilateral lateral views in a wieghted position with the knees flexed and ankles DF. I don't know a whole lot about xrays but it would seem that you maybe able to see an ant translation compared to the opposite side if it is as excessive as you noted. If you havent already I would also look at the distal Tib-Fib joint and see if it is hypomobile, this would create excessive torque/strain on the superior Fib.

Dr.Wagner -> RE: Proximal tibiofibular instability (May 24, 2008 4:59:13 PM)

I personally do not know of a single view that is absolutely definitive, as if there were true concerns for soft tissue injury, MRI is always consdered the radiation and wonderful detail. 
My suggestion is to speak with a radiologist to discuss this and as with our radiologists, they will suggest an MRI if ligamentous injury is suspected.

Sorry for the delayed response.

bonez -> RE: Proximal tibiofibular instability (May 25, 2008 12:19:05 AM)

My post was due purely to the physics of xray and the anatomy needed to be seen. Xray always reduces 3d objects to a 2d surface. As a result structures that lie in plane but seperated will be flattened onto each other. Thus rendering their relationship obscure.
The basics of assessing dynamic instability with xray revolve around a nuetral view showing the anatomy in question then some motion or force is applied and a new picture shows movement.
Now you must have some min/max limits validated before you can call a condition.
A case in point is the atlanto-dental interspace on Cervical flexion films for instability.
Dr Wags is right that if you need to assess the presence or absense of holding elements then MRI would likely show the tissue in question.

Chocco -> RE: Proximal tibiofibular instability (May 27, 2008 10:51:21 PM)

The problems I see with MRIs, Is that A) I've never seen a Weightbearing MRI film and B) Every MRI  I've seen is done in only one position. If you are looking for an increased anterior translation of the fibula when the knee is flexed you may need to compare the flexed knee with the straight knee. MRIs may be able to be done in multiple angles I have just never seen them. I know that the MRI would show if there were an injury to the ligamentus tissue, but would it catch hypermobility or a positional fault. Please don't take this as an argument, I am just trying to learn a little more about diagnostic tests.

Dr.Wagner -> RE: Proximal tibiofibular instability (May 28, 2008 1:45:01 PM)

Well the next and likely the first question should be this  "Does the patient NEED a test?"  Is this a surgical condition, where a test may help...or will it guide treatment?  To be honest, likely you are treating it as a fibular dysfunction anyway and the patient is getting better.

bonez -> RE: Proximal tibiofibular instability (May 28, 2008 7:11:34 PM)

Chocco Dr Wags is right as I know of no surgery for a dynamic fibular problem. Not to consider what a nail in the prox fibula would do to the ankle mortise either.
In the old days motion fluro was a neat trick but at the expense of a BIG patient radiation dose. The new tools ct and mri use somputer reconstrution to create the image you see. They need absolutely zero movement to be precise so I doubt that we will see them for this application.
I too have wanted the chance to see weight bearing studies. Think of the mri of circumfrential disc bulging that does not quite equate to the patient's S&S. I wonder what it might look like under load. Does it bulge more to one side to account for neural symptoms?

cadenz2 -> RE: Proximal tibiofibular instability (May 30, 2008 11:52:56 PM)

Thanks all for your replies. 

I agree that there is no NEED for a radiological investigation.  However, it just would be good to have a firm diagnosis.  The patient has had quite debilitating symptoms for about a year and it would also be helpful to know if any surgical option is available to patient. Presumably, doing an MRI in knee extension would not show any subluxation and it's with flexion that the fibula anteriorly translates.

The inferior tib-fib joint is ok.    

Thanks again everyone. 

TexasOrtho -> RE: Proximal tibiofibular instability (May 31, 2008 1:17:32 AM)

Theres a good article I found called "When Do Symptoms Becomes a Disease?" by Robert Aronowitz I can share with you.  It was published in the Annals of Internal Medicine.  I used to thirst for the patients to have a definitive diagnosis as well, but experience and this article have steered me away from putting too much stock into having a diagnosis. 

For the life of me I cannot locate the file on my computer right now but here is the abstract.
When do symptoms become a disease? Are there rules or norms, currently or in the past, that tell us when a particular collection of largely symptom-based criteria has enough specificity, utility, or plausibility to justify the appellation disease? The history of numerous symptom-based diagnoses in use today suggests partial answers to these questions. The 19th-century shift to understanding ill health as a result of specific diseases, increasingly defined more by signs than symptoms, led to a loss of status for illnesses that possessed little clinical or laboratory specificity. Nevertheless, clinicians then and now have used symptom-based diagnoses. Some of these diagnoses owe their existence as specific diseases to the norms and practices of an older era much different from our own. Others have not only thrived but have resisted plausible redefinition done by using more "objective" criteria. Many strategies, such as response-to-treatment arguments, quantitative methods (for example, factor analysis), and consensus conferences, have been used to find or confer specificity in symptom-based diagnoses. These strategies are problematic and have generally been used after symptom-based diagnoses have been recognized and defined. These historical observations emphasize that although biological and clinical factors have set boundaries for which symptoms might plausibly be linked in a disease concept, social influences have largely determined which symptom clusters have become diseases.


I'll locate the full text.

Chocco -> RE: Proximal tibiofibular instability (May 31, 2008 5:18:13 PM)

Let me clearify I wasn't suggesting the patient actually get the x-rays just hypothesizing that if you were looking to find proof of instability that an xray may be more valuable than an MRI- Seems like having MRIs with the flexibilty of Xrays would be the best ( if it existed)


Chocco -> RE: Proximal tibiofibular instability (May 31, 2008 5:45:40 PM)

In response to Rod's post. ( a little off the subject)

  One of the things that bothers me the most about the direction of our field is the increased teaching of only " symptom reproduction model " evaluations and treatments with little to no background behind them. I  have been practicing for a little over six years. When I started working seemed like PTs that graduated years before me had a better understand of the pathophysiology behind conditions then I did. I initially thought it was my schooling but seeing students come through the clinics I have worked in it seems to be the trend. I love McKenzie and Mulligan treatments for example and I know McKenzie courses get more in depth on evaluation , but students and young PTs are practicing purely on symptom reproduction. If you do THIS it gets better, I you do THAT it gets worse- so DO THIS  and DON'T do THAT. But physiologically when asked they can explain why it gets better and why it gets worse. I love treating using Mulligan techniques ( look at my past posts) but I went to a Mulligan  course where the instructor literally said " Just tell them its magic, It doesn't matter how it works, because it will work"( I wrote that quote down). I may be a little biased because I like reading about normal biomechanics and pathophysiology but we lose credibility as a profession every time we tell the patient I don't know. I'm not saying you have to have all the answers but atleast be able to explain and back up what you are doing.  I feel that evidence based practice is important but only if you read the articles to learn from them instead of just referencing them to prove what your doing is right.
Sorry for the ranting
I am done now

TexasOrtho -> RE: Proximal tibiofibular instability (May 31, 2008 7:38:17 PM)

Chocco.  I've also been praciticng six years and have come full circle on my approach as well.  I am very meticulous about my understanding and application of clinical practice.  For me this involves knowing where to place my energy.  For me it happens to be rigorous study of evidence from basic science up to systematic reviews.  I believe it's made me a better clinician, but it's also made me chill out a little bit when I don't know "everything".

You do realize how unspecific radiographs and MR can be for a wide variety of musculoskeletal problems from LBP through rotator cuff pathology?  Even orthopedists, neurologists, and radiologists don't know some things and it doesn't seem to have hurt the credibility of their profession.  Conversely, many chiropractors make diagnostic claims that are way off base and their credibility is certainly in question. My point (and the point of the article - written by a pretty sharp diagnostician BTW) is that a diagnosis isn't a prerequisite for an effective treatment program.  It is a complex construct that incorporates clinical, social, and even political factors.  Given this the value of a "firm diagnosis" diminishes slightly. 

You and I see this differently, you say we loose credibility when we tell a patient we don't know.  I say we loose credibility when we pass something to a patient as a fact, when it is really more of a very educated guess.  It's an interesting difference that probably doesn't change much of what we do from day to day.  In fact we might have very similar practice patterns.  Sorry for taking the jam out of your doughnut as I wasn't trying to piss you off.  If you are interested I can email you that article. 

Shill -> RE: Proximal tibiofibular instability (June 3, 2008 6:03:12 PM)

Chocco said 

...we lose credibility as a profession every time we tell the patient I don't know.

I actually think this is not true, as Rod noted.  We let patients know that honestly, most often we dont necessarily know the "why" part, occasionally we do, but usually not.  Even if we think we know, it may not be correct, or our theory could be completely disproven later.  We let them know that others who tell them they know every time, exactly what is going on, are simply FOS.  We should be willing to not need to blow smoke to help people. 

Chocco -> RE: Proximal tibiofibular instability (June 4, 2008 3:34:28 AM)

I'm not claiming I know everything that is going on with my patients, I think we owe it to our patients to explain to them why we are doing what we are doing to them. I think if you do a mckenzie eval and you determine the patient is a D2 derangement that you should explain to them what the theory behind extension exercises is, why you think it will help them. I never tell a patient I know exactly what is going on, but i let them know based on what i have seen this is what we are going to do and this is why.

TexasOrtho -> RE: Proximal tibiofibular instability (June 4, 2008 3:52:58 AM)

That sounds a lot different than your earlier post Chocco.  I agree with you on this one.

Chocco -> RE: Proximal tibiofibular instability (June 4, 2008 1:57:50 PM)

Maybe I did a poor job differentiating from the original intent of this thread whcih was based on diagnostic test. When you mentioned in your response above about symptom based diagnosis It switched that light of in my head where I needed to vent. My post actually had little to do the article you mentioned. Your post itself didn't piss me off, just an overall displeasure with the lack of education about the how and why of symptom reproduction model techniques, other than the this feels better, so  do this with out any further information as to why they are doing the technique with the patient or the theory behind it.
I'm not sure this clarifies anything I guess i need to work on that
I would like to read that article if you come across it, or if you have any info on it I can look it here.

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