Proximal Tibiofibular Ligament Tear - A Rare Case Presentation | OEP367

A Proximal Tibiofibular Ligament Tear is quite rare.  In today's episode I discuss what this patient case presents like and how we propose managing it.

👉(Video) Proximal Tibiofibular Ligament Tear Evaluation (YT short)
👉(Video) Proximal Tibiofibular Ligament Tear Evaluation (IG Reel)

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Transcript

Hello everyone and welcome to episode 367 of the Orthoeval Pal Podcast. I'm your host, Paul Markey, and today we're going to be talking about proximal tibiofibular ligament tear. It's going to be a rare case presentation. We're going to be talking about the anatomy surrounding the proximal tibial fibular ligament. We're going to be discussing this patient's clinical presentation. We'll go over the management of this injury and so much more. But before we get started, I want to apologize because we have a long intro today for some other things besides what we're gonna be talking about, but I do wanna ask a huge favor. It's been a while since I've asked this, but I'm wondering if you can head over to Apple Podcasts, give us a rating and review for the Orthoevalpal podcast. I'm doing a complete website revamp and looking to really optimize the Orthoevalpal content this year. I wanna know what we're doing well, what we could be doing better, so be sure to add that to it. So if you could jump over to Apple Podcasts and give us a rating and review, I would really appreciate that. Also, before we get started, I want to mention our current sponsor, Rangemaster. Rangemaster is known for their shoulder rehab equipment. They offer products from shoulder wands to finger ladders, overhead pulleys to shoulder rehab kits. Rangemaster is your one stop shop with the treatment of frozen shoulders, post op rotator cuff repairs, total shoulder and reverse total shoulder replacements, and more. If you'd like to get a free sample of Rangemaster's Blue Ranger pulley system, just email jimmyrangemaster.com and add Orthoevalpal in the subject line, and they will get you a free Blue Ranger pulley system. Now today I'd also like to welcome a new sponsor, Medcor Professionals. Now I know the folks at Medcor Professionals personally. They're a locally owned and family operated medical supply company. They carry everything from radial pressure wave units to traction devices, resistance bands to compression garments. Most impressively though is their customer service. It's second to none. If you are looking for a medical product for your clinic or products for your patients, go to www.medcorpro.com, and if you use coupon code OEP10, you get $10 off your next purchase. And I will have a link in the show notes so you can click on that. It's medcorpro.commed corpor0.com. Welcome back everyone. So I hope you're having a great day. Here in northern Maine, we just had some nice chilly days of 21 below 0, without the windchill, and only for about 3 days. So which is good because it used to be about 3 weeks in the past. So global warming is warming northern Maine here. But nonetheless, we have a very interesting and unusual patient presentation today. And I'm gonna tell you, I probably see more of these unusual cases. And as I think about that, like how often I see an unusual case presentation, is it because there are more of them happening or is it because I have a lot of experience and I'm starting to recognize these better because I'm able to tear down the evaluation a little bit better? And I think it's more the latter because oftentimes I get patients who come in with a diagnosis and have something completely different or something very unusual that we kind of tease out just because we get a little deeper with our evaluations. And also listening to your patient makes a huge difference. They will kind of tell you what's going on. Oftentimes you don't even need to put your hands on the patient. They will tell you what's going on. But I do want to bring to you our patient's story today. She's a 62 year old female. 3 years ago fell through a threshold and twisted her knee and ankle very aggressively on the right side. She was immobilized for a very long time with the thought of, you know, this tissue scarring down, and we're going to talk about what we're talking, you know, what we're discussing today in just a little bit. When she came out of the knee brace and ankle brace, she continued to have what felt like a varus giving way of the knee, and the ankle would roll into inversion, kind of like your typical inversion ankle sprain. She was conscious of every step she took, and she really still is, like when she walks into the clinic, for treatment for something else, you can tell she's very guarded and she has to watch where she puts that foot because her knee and her ankle can kind of give way a little bit. It's been a complicated case and she was not able to have surgery because of some insurance reasons, but hopefully at some point get this addressed a little more aggressively. But on evaluation, she had obvious lateral ankle instability with a positive talar tilt test, Okay, so some what appeared to be some calcaneofibular ligament instability. Interestingly, also had giving way when testing her eversion strength. So if I'm testing eversion, a little bit of dorsiflexion. She had some weakness and some kind of like some giving away, and it was kind of interesting. It wasn't super painful, but she just didn't feel comfortable resisting, and especially when we hit the peroneus longus muscle. There are also, some paresthesias over the dorsum of the foot, which led me to think that, you know, she had some common peroneal nerve, injury near the proximal fibular region, because she didn't have any obvious radiculopathy coming from her back. She had good reflexes, good sensation, negative straight leg raise test. So when looking at her lateral knee, we noticed that it looked like the proximal head of the fibula was swollen, and it really wasn't swollen. It was just kind of protruding a little bit more. So I think here we should just review some anatomy surrounding this area so it just makes sense when we jump into the next section. So ligamentously on the outside of the knee, we have an anterior and posterior tibiofibular ligament. Now I'm gonna screw this up. I know I will because I did on my Instagram and I, really don't do a lot of editing video or audio, so you get what you get, but I know I'm gonna mess up tibiofibular ligament because I'm gonna say it several times here. But if we if we look at there's an anterior and posterior tibiofibular ligament and then centrally the arcuate ligament complex also attaches to the proximal fibular head. Now the LCL goes from the lateral femoral condyle down to the proximal fibula. And just inferior to the tibiofibular joint is the interosseous membrane between the tibia and the fibula. Okay, so that also helps to hold them together. But the biggest supporter is the anterior and posterior tibiofibular ligament. Muscularly, there is the biceps femoris, the lateral hamstring, which, from above attaches to the fibula as kind of an anchor, all right? So let's not forget here also the common peroneal nerve which travels just posterior and inferior to the proximal fibular head. This is very easy to injure as we know it's, you know, one of the 2 most exposed large peripheral nerves in the body, you know, along with the cubital tunnel and ulnar nerve. So very easy to injure with any sort of strain, sprain, trauma, compression to that area. So now let's get back into our knee exam of this patient. Put her on the table. She has full knee range of motion, full flexion, full extension without any pain. She has a negative Lachman test. She has a negative posterior drawer. When we do a valgus stress test at 0 20 degrees, that's normal. When we do a varus stress test at 0 degrees, that's normal. But when we place her in 20 degrees of flexion and do a varus stress test, she feels some mild discomfort on the lateral side of the knee, some kind of like sense of instability, but nothing's too severe. She has no joint line tenderness and no intra articular effusion. So by identifying that, first of all, we have a good location because sometimes it can be tricky and people will miss a fibular problem or a joint line problem because they can't identify the difference between the two of them. The other big one here is there's no intra articular effusion so it rules out things like an ACL, PCL, meniscus, chondral lesion, things of that sort inside the knee joint. So we are talking about, something that is extra articular. So she has no palpable tenderness to the outer proximal fibula. So you know we've been talking about this area and you'd think it would be tender, but really it's not. Okay. She has some mild tenderness just anterior, a little bit more than posterior to that tibiofibular joint. Okay. She does have a positive Tinel's at the common peroneal nerve just posterior and inferior to that proximal fibula. So she has had some irritation, some stress, some strain, some compression to that common peroneal nerve that increases the tingling down into the, dorsum of the foot. Now I take a hold and just imagine this, okay, so I'm with my right hand, I am holding her tibia with my left index finger and thumb. I grab a hold of her proximal fibula and I shift it posteriorly and anteriorly and this is where it rears its ugly head. I have all kinds of crazy motion there, anteriorly and posteriorly compared to the other side. So you really want to if you want to take a look at what this looks like, I am going to link my Instagram, reel of this patient, which has gone crazy. I think something like 110,000 views. And it's really easy to see where this instability is. And and if you think about everything that attaches there, you can see why this patient has an instability. Okay, so what does her gait look like? It is slightly toed in, and inverted at the foot and ankle some because she can't use her peroneals to pull the foot out and evert it a little bit because it gives her, this weird sense of instability at the proximal fibula. Feels like the ankle wants to roll in and the knee wants to give out kind of spontaneously, So she goes into kind of like a varus gait when she walks. And here we have this very unstable proximal tibial fibular joint. And she was unable to have surgery, as I said earlier, because of insurance reasons. And since I put up my Instagram post, I have had a ton of people respond and say, you know, I had surgery. They put a button in, tied it in, scarred down, and, you know, a year later, I'm doing significantly better with much better stability, and the foot and ankle feel better also just by fixing that tibial femoral joint and stabilizing it. This ligament won't heal on its own and in the meantime, you know, we have to think about what we are going to do to help give her some stability here. So we're proposing a custom made brace or a fibular fracture brace to place pressure on that lateral and proximal fibula, but not over the common peroneal nerve, and we want to kind of just pull that fibula to the tibia and give it some stability there so the muscular structures attaching to it have a good anchor. All right, so we want this brace also to have a strap that goes around the calf, so as she goes to push off or she goes into mid stance to terminal stance phase of gait, as she contracts that calf, it's going to bulge out a little bit. It's going to give a little extra pull to that fibula toward the tibia and should give her more stability. So just putting a simple patella Chopat strap on there, really give her quite a bit of comfort and better control at the foot. So we wanna do something that fits her just a little bit better and doesn't give her pressure only at one spot. And again, we want to protect that common peroneal nerve. So if you want to see how unstable this joint is, again, check the link in, my Instagram link, in the show notes. I also did a YouTube short on this so you can get it on YouTube. Also, I put up about 6 new videos in the last 2 weeks, so be sure to check those out on the YouTube channel. If you've had a patient who's had this injury and they've had surgery for it, I'd love to hear about it, okay? I want to know how well your patient did. It's not something you see very often. It's super rare. So if you did have a patient who had that fixed, I'd love to know about it. Email me. The link is in the show notes. Folks, I hope you found today's episode interesting, thought provoking. Be sure to stay tuned for the unveiling of our new website that should be happening in the next week to 2 weeks. Hopefully, by the 1st week of February 2025 it will be up and running. Be sure to check it out. We'd love to, get your comments on, how you think it looks. So super excited about that. As always, be kind to each other and take care.