There are many causes of knee pain. One often overlooked cause is a simple dysfunction of the proximal tibiofibular joint. The proximal tibiofibular joint is actually a joint that is outside the knee. It is found by locating a medium-sized bump on the lateral leg about two inches down from the knee. The hamstring tendons attach at this point and can also be used as a guide. Bend your knee to 90 degrees and locate the hamstring tendons as a cord that is present on the outside and just behind the knee. These tendons can be verified by pulling your leg backwards against resistance and seeing if the tendons tighten. If they do, you have the right area. Find the medium-sized bump on the bone where the tendons end. This is the proximal tibiofibular joint.
A recent case study reported in the Journal of Manipulative and Physiological Therapeutics1 by George G. DeFranca, DC, examined the progress of this type of injury. The patient had complained of left-sided knee pain for five years. The original injury had occurred when she arose from a chair and twisted to the left. Her knee went "twang" and began to hurt immediately. The pain persisted, involved the entire left upper leg and low back, and worsened with climbing stairs, riding in the car, and walking. She was seen by many different doctors and was provided with many diagnoses. She was said to have a meniscus tear, ligamentous injury, or arthritis.
She consulted a chiropractic doctor and was found to have pain at the left tibiofibular joint, a reduction of normal motion of this joint, and tight hamstring tendons on the left. Having the patient stand on the sore leg and bend the knee to 30 degrees caused increased pain at the joint. This is a good test for tibiofibular joint dysfunction and is nonpainful in a normal joint. Painful knees can often be relieved by placing the patient's other non-weightbearing foot behind the painful tibiofibular joint and having the patient press on the joint. The entire maneuver would have the patient stand only on the painful leg with it bent at 30 degrees, pressing the other foot behind the painful tibiofibular joint. Pain upon one-leg standing that is relieved with pressure from the other foot is considered a positive test for this injury.
There were also findings of low back dysfunction on the same side which were considered secondary to the tibiofibular joint dysfunction. The first treatment consisted of chiropractic manipulation of the tibiofibular joint only. She reported a 90 percent improvement after the first treatment. She was treated a total of seven times before being released to follow up care only. During the course of treatment both the tibiofibular joint and the low back were manipulated in a chiropractic manner. She also received hamstring stretching exercises, and self-mobilization instructions for the tibiofibular joint.
The case study then continues with an in-depth discussion of the proximal tibiofibular joint. The article concludes that the proximal tibiofibular joint should be considered in any case of lateral knee pain. The joint can be injured by severe or seemingly mild trauma, and manipulation of the joint can provide relief. One should not forget to examine and treat any dysfunction of the low back which may be associated.
If you or a patient have knee pain that fits some of the patterns noted here, the tibiofibular joint should be examined and appropriate treatment rendered. The condition is often overlooked. The examination is relatively quick. And it does respond readily with proper care.
(1) DeFranca GG, Proximal tibiofibular joint dysfunction and chronic knee and low back pain. JMPT 15(6): 382-87, July/August 92.
Editor's note: Inquiries may be made to Dr. John McDaniel at 2290 El Camino Real, Ste. 8, Mt. View, CA 94040-1613. Tele: (415) 967-1152.
John McDaniel, DC, CCSP
Mt. View, California
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