The proximal tibiofibular joint is a less common source of pain outside the knee. It is often overlooked as the cause of lateral knee pain as the knee joint and tendon structures are close by. What are the possible causes of fibular head pain, and what can we do? 

What is the proximal tibiofibular joint? 

The proximal tibiofibular joint lies between the tibia and fibula near the outer knee joint. You can locate the joint by placing your hand on the outside of the knee. Feel for the bony prominence on the outside of the knee, which is the head of the fibula. The joint is just above this lump. A strong capsule and ligaments surround the joint. A large nerve, the common peroneal nerve, wraps around the fibula neck under the joint. 

Sometimes, the proximal tibiofibular joint communicates with the knee joint. Therefore, knee joint pathology, such as arthritis or swelling, may irritate the proximal tibiofibular joint. 

Although a tight capsule surrounds the joint, we know that the joint moves out and in and also rotates. 

Causes of fibular head pain 

When a patient complains of pain at the fibula head and superior tibiofibular joint, possible causes include the following:

Trauma

A direct knock or hit to the fibula head can damage the superior tibiofibular joint. Other mechanisms of injury include a knee twist or landing heavily on the knee with the knee joint bent. Trauma may lead to a fibula fracture, superior tibiofibular joint cartilage damage, ligament sprain and popliteus tendon tears. 

Proximal tibiofibular joint arthritis 

Arthritis presents with joint narrowing, swelling and bony spurs. These changes can occur by itself or with knee joint arthritis. 

Ganglion 

A ganglion is a cyst containing a thick jelly-like substance. These slow-growing cysts can press on structures close to the fibula head, such as the common peroneal nerve, causing nerve symptoms in the lower leg. 

Other causes of pain at the head of the fibula include biceps tendonitis, popliteus tendonitis, and lateral ligament sprain, 

Fibular head pain: how to diagnose

Symptoms 

Ususally, pain occurs after running for 10-15 minutes. Downhill running is generally more problematic. There is little or no pain with other activities such as walking, cycling or daily living activities. Most patients say pain localises outside the knee but can sometimes radiate to the iliotibial band or the kneecap. Sometimes, swelling or a click can be present. Other knee disorders, such as ITB friction syndrome, patellofemoral pain, meniscal tear, and knee arthritis, can present similar symptoms. 

Your doctor will examine your knee to confirm proximal tibiofibular joint pain and exclude other causes. Some findings that make this joint more likely to be the pain source include the following:

  • Tenderness on touching the proximal tibiofibular joint 
  • Increased movement of the superior tibiofibular joint
  • Stress testing of the outside knee can find looseness or laxity of the ligaments. 

Doctors should assess other structures, including the lateral knee ligament, common peroneal nerve and the knee’s outside (lateral) compartment. 

Investigations

Generally, a plain knee X-ray can show narrowing and bony spur formation in arthritis. An abnormal joint position might point to instability. MRI is usually more helpful in finding joint fluid, bone swelling, and cartilage damage. We also use imaging to exclude other common causes of outside knee pain. 

X-ray with an arrow pointing to the fibular head

Fibular head pain treatment 

It is essential first to find a specific cause of your fibular head pain. 

For superior fibular joint pathology, we usually start with simple treatments for acute pain, such as ice packs and oral anti-inflammatory medication. Physical therapy incorporating soft tissue massage and joint mobilisation can improve the function of the head of the fibula and surrounding structures. Exercise therapy can correct muscle imbalances and reduce abnormal forces on the joint. Balance exercises with mini-traps or bosu balls will help stabilise the joint. Sometimes, foot orthotics may help to redistribute forces away from the damaged joint. 

Injections 

If the superior tibiofibular joint is damaged, we can use injections to reduce pain and improve function. Cortisone is a potent anti-inflammatory that reduces pain and swelling from a swollen or arthritic joint. However, excessive cortisone use can cause more damage to the cartilage. Platelet-rich plasma, or PRP, is anti-inflammatory but less toxic to the joint. We obtain PRP by spinning blood in a centrifuge and separating the plasma from the red and white cells. 

The superior tibiofibular joint is small and surrounded by a tight capsule. So, most doctors perform injections with ultrasound guidance to improve accuracy and ensure the injection goes into the right spot. 

Surgery

We should only reserve surgery for cases that fail non-surgical treatments. Surgical treatments include ligament reconstruction. Fixing the joint may improve stability in cases associated with superior tibiofibular joint instability. 

Other frequently asked questions on fibular head pain

Can nerve damage cause fibular head pain? 

Yes. The common peroneal nerve wraps around the fibular neck. Irritation or instability of the proximal tibiofibular joint can cause nerve trapping, leading to pain, numbness, and pins and needles in the outer lower leg. Calf or foot weakness is sometimes present in severe cases of nerve trapping. 

Is tendonitis a common cause of fibular head pain? 

Sometimes. The popliteus tendon starts in the knee joint and wraps around the outer part of the tibia. Popliteus tendonitis can cause pain in the outer knee radiating to the back of the knee. Also, the biceps tendon starts at the lower outer hamstring and travels down the outer knee. It attaches to the head of the fibula. Biceps femoris tendonitis is uncommon and causes pain close to the fibular head. 

Final word from Sportdoctorlondon about fibular head pain

Fibular head pain is common and caused by various structures, including the proximal tibiofibular joint, ligament damage or tendonitis. Damage to the superior tibiofibular joint is an under-recognised cause of pain at the fibular head treated with physical therapy, taping and injections. 

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