Proximal Tibiofibular Joint Injection

Other Names

• Proximal Tibiofibular Joint Injection
• Proximal TibFib Injection

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Background

Illustration of the proximo tibiofibular joint

Key Points

• Needle: 1-1.5 inch, 25 gauge
• Transducer: High frequency, linear
• Optimal approach is short axis, out of plane

Anatomy of the Proximal Tibiofibular Joint

• Synovial joint articulating the fibular head and lateral tibial plateau
• Surrounded by fibrous capsule supported by anterior-superior and posterior-superior tibiofibular ligaments

Palpation Guidance vs Ultrasound Guidance

• There are no studies evaluating the success a palpation or landmark based approach
• Smith et al compared ultrasound guidance vs palpation guidance in cadavers
  • Success rate was 100% with ultrasound, 58% with palpation guidance
• Clinical outcomes comparing ultrasound and palpation guidance have not been described

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Indications

• Proximal Tibiofibular Joint Pain

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Contraindications

• Absolute
  • Anaphylaxis to injectates
  • Overlying cellulitis, skin lesion or systemic infection
• Relative
  • Can be treated with less invasive means
  • Hyperglycemia or poorly controlled diabetes
  • Lack of symptom improvement with previous injection

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Procedure

Transducer and needle position for proximal tibiofibular joint injection

Proximal tibiofibular joint injection using an out-ofplane (short-axis) approach. The needle tip is depicted by the yellow arrow, and the asterisks delineate the anterior superior tibiofibular ligament.<ref name="malanga">

Equipment

• Sterile prep (i.e. chloraprep, chlorhexidine, iodine, etc)
• Gloves
• Needle: typically 21-25 gauge, 1.5 inch
• Syringe: 5-10 mL
• Gauze
• Ethyl Chloride
• Bandage
• Injectate
  • Local anesthetic
  • Corticosteroid
• Sterile probe cover

Ultrasound Findings

• Setup
  • Transducer: high frequency, linear
  • Depth is usually 2-3 cm
  • Probe is typically in transverse oblique plane, although this is highly variable
  • Use fibular head as a point of reference
  • Significant individual variance
• Common ultrasound findings include
  • Cortical irregularities
  • Joint effusion
  • Less commonly, ganglion cyst

Technique: Short Axis, Out of Plane

• Patient Position
  • Lateral decubitus position
  • Affected knee is facing up with the knee flexed 20-30 degrees
• Transducer position
  • Transverse oblique over the proximal tibiofibular joint
• Needle Approach/ Orientation
  • Out of plane
  • Inferior to superior
• Target
  • Proximal tibiofibular joint
• Pearls and Pitfalls
  • Careful pre-scan to identify and avoid the common, superficial and deep peroneal nerves

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Aftercare

• No major restrictions in most cases
• Can augment with ice, NSAIDS
• Consider Knee Compression Sleeve to reduce re-accumulation

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Complications

• Infection
• Damage to surrounding tissue

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See Also

• Procedures Main
• Ultrasound Main
• Knee Pain Main

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