A 17 year old with isolated proximal tibiofibular joint arthritis
© Canna et al.; licensee BioMed Central Ltd. 2013
Received: 19 July 2012
Accepted: 8 January 2013
Published: 9 January 2013
The proximal tibiofibular joint (TFJ) is rarely affected in rheumatic diseases, and we frequently interpret pain of the lateral knee as the result of overuse or trauma. Nonetheless, the TFJ is a synovial joint that communicates with the tibiofemoral joint in a proportion of patients. While proximal TFJ arthritis has been rarely associated with existing spondyloarthritis, isolated TFJ arthritis as the presenting manifestation of spondyloarthritis has not yet been described. Here, we report the clinical and radiographic presentation of an adolescent with chronic proximal TFJ arthritis heralding spondyloarthritis highly suggestive of ankylosing spondylitis.
While pain and tenderness at the fibular head usually suggests trauma or overuse injury, arthritis should be included in the differential diagnosis. The proximal tibiofibular joint (TFJ) is a synovial-lined arthrodial plane joint, articulating between the lateral tibial condyle and the fibular head. The joint is supported by the lateral collateral ligament, which attaches superiorly to the lateral femoral condyle. The TFJ mainly functions to dissipate rotational stress at the ankle, and provide tensile rather than weight-bearing support.
There is a single report of TFJ arthritis complicating existing Ankylosing Spondylitis (AS). Hong et al. reported evidence of TFJ arthritis in three of 16 known AS patients presenting for evaluation of knee pain. All of these patients had concomitant radiographic findings consistent with AS. Here, we report a highly active adolescent male with isolated, chronic TFJ arthritis as the presenting sign of ankylosing spondylitis.
He returned for orthopedic evaluation 8 weeks after the CT scan and an MRI with gadolinium showed a moderate TFJ effusion with persistent bony edema and surrounding synovial enhancement without synovial thickening. There was also a small subchondral erosion of the lateral tibia (Figure1C & D). Upon review of his CT scan, the erosion was evident (Figure1E).
While this patient’s age at onset of symptoms exclude him from classification as enthesitis-related arthritis (ERA) or seronegative enthesopathy and arthropathy (SEA) syndrome, his presentation is relevant to the evaluation of younger patients[4, 5]. He does not meet criteria for AS based on the modified New York criteria, but these criteria rely on X-ray evidence of sacroiliac involvement that may not be evident early in disease. The Assessment of SpondyloArthritis International Society (ASAS) criteria are more appropriately applied to this patient. While he does not meet the criterion of > 3 months of inflammatory back pain, his axial imaging is strongly suggestive of sacroiliitis, and his HLA haplotype and peripheral arthritis strongly support an AS diagnosis.
Isolated inflammatory arthritis of the proximal TFJ joint should be included in the differential diagnosis of lateral knee pain and may require contrast-enhanced MRI to demonstrate synovitis. The most common cause for pain at this site is recurrent traumatic TFJ subluxation/dislocation, often seen with high-impact activities and which can result in bone marrow edema or other radiographic signs suggestive of inflammation[2, 10]. The differential diagnosis of pain in this area should include infection, chronic arthritis (such as in rheumatoid arthritis), degenerative disease, neoplasm (e.g. osteosarcoma), pigmented villonodular synovitis (PVNS) and ganglion cyst[10, 11]. In patients with a communication between the two joint spaces arthritis of one joint could, via transfer of inflammatory cells/mediators, result in arthritis of the other.
The relative rarity of TFJ arthritis should not overshadow its association with AS. TFJ arthritis masquerading as trauma or overuse could delay diagnosis or treatment of axial disease in AS. Increased time between symptom onset, diagnosis, and treatment have been associated with more severe clinical and radiographic disease in AS. Thus, when a practitioner confirms proximal TFJ arthritis, consideration for occult signs of spondyloarthritis should follow.
Inflammatory arthritis of the proximal tibiofibular joint is an uncommon but likely underdiagnosed cause of lateral knee pain. Arthritis of this joint has been reported in connection with ankylosing spondylitis. Practitioners should be careful to evaluate for arthritis as part of a work-up for chronic lateral knee pain and stiffness, and should consider concomitant evaluation for spondyloarthritis.
Written informed consent was obtained from the patient for publication of this Case Report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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