Division of Clinical Sciences, Life University, Marietta, GA, USAUnited States
Division of Basic Sciences, Life University, Marietta, GA, USAUnited States
Also available as PDF (figures and tables appear in the PDF).
In this article, a case of the lower leg and feet pain and cramps in a 5-year-old girl disturbing the child for two-years was described. These symptoms had been occurring just during the nights and lasted sometimes for 2-3-hours. There were no visible causes of this disorder. Previous examinations in a pediatric office and by a podiatrist did not reveal any pathology. In our office, both fibular heads were found to be subluxated postero-medially. We hypothesized that a causative factor of the pain and cramps was the involvement of the common peroneal nerve due to this subluxation. Manipulation of the fibular heads (a high-velocity, low-amplitude thrust) eliminated these symptoms after just two visits. In the future, these symptoms in the child occurred just a couple of times during the next eight-years of follow-up observations. Various types of treatment of the proximal tibiofibular joint pathology, the common peroneal nerve involvement, and the significance of manipulative therapy in this type of involvement that resulted in rapid and high effectiveness, are discussed in the article.
Keywords: Proximal tibiofibular joint (PTFJ); Symptomatic subluxation; Manipulative therapy; Joint dislocation; Postero-medial subluxation; Proximal tibiofibular joint (PTFJ); Symptomatic subluxation; Manipulative therapy; Joint dislocation; Postero-medial subluxation
anipulative therapy is becoming a more and more popular
type of treatment and is actively used not only in the man- M 1,2 agement of spinal painful syndromes. This treatment approach
can also effectively suppress the pain occurred in other parts of
3,4 the musculoskeletal system.3,4 The musculoskeletal pain where ma-
nipulative therapy is really effective and more preferred than other
types of pain management is usually associated with minor dis-
placement of the articular surfaces in relation to each other, known
as subluxation (partial dislocation).5
Although subluxations could potentially develop in all
bone articulations, the reports about the effectiveness of manip-
ulation in the treatment of peripheral joints mostly describe the
ones affecting large or medium-sized joints.6 There is relatively less
information in the literature regarding subluxation in smaller pe-
ripheral joints of the body. The proximal tibiofibular joint (PTFJ)
is one of these small articular structures. Less common attention
cc cc Copyright 2022 by Plotkina O. This is an open-access article distributed under Creative Commons Attribution 4.0 International License (CC BY 4.0), which paid to this joint subluxation, could be associated with its low fre-
7,8 quency,7,8 or with uncommon misrecognition of this clinical pa-
9-11 thology and therefore, with untimely assistance.9-11
In this article, we present a case report about a relatively
rare happening of PTFJ subluxation in a child that was found to
cause lower leg pain and cramps in fact for at least two-years, and
in whom we were able to successfully eliminate these symptoms
and their cause by manipulation on these joints.
Patient R., 5-years old, female, was brought by her mother to the
doctor’s office with complaints of moderate to severe pain and
cramps in her lower legs and feet. These symptoms occurred al-
most every night, often making her to cry and even scream be-
cause of the pain. The mother explained that these symptoms
had begun two-years ago without any visible cause: no falls, vis-
ible traumas, peripheral nerve disorders, etc. Usually, these clini-
cal manifestations developed 3-4 times a week during the nights,
when after 1-2-hours of sleeping they suddenly awoke her up.
The duration of attacks at the beginning was 30-40-minutes, in-
creasing later sometimes up to 2-3-hours. During the daytime the
girl was physically active, having no complaints.
The mother stated that she attempted the conservative
care of changing shoes, padding, use of analgesics (Advil or Ty-
lenol), and limitation of physical activity. However, none of these
approaches helped. The girl was examined by a pediatrician who
found her healthy. A podiatrist did not establish any specific di-
agnosis, although noticed the pronation type of both feet, with
decreased arches. He suggested she might need foot surgery in
the future.
In our office, a thorough examination was performed.
The musculoskeletal system was also examined using the specific
evaluation system, activator protocol.12 The examination revealed
no neurological dysfunctions, muscle weakness, or restrictions of
range of motion. Posterior subluxation of both proximal fibular
heads was the only finding.
Manipulation was used as a treatment. For this, the cor-
rections of subluxation of both proximal tibiofibular joints by
applying a high-velocity, low-amplitude thrust to both fibular
heads were carried out each visit.
After the first visit (three-days later), the mother in-
formed that the duration of pain and cramps attacks during the
nights was reduced to 5-10-minutes instead of 30-40-minutes be-
rd fore the treatment. By 3rd visit (five-days later) the patient’s moth-
er stated that these symptoms were completely absent during the
night. The subluxation of the right proximal tibiofibular joint was
eliminated after four visits, but on the left one only by the 9
visit (three-weeks later). During this time the pain and cramps
occurred just once in the left leg, which could be associated with
the longer presence of left tibiofibular joint subluxation (Figure
1). After that, the aforementioned attacks, accompanied by only
mild pain, occurred in the patient just a couple of times during
the next eight-years of follow-up observations.
Figure 1. Duration of Night Pain in Lower Legs and Feet Before Each Visit
Thus, in the present case, the pain and cramps in the lower legs
and feet seem to have been associated with the subluxation of
both proximal tibiofibular joints. This was confirmed by the re-
sults of our examination and the rapid and high effectiveness of
the performed manipulations.
The PTFJ is a small, plane-type synovial joint with mini-
9,10,13,14 mal movement. This joint is quite stable articulation due
9,11 to bony congruency and ligamentous and muscle support.9,11
7,13,15 Pathology of PTFJ is relatively rare, potentially it could be
16,17 associated with a number of diseases such as osteoarthritis,
18 19 16 neoplasms, ganglion, pigmented villonodular synovitis, etc.
However, despite the relative stability of PTFJ, its damage most
frequently results from injury, and is often accompanied by its dis-
13,14,20 14 location, fibula fractures, rupture of ligaments around the
12 21 joints and muscle tendons.21 This kind of problems occurs more
frequently in young males, and usually is the result of sports ac-
11,13,22 tivity, but also was described in ballet dancers, soccer players,
7 15 equestrian jumpers,7 parachutists.15 The clinical experience shows
also that in the case of just PTFJ subluxations without visible
14,20,23 joint dislocation, these damages often are less recognized,
remain undiagnosed due to difficulties with radiographic identi-
14,24 16 fication, lack of emphasis in the literature and textbooks, in
10 20,25 polytrauma scenario, or in children.
In the classification of the PTFJ injury in the modifica-
tion of Ogden made in 1974,14 the traumatic damage of these
joints is divided into four types: type I–subluxation, usually atrau-
matic, without visible dislocation; type II–antero-lateral disloca-
tion; type III–postero-medial dislocation (usually as a result of
direct knee trauma); IV–superior dislocation. The majority of
th 10,13,14 PTFJ trauma (up to 85%) is type II injury. It is often associ-
ated with common peroneal nerve palsy, ligamentous injury, and
bone fracture, which certainly requires surgical intervention.8
Quite frequently PTFJ trauma, as shown above, involves
the common peroneal nerve with various degrees of damage.18
Depending on the nature and degree of involvement, this dam-
age could be manifested by some sensory or minimal motor dis-
turbances, or more serious peroneal nerve palsy8,26 whose hall-
mark clinical manifestation is foot drop.27 Sarma10 stated that in
any knee injury accompanied by common peroneal involvement,
occult PTFJ dislocation or subluxation should be clinically sus-
pected and ruled out.
The case presented demonstrates the pathology of both
proximal tibiofibular joints. Neither the child nor the mother
could recall any visible trauma, and the examination found no
neurological dysfunctions, muscle weakness, or restrictions of
range of motion. Only the use of the special evaluation system,
however, made it possible to identify postero-medial subluxation
of both PTFJ. Based on Ogden’s classification,14 this pathology
corresponds to Type I of PTFJ injury and fits the definition of
this joint subluxation as “excessive, symptomatic motion without frank
28 20 dislocation”,28 or as symptomatic hypermobility of the PTFJ.20
Evidence of the relationship between the symptoms
and subluxation, as mentioned above, is suggested by the rapid
and high effectiveness of the treatment. The restoration of the
congruency of both joints in our patient just through the me-
chanical correction (posterior-to-anterior push of the proximal
fibular heads) made it possible to eliminate the night pain and
cramps in both lower legs and feet in fact permanently within a
very short time of only two-visits. This is essential because the
complete stabilization of PTFJ subluxations usually requires a
13,29 longer time.
It is interesting to analyze the nature of pain and cramps
in the present case. Potentially, any subluxation could result in
pain due to the involvement of the enthesis. In this situa-
tion, the pain would have been localized just in or around the
involved PTFJ. However, the patient complained of pain in the
areas which are at a certain distance from the involved joints. We
assumed that the common peroneal nerve can be involved in the
pathological process because a part of it is located exactly behind
the proximal fibular head.
The common peroneal (common fibular) nerve is a
branch of the sciatic nerve. It is well-known that the nerve passes
over the posterior aspects of the proximal fibular head, where it
10,25,32 is susceptible to injury. Just inferior and lateral to the fibular
head at the fibular neck, it divides into two nerves – the superficial
16,33 and deep fibular nerves. In addition to innervating the muscles
that compose the anterior and lateral muscular compartments of
the lower extremity, the common peroneal nerve carries afferent
cutaneous sensory fibers. They are responsible for sensation in
the anterolateral aspect of the lower extremity that extends from
midway down the leg to the majority of the dorsal aspect of the
foot and toes.33
The distribution of pain in our patient exactly corre-
sponds to the areas innervated by the sensory fibers of this nerve.
We assume also that with a high degree of probability the cramps
can be caused by the irritation of the motor fibers of the com-
mon peroneal nerve. The causative factors of the nerve involve-
ment, in this case, are posteriorly subluxated proximal fibular
heads which can compress or stretch the common peroneal nerve
8,26 before it divides into superficial and deep fibular branches. This
27 10 irritation of both sensory and motor fibers, in our opinion, can
be the plausible explanation for why the child experienced night
attacks of both pain and cramps in the legs in this case. Although
during the day examination no objective neurological signs were
revealed, the disappearance of these symptoms after elimination
of the subluxation represents the good evidence and confirma-
tion of our assumption about common peroneal nerve involve-
ment.
Therefore, this compression could compromise both
sensory and motor functions of the nerve. We found the possible
confirmation of our concept in the article of Hardin and Deven-
dra.33 These authors noted that incorrect or too tight placement
of a splint or cast under the knees, across the fibular head after a
trauma or burn, can result in compression of the common pero-
neal nerve. We believe that one of the likely mechanisms of the
nerve compression in these cases could be the posterior proximal
fibular head subluxation caused by this tightness.
In our present case, the treatment of both PTFJ sub-
luxations turned out to be correct and highly effective. Lower leg
pain and cramps ceased to bother the child already after the sec-
ond visit, which occurred quite soon after the beginning of the
care. The previous treatment (use of analgesics, changing shoes,
padding) was ineffective.
In general, the treatment of PTFJ injury depends on
many factors. In the case of tibiofibular instability, some clinicians
recommend surgical treatment, even if the injury is not associ-
30,31 25 ated with trauma. Other specialists, however, prefer to use the
14,23 surgery only when the conservative treatment is ineffective, or
only when chronic problems or neurological symptoms exist, and
surgery is generally considered a last resort.30 After analyzing 44
publications, Kruckeberg34 found that such surgical approaches
as fixation and fibular head resection are not safe and are associ-
ated with high complication rates.
Based on the data of other clinicians, the character and
duration of the treatment should depend on the type of PTFJ
15,23 injury and its severity. In the case of PTFJ subluxation (tak-
ing into account Ogden’s classification) the conservative treat-
ment is usually the first choice,35 but with varying degrees of effi-
ciency and therapy duration: immobilization, anti-inflammatory
15 29 drugs,15 physical therapy,29 wearing a supportive strap around the
20 15,36 21,24,37 involve PTFJ, mobilization, manipulation. Although
20,23 subluxation of this joint is less recognized than its dislocation,
the use of manipulation in this type of injury can be quite suc-
21,37 38 cessful. For example, De Franca reported immediate and
dramatic relief of knee and thigh pain after the manipulation of
the PTFJ. Beazell37 used the PTFJ manipulation in a young run-
ner with three months of knee pain, and this patient was able
to resume running without pain in just one week after the initial
intervention.
Taking into consideration the objective finding (poste-
rior subluxation), we have chosen the most logical and easiest
treatment approach which resulted in the alignment of the PTFJ
articular surfaces. It was the manipulation. And this approach has
led to a rapid and stable clinical effect.
1. Lower leg pain and cramps could be associated with PTFJ sub-
luxation.
2. In the case of posterior PTFJ subluxation, the subluxated
proximal fibular heads can compress and/or stretch the common
peroneal nerve.
3. The common peroneal nerve involvement can be the most
likely causative factor of lower leg pain and cramps in the case
of PTFJ subluxation.
4. The high-velocity low-amplitude thrust manipulation could be
the primary and optimal treatment in the case of PTFJ injury if
its damage is limited just by subluxations of these joints.
We would like to thank Professor Brent Russell from Life University
for his help and recommendations in the process of preparation of
this article.
The authors declare that they have no conflicts of interest.