A 29-year-old professional international rugby union player presented to the emergency department after an accident during a training session, reporting pain in his right knee. He described running towards an opponent while in possession of the ball, when he was tackled with his foot planted on the ground. He then described a twisting of his knee as he was pulled to the ground, leading to immediate pain and an inability to bear weight on that leg.

On examination, there was a palpable deformity in the region of the right fibular head with associated tenderness. Distal neurovascular status was normal. The patient’s medical history was notable only for a repair of a ruptured Achilles tendon during his professional career, from which he made an uneventful recovery and return to international rugby. His general history and physical examination were unremarkable.

Initial investigations included routine blood tests and plain film radiology (fig 1A). The anterior–posterior x ray scan showed a proximal tibiofibular dislocation. After initial attempts to reduce the dislocation failed, an MRI was performed to further delineate the anatomy (fig 1B). This showed anterolateral dislocation of the tibiofibular joint with an intact but lax arcuate ligament—in effect, a Hill–Sachs-type lesion.

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Figure 1 (a) Plain x ray film showing proximal tibiofibular joint dislocation; (b) T2-weighted axial MRI scan confirming diagnosis; (c) post-operative plain x ray film.

After the unsuccessful attempt to reduce the dislocation under sedation in the emergency department and performance of the MRI, a decision was made to proceed with operative management. The patient was taken to theatre for reduction of the dislocation, where he received a general anaesthetic. An initial attempt at closed reduction was unsuccessful. A short incision was then made anterior to the joint. The biceps femoris muscle was partly dissected off the fibular head. The dislocation was reduced with some difficulty, and reduction was maintained using a K wire. A further plain x ray film confirmed that the joint was reduced (fig 1C).

The patient had an uncomplicated postoperative course. He was seen by the resident physiotherapists on the morning after surgery, and a rehabilitation programme was devised. He began mobilising on a non-weight-bearing basis.

The patients was discharged on the afternoon after his surgery, and was followed up in the outpatient department 8 days post-operatively. He underwent elective removal of the K wire 6 weeks later and began full weight-bearing. He then underwent a rehabilitation programme consisting of light plyometrics and fast foot exercises. He was declared to have full function 10 weeks after his injury. He came off the bench for his professional club side a further 2 weeks later and resumed his international career later the same season. At the time of reporting, he is still a starting international player.

DISCUSSION

Proximal tibiofibular joint dislocation occurring in isolation is a rare injury,1 historically seen most commonly in horse riding.2 In a sporting setting, such an injury has been described in soccer,6 snow-boarding,8 long jump9 and rugby union.10 However, to date, we are unaware of such a case in an elite professional rugby union player.

Proximal tibiofibular joint injuries are classified into subluxations and dislocations. The latter can be anterolateral, posteromedial or superior.3 The commonest subtype is an anterolateral dislocation.

The most common mechanism of injury is a twisting fall on an inverted foot with the knee flexed and the leg adducted.4 In our patient, the mechanism was one of the player being pulled to the ground with a planted foot, resulting in a twisting of the knee.

Several treatment options are outlined in the literature although no clear algorithm exists. Acutely, closed reduction has been described as being almost invariably successful5 and saving the patient from surgery.10 Rajkumar and Schmitgen reported a case of open-reduction internal fixation in a professional soccer player,6 and Robinson et al describe similar surgery for a young athlete.7

The post-operative management outlined in previous reports varies from 6 weeks of immobilization in a cylinder cast4 to early range of motion exercises, as chosen for our patient. Previous reports also suggest that the outcome varies from limitation of activities4 to full return to elite level activity, as outlined in our case.

Isolated dislocation of the tibiofibular joint is a rare injury. Furthermore, there are no previous reports in an elite rugby player. Hence, no clear paradigm exists for treatment. In the past, opinion has varied as to the necessity and duration of immobilization. We describe a method that allowed early return to maximum performance. Of particular note, this patient made an early, try-scoring return to competition.