nyuuzyou/wikis huggingface dataset:
TMJ Injection

==Technique==
===Landmark Guided===
*Relaxed, closed-mouth approach. 
*Place finger in the depression under the zygomatic arch, against the zygoma, and draw a curved line approximating the bottom of the arch. 
*Ask the patient to open and close their mouth and confirm the location of the posterior mandible. Feel the head of the mandible pass anteriorly underneath your finger and then resume its posterior position
*Needle (27-gauge 3.2 mm) entry is 1cm below the apex of the zygomatic arch with slight 10° posterior angulation, and 45° of cephalad angulation
*If the needle inadvertently made bony contact shallower than 25 mm, withdraw the needle several mm and redirect superiorly to avoid the mandibular condyle.
*After aspiration, inject 1 mL was at 25 mm depth
===Ultrasound Guided===
*Challenging, consider using if failed landmark guided injection
*Use a high-frequency linear small footprint probe
*Place longitudinally over the TMJ. 
*Visualise superficial temporal vessels overlying the joint. 
*Move probe cranially to allow needle to enter skin
*Enter joint space in plane with 23G needle
*Inject solution into joint space
==Complications==
Damage to the collateral ligaments of the disc and the adjacent soft tissue, facial nerve palsy.
==Aftercare==
Avoid NSAIDs if prolotherapy or PRP.
==References==
Category:Head and Jaw Procedures
Category:Stubs
Tarsal Coalition

This is a congenital foot deformity where there are two or more tarsal bones that have fused together or have failed to separate during fetal development.
== Aetiology ==
Probably present at birth, but symptoms are rare in childhood due to flexible cartilage surrounding ossification centres
If movements at the subtalar joint are congenitally blocked by tarsal coalition, then the ankle joint remodels into a ball-and-socket joint to allow inversion and eversion.
== Epidemiology ==
Affects 1-2%. Calcaneonavicular and Talocalcaneal coalition are the most common (90%), and 50% are bilateral.
== Classification ==
* Calcaneonavicular coalition
* Talocalcaneal (Subtalar) coalition
== Assessment ==
It leads to a painful stiff foot during early adolescence. It often presents with recurrent ankle sprain and a rigid flatfoot. In children aged 8-14 there may be progressive lateral ankle pain and a mildly stiff hindfoot.
Most patients have a fixed hindfoot valgus. There is limited subtalar movement, which is worse in talocalcaneal coalition. There is a loss of the longitudinal arch. With tiptoe standing the arch does not reconstitute. 
Plain films demonstrate calcaneonavicular coalition. X-ray is less likely to demonstrate talocalcaneal coalition, where it is usually the middle facet, and so CT is the gold standard imaging method.
== Management ==
* Activity modification
* Footwear adjustment
* Orthoses
* Surgery if unsuccessful
==References==
Category:Foot and Ankle Conditions
Category:Developmental Disorders
Tarui Disease

Tarui Disease (also known as Glycogen Storage Disease Type VII) is an autosomal recessive disorder of carbohydrate metabolism characterised by the absence of phosphofructokinase. It belongs to the group of Glycogen Storage Diseases.
== Pathogenesis ==
The disorder is inherited in an autosomal recessive manner, caused by pathogenic variations in the gene that codes for the M isoform (muscle) of PFK. 
PFK is an enzyme involved in the process of glycolysis that converts fructose 6-phosphate to fructose 1,6-bisphosphate. When there is a deficiency of PFK, it leads to secondary glycogenosis.
== Clinical Features ==
Typically, the disease shows symptoms in childhood, including fatigue, muscle cramps, and exercise intolerance. Symptoms worsen after a high-carbohydrate meal or glucose administration before exercise due to a decrease in free fatty acids and ketones. 
PFK-deficient muscles cannot metabolize glucose, which is thought to be why patients do not experience a second wind like those with McArdle disease. Exertional rhabdomyolysis with myoglobinuria is common, and some patients also experience erythrocyte hemolysis, which is compensated for by increased red blood cell production. Gout with myogenic hyperuricemia can occur even without apparent skeletal muscle involvement. 
In some cases, patients present with progressive muscle weakness and atrophy in middle age or later adulthood. Severe infantile-onset cases have been reported, with symptoms such as central nervous system disease, skeletal myopathy, and cardiomyopathy. There may be a second genetic condition in these cases, as the mechanism behind multisystem disease is unclear but may be due to the absence of an activator common to all PFK isoforms. 
== Diagnosis ==
The concentration of serum creatine kinase is usually high, and red blood cell PFK activity is usually reduced by about 50 percent. Patients may have mild hemolytic anemia and mild hyperbilirubinemia, although anemia is rare, but there may be an increase in reticulocytes. Patients often have hyperuricemia due to increased degradation of purine nucleotides in muscles. The ischemic forearm exercise test does not show an increase in lactate levels, but ergometric exercising demonstrates a late rise in lactate, which may be due to the shunting of glucose 6-phosphate through the pentose phosphate pathway. 
Muscle biopsy reveals a slight increase in subsarcolemmal glycogen that has a normal appearance, while older patients may have an abnormal polysaccharide with a filamentous fine structure resembling that of glycogen brancher enzyme deficiency. PFK activity is deficient in muscles and reduced by about 50 percent in erythrocytes. 
A genetic diagnosis can be made by sequencing analysis of the PFKM gene, and in patients of Ashkenazi Jewish ancestry, genetic testing for the two most common mutations in this population is recommended.
== Treatment ==
There is no specific treatment
== Resources ==
GeneReviews - Tarui Disease
Category:Muscle Disorders
Category:Glycogen Storage Diseases
Third Occipital Nerve

== Location ==
Occipital region of the scalp close to the midline.
== Origin ==
The posterior root of C3, otherwise known as the the Glossary-Definition::Third Occipital Nerve (Glossary-Term::TON), gives off a medial branch which traces a path between the semispinalis capitis and cervicis muscles, before passing through the splenius capitis and trapezius muscles. Subjacent to the trapezius the medial branch gives off the third occipital nerve.
==Course==
The third occipital nerve runs as thin fibers vertically, medial to the greater occipital nerve 2, for a short distance, before passing laterally, crossing the greater occipital nerve and running as far as the retroauricular line, where there maybe overlap with small twigs from the lesser occipital nerve. Vertically the fibers do not extend beyond the superior nuchal line.
==Branches==
There are no named branches of the third occipital nerve, however multiple small twigs intercommunicate with branches of the greater occipital nerve. Far laterally, the branches may overlap with small twigs from the lesser occipital nerve.
Some of the branches transverse medially, across the midline, and intercommunicate with the contralateral third occipital nerve 1.
==Supply==
The third occipital nerve supplies an area of the medial occipital scalp, overlapping with areas supplied by the greater and lesser occipital nerves.
==See Also==
*Third Occipital Nerve Injection
*Chronic Post-Traumatic Neck Pain
==References==
Category:Nerves of the Spine
Third Occipital Nerve Injection

==Background==
==Anatomy==
The third occipital nerve (TON) arises from the medial branches of the posterior ramus of the third cervical spine nerve. It arises between the axis and third cervical vertebral, with or without a communicating branch with the GON. It provides sensory distribution to the lower aspect of the posterior suboccipital neck, dividing into 1-3 ascending branches which nearly reach the superior nuchal line. See Kim et al for a review of the anatomy
==Indications==
==Contraindications==
==Technique==
===Ultrasound Guided===
The third occipital nerve can be blocked using ultrasound guidance, which is significantly faster and requires fewer needle passes than fluoroscopy, and has comparative success rates of 95-100%.
*Position: Lateral decubitus, head supported in a neutral position
*Scan neck in coronal plane, looking for the drop-off in contour that corresponds to C2-3
*Identify the vertebral artery, which is cephalad and anterior
*The third occipital nerve is an oval hypoechoic structure, with hyperechoic stippling
*Visualise in transverse, use colour doppler to identify vascular structures and the safest needle trajectory.
*Use a posterolateral approach, in plane technique, advance the needle until it contacts the periosteum
*Before injection, visualise with a coronal view to ensure the needle tip is next to the third occipital nerve. If the nerve could not be identified then ensure it is over the C2-3 joint.
*Aspirate for blood
*Inject 0.9mL of local anaesthetic.
===Fluoroscopy Guided===
*Position: Lateral decubitus
*Obtain a lateral radiographic image
*Target three sites: C2-C3 joint line, cephalad quarter of C2, and the caudal quarter of C2. 
*Use a single skin puncture for all targets
*Visualise needle tip resting on periosteum in the lateral view.
*Obtain an anteroposterior view, and confirm needle tip is resting on the lateral aspect of the articular process.
*Withdraw 1-2mm to reduce the risk of intraarticular injection
*Aspirate for blood
*Inject 0.3mL of local anaesthetic/contrast solution under live fluoroscopy for each of the three locations, for a total volume of 0.9mL
===Landmark Guided===
===Post-Injection Procedure===
Test for characteristic numbness under the suboccipital region to confirm correct placement of local anaesthetic. The patient will not always have complete loss of sensation to touch, but should have loss of sensation to cold and pin prick.
==Complications==
==Aftercare==
==Videos==
<youtube>gwy3ggsx8c8</youtube>
<youtube>_lH8ZGx900w</youtube>
==See Also==
* Cervical Facet Joint Injection
* Greater Occipital Nerve Injection
* Paraspinous Cervical Block
* Lesser Occipital Nerve Injection
==References==
Category:Cervical Spine Procedures
Category:Infoboxes
Category:Stubs
Thoracic Pain Maps

==Thoracic ZA Joints ==
thumb|left|Thoracic ZA Joint pain patterns in normal volunteers. From Dreyfuss 1994 
Thoracic facet joint pain is felt in the parasagittal region and doesn't cross the midline.
==Thoracic Costotransverse Joints==
Costotransverse joint pain is felt in the parasagittal thoracic spine. It does not or only rarely causes midline or arm pain. It does not cross the midline.
==Thoracic Interspinous Ligaments==
Kellgren in 1939 produced the original referred pain maps from noxious stimulation of the interspinous ligaments. Kellgren’s findings were reproduced by Feinstein et al. 1954 who produced similar maps. Pain patterns are not identical between studies, and vary between individuals.
400px|Referred pain patterns from noxious stimulation of the thoracic interspinous ligaments. Kellgren (1939).
==See Also==
*Somatic Referred Pain
*Lumbar Pain Maps
*Cervical Pain Maps
==References==
Category:Pain Maps
Category:Thoracic Spine
Thoracic Spine Examination

==Thoracic Spine==
Observation
*	Carriage of head and shoulders 
*	Muscle bulk symmetry 
*	Scolosis/Kyphosis 
*	Flat spots 
*	Axillary creases 
*	From side 
*	From front
Surface landmarks
*	Medial spines scapulae T3 
*	Inferior angle scapulae T7 
*	12th rib T10 
*	Ribs 1 to 12 posterior angles and attachments 
*	in front 
*	7th and 9th costal cartilages 
*	Trapezius 
*	Levator scapulae 
*	Rhomboids 
*	Lateral border scapula and muscle attachments 
*	Supraspinatus 
*	Infraspinatus
Active movements 
*	Flexion 
*	Extension 
*	Sidebending 
*	Rotation
Passive movements 
(Gross and segmental) 
*	Flexion 
*	Extension 
*	Sidebending 
*	Rotation
Segmental Pain
*	Skin drag 
*	Skin rolling 
*	Vertebral springing 
*	Zones of irritation supra sp lig 
*	Spinous processes 
*	PA palpation
*	Transverse palpation
*	Transverse processes 
*	Provocation test
Neurological Exam
* Observe for abdominal wall bulging as a sign of motor weakness
* Sensation over cutaneous segments, the intercostal nerves follow from the angle that the ribs form. Epigastrium is T6. Umbilicus is T10
* Abdominal reflex
==The Ribs==
Observation
*	Thoracic observation 
*	Full inhalation 
*	Full exhalation
Landmarks
*	As for thoracic spine
Palpation
*	Hands on rib cage
*	Front to, back springing
*	Monitor 2 to 10 supine inh/exh 
*	Costal cartilages + inh/exh 
*	Monitor 2 to 10 prone
*	Mid Trapezius 
*	Rhomboids 
*	Serratus Posterior Superior 
*	Pectoralis Major 
*	Pectoralis Minor 
*	Sternalis 
*	Serratus anterior
==Paediatric Examination of the Whole Spine==
A consensus approach to the MSK examination in children was developed by Foster et al in 2011. They did not differentiate between cervical, thoracic, and lumbar spine. The underlined components are those that are additional to the adult examination. The italicised components are those that the doctor should be aware of but not necessarily competent in.
With the patient standing:
* Look at the spine from the side and from behind
* Look at the skin and natal cleft
* Look at limb and trunk proportions
* Look at the face and jaw profile
* Feel the spinal processes and paraspinal muscles and Temporomandibular joints (TMJs)
* Assess movement: lumbar flexion and extension and lateral flexion; cervical flexion, extension, rotation and lateral flexion, thoracic rotation
* Assess TMJ opening 
* Options – Schober’s test, “stork test”
With the patient sitting on couch (standing in younger child):
* Assess thoracic rotation
With the patient lying on couch:
* Perform straight leg raising and dorsi-flexion of the big toe
* Assess limb reflexes
== References ==
Category:Examination
Category:Thoracic Spine
Tibial Nerve

== Course ==
It forms the medial portion of the sciatic nerve. It leaves the sciatic nerve in the lower thigh and runs to the central popliteal fossa between and deep to the Semitendinosus and Biceps Femoris muscles. It courses into the lower leg under the fibrous arch of soleus, along the Tibialis Posterior. It reaches medially to lie posterior to the medial malleolus of the ankle under the flexor retinaculum.
== Branches ==
=== Branches in Thigh: ===
Motor: Gastrocnemius, Popliteus, Plantaris
Sensory: knee and superficial tibiofibular joints, Sural Nerve to posterolateral calf and lateral foot skin.
=== Branches in Leg: ===
Motor: Soleus, Tibialis Posterior, Flexor Digitorum Longus, Flexor Hallucis Longus
Sensory: Ankle Joint, Medial Calcaneal Nerve to heel and medial sole of skin
=== Branches in Foot: ===
Motor: Medial Plantar Nerve, Lateral Plantar Nerve
Sensory: Medial Plantar Nerve, Lateral Plantar Nerve
==Lesion Effect==
A high lesion of the tibial nerve results in 
*Loss of flexion of the toes and inversion of the foot.
*Loss of sensation of the sole of the foot, inferior aspect of the toes, and nail beds
==References==
Toe Joint Aspiration

==Indications==
==Contraindications==
==Equipment Needed==
==Procedure==
===General Setup===
*Prep area with betadine or chlorhexadine using circular motion moving away from joint x 3
*Drape joint in sterile fashion 
*Inject lidocaine with 25-30ga needle superficially and then into deeper tissues
*Insert 18ga needle (for larger joints) into joint space while pulling back on syringe 
*Stop once you aspirate fluid; aspirate as much fluid as possible
**Send: cell count, culture, gram stain, crystal analysis
===Metatarsophalangeal===
*Patient supine with flexion of the MTP joint 15-20 degrees and apply gentle traction 
*Insert needle dorsally just medial or lateral to midline between the metatarsal head and base of proximal phalanx
===Interphalangeal===
*Patient supine with joint flexed 15-20 degrees with gentle traction 
*Insert needle dorsally, medial or lateral to midline between head of proximal phalanx and base of more distal phalanx
==Evaluation==
==Complications==
==External Links==
*Merck Manual - How To Do Metatarsophalangeal Joint Arthrocentesis
===Videos===
<youtube>cmHQ5k6QRZc</youtube>
==References==
Category:Foot and Ankle Procedures
Topiramate

Topiramate is generally better tolerated than valproate for migraine prophylaxis. According to a comparative study, topiramate at 50 mg/day showed fewer side effects compared to valproate at 400 mg/day, with significant reductions in headache severity and fewer adverse events. The American Academy of Neurology and the American Headache Society also support the use of topiramate as a first-line option for migraine prevention, noting its favorable side effect profile compared to valproate.
== Resources ==
== References ==
Category:Pharmacology
Transient Osteoporosis of the Hip

Bone marrow oedema syndrome is also referred to as "transient osteoporosis of the hip."
== Terminology ==
The more appropriate term would be bone marrow oedema of the proximal femur as the more distal parts of the femur are not affected. 
==Aetiology==
The aetiology is unknown. Risk factors are pregnancy, excess alcohol consumption, steroid use, and hypothyroidism.
==Epidemiology==
Originally described in pregnancy, but is most commonly seen in middle aged men with hip pain.
==Investigations==
Osteopaenia may be seen in hip radiographs but is often normal. Osteopenia may only show up 4-8 weeks after the onset of hip pain.
On MRI there may be increased T2 signal in the bone marrow of the femoral head and neck. There can be extension into the subtrochanteric region and there is also often a joint effusion. The main differential is osteonecrosis, but in osteonecrosis the signal change is focal rather than diffuse..
Bone scan shows diffuse and homogeneously increased uptake involving the femoral head and neck. MRI has made bone scan obsolete.
==Prognosis==
The condition is self-limiting in most cases and the osteopenia usually resolves within nine months of symptom onset. However it is a risk factor for potential progression to advanced avascular necrosis.
== Resources ==
==References==
Category:Pelvis, Hip and Thigh Conditions
Traumatic Brain Injury

This article focuses on chronic pain following traumatic brain injury. See open access article by Irvine et al.
==Epidemiology==
Global incidence of TBI is 106 per 100,000 people.
==Classification==
 Classification of Traumatic Brain Injury
Feature 	Mild 	Moderate 	Severe
Loss of consciousness	<30 min	30 min - 24 h 	> 24 h
Amnesia 	<24 h 	1-7 d 	>7 d
Glasgow Coma Score 	13-15 	9-12 	1-9
Structural Imaging 	Normal 	Abnormal, transient changes	Abnormal, lasting changes
==Clinical Features==
Among 23 studies with 4200 patients, 51.5% had chronic pain, 57.8% of those had post-traumatic headache (some studies up to 81%). Headache at the time of injury was 71%, and by one year this had dropped to 41%. 12% had CRPS with severe TBI. Post-traumatic stress disorder can occur.
==Mechanisms==
*Descending regulation of pain. 
**Lower pressure pain thresholds, decreased conditioned pain modulation (similar to post-stroke, post-surgical, fibromyalgia), reduced firing LC, dysregulation PAG output. 
**Treatment alpha-2 agonists, selective serotonin-NA reuptake inhibitors.
*Ascending pathways. STT (post thalamic stroke pain), demonstrated on diffusion tensor tractography. 
**Treatment deep brain and motor cortex stimulation, or target posterior limb capsule.
*Dopamine & Substantia Nigra. Injury to substantia nigra and other dopaminergic centres. 
**Treatment levodopa.
*Neuroinflammation
*Neurodegeneration
*Axonal damage.
All of these areas are potential mechanisms for persistent post-traumatic headache, not cervical pain.
==See Also==
*Chronic Post-Traumatic Neck Pain
==References==
Category:Cervical Spine Conditions
Category:Head and Jaw Conditions
Triceps Tendinopathy

==Definition==
Tendinopathy and pain at the triceps tendon.
==Epidemiology==
Triceps tendinopathy is uncommon.
== Risk factors==
* It is sometimes seen in weight lifters or labourers.
*Repetitive elbow extension against resistance
==Diagnosis==
Pain at the posterior elbow with resisted elbow extension, and tenderness at the triceps insertion.
Category:Elbow and Forearm Conditions
Category:Tendinopathies
Tricyclic Antidepressants

Tricyclic Antidepressants (TCAs) are well-studied and widely recommended as a first-line therapy for neuropathic pain. They have proven efficacy in managing peripheral neuropathy, post-herpetic neuralgia, and neuropathic pain following spinal cord injury, and exhibit limited efficacy for radiculopathy, HIV, and chemotherapy-induced peripheral neuropathy. The primary pain-relieving mechanism of TCAs is the inhibition of serotonin and norepinephrine reuptake, although they also block histamine, adrenaline, acetylcholine, and sodium channels, which contributes to their broad side effect profile. Notably, their analgesic effect is independent of their antidepressant effect and occurs at a lower dosage (20-30% of the antidepressant dosage).
A Cochrane review of 61 randomized controlled trials found that TCAs had a number needed to treat (NNT) of 3.6 to achieve moderate pain relief, with a number needed to harm (NNH) of 28 for major adverse effects and 9 for minor adverse effects. A separate trial determined that high-dose TCAs had an NNT of 7.6 and an NNH of 9.2 in neuropathic pain associated with spinal cord injury. It is recommended to trial TCAs for four to eight weeks; inadequate pain relief should prompt consideration of alternative first-line medications or combination therapy. 
== Prescribing ==
For nortriptyline and amitriptyline, start at 10–25 mg at dinner time. The maximum daily dose is 150mg. 
Caution is advised when prescribing TCAs to elderly and frail patients due to potential adverse effects, such as falls, cardiac arrhythmias, orthostasis, urinary retention, and dry mouth. Also further caution with autonomic neuropathy, urinary retension, glaucoma, or if also taking an SNRI, SSRI, MAOI, and/or tramadol.
==References==
Category:Pharmacology
Ulnar Nerve

==Motor Supply==
All but five intrinsic hand muscles are innervated by the ulnar nerve. The remaining are innervated by the C8-T1 roots via the Median Nerve. The mnemonic AbOF can be used to remember which muscles are above the law in that they aren't innervated by the ulnar nerve: the abductor (Ab) and flexor (F) pollicis brevis, opponens pollicis (O), and lateral lumbricals (Law).
==Clinical Relevance==
Importantly, the ulnar nerve doesn't provide sensation to the medial forearm. That is innervated by the Medial Antebrachial Cutaneous Nerve. Therefore, an ulnar lesion at the elbow results in anaesthesia of the ulnar hand and fingers, but not the forearm.
Nerve compression in the Guyon canal results in anaesthesia of the ventral palm and fifth finger. Dorsal sensation is supplied by the dorsal sensory branch of the ulnar nerve.
== References ==
Ultrasound Guided Injections Evidence

The two most important aspects to consider when comparing ultrasound vs landmark guided injections are accuracy and efficacy. 
For accuracy, the research literature shows ultrasound to be superior to landmark guided injections. This has important implications for precision diagnosis with injection of local anaesthetic.
The research on efficacy is less conclusive and more higher quality studies are needed. The current evidence shows that ultrasound guided injections are superior to landmark guided injections for the glenohumeral joint, subacromial space, biceps tendon sheath, joints of the hand and wrist, knee, ankle, and foot. 
==Reviews==
*Daniels et al 2018 (open access)
*Finnoff et al 2015
Summary of Findings of Daniels et al for ultrasound guided injections (USGI) and landmark guided injections (LMGI)
Structure 	USGI Accuracy	LMGI Accuracy	Efficacy 	Level of Evidence
Glenohumeral joint 	92.5% 	72.5% 	USGI superior	2
Acromioclavicular joint 	90-100% 	16.7-72% 	No difference	2-4
Subacromial space 	- 	- 	USGI superior	2
Biceps tendon 	86.7% 	26.7% 	USGI superior	1-2
Elbow joint 	91% 	64-100% 	- 	1
Hand and wrist joints TMC, STT	94-100% 	59-81.8% 	- 	2-4
Hip joint 	97-100% 	66.7-77.5% 	USGI superior	1-4
Knee joint 	95.8-100% 	55-100% 	USGI superior	1-2
Foot and ankle 	100% 	58-85% 	No difference	2-4
==References==
Category:General Procedure Concepts