Temporomanibular Joint (TMJ)

When I was 18 years old (going back 16 years now) I noticed my right jaw clicking and clunking. 

When I mentioned this to my dentist, I was told it was normal. 

I didn’t know any better then to tell my dentist my left jaw didn’t click and clunk. I wondered, how could it be normal? 

Then my left side started to act up too.  

I played hockey (still do) which involved a whole lot of body checking and contact. 

I remember one morning waking up after sleeping at a friend’s house and putting my hands behind my neck and stretching. 

What happened next was “burning” in the right side of my neck and inability to move my neck in any direction.

I still played in the championship game that morning (turning my whole body in the corners so I could hits coming). 

What I now know after all my study and work as a physiotherapist is jaw clicking isn’t normal, and the “burner” I experienced in the right side of my neck way back when was a protective muscle spasm, resulting from an underlying hypermobile (moves too much) segment in my neck (likely related to hockey). 

When I started studying Kinesiology at the University of  Waterloo, I started experiencing intense right upper trapezius tightness and headaches so bad I would have to rest mid-day, just so I could make it to the end of the day still functioning.  

HEADACHE, NECK PAIN, JAW PAIN AND/OR CLICKING.. ALL RELATED

The trigeminal nerve (or Cranial Nerve 5 – one of the nerves that comes out of our heads), is responsible for our jaw muscles and sensations at the side of the face.

This nerve receives input from the upper three bones and nerves in our neck. So when there’s something not working at the top of the neck (or base of the skull) it affects the area from the nerve to the jaw. 

Headaches we feel at the front of the head can be the result of an irritated trigeminal. 

WHAT ABOUT CLICKING?

The jaw joint contains a disc (like a thick rubbery washer). Like most joints in the body, the jaw has a capsule (fibrous covering) and ligaments that hold it in position. 

These ligaments help keep the jaw bones gliding properly over the disc.

The jaw is highly vascularised (blood flow) and innervated (nerve supply). 

It therefore is susceptible to pain and inflammation. The click or clunk is considered to be the disc repositioning itself in the joint. 

HOW DOES THE JAW WORK?

With the mouth closed, the disc rests between the two bones that make up the jaw and the back ligaments are relaxed. 

When the mouth opens the jaw bone, mandibular slides forwards and rolls forwards.

At the end of jaw opening, the disc is pulled backwards by one of the two ligaments (stratum superior) which is elastic.

The lower ligament is not elastic (does not stretch) and helps to maintain the proper position of the disc with the jaw bones (condyles).

Muscles that help the jaw move include:

1. Lateral Pterygoid

2. Masseter (closes the jaw)

3. Medial Pterygoid

4. Temporalis (closes the jaw)

TMJ PATHOLOGY – WHAT WENT WRONG?

Tissues at the back of the joint and disc are not designed to withstand constant compression or tensile loading. 

Prolonged mouth opening (singing, dental work) may overstretch the tissues at the back of the jaw. 

Compression to the area may be the result of trauma to the chin (punch, car accident) that results in inflammation to the area. 

Stress that causes us to clench or tighten muscles in the jaw (from facilitation of the trigeminal nerve or muscle strain) can also create compressive forces. 

Pain will occur if the jaw bone is not resting properly and is compressing tissues.

If there’s pain with the jaw opening, it might be from tissues being over-stretched. 

The click or clunk is the disc repositioning itself in the joint (not moving properly). 

There may also be issues within the joint, such as small joint surfaces, wearing of the joint surfaces, hypermobility of the joint from loose ligaments, or changes in the disc itself. 

TREATMENT OPTIONS

Your dentist might prescribe a mouth guard that helps to reduce compressive stress to the joint if you’re a clencher at night.

If the issue is in the joint itself or the disc isn’t resting properly, the dentist may use splinting to help reposition the jaw and disc.

If tissues are inflamed, ice and anti-inflammatories might be in order.

Stiffness in the back part of the jaw will respond well with manual therapy and stretching exercises. 

If there is hypermobility of the joint from overstretched ligaments, you’ll have to be aware not to overstretch the jaw. It has been suggested in these cases

opening the jaw be limited to the point where the tip of your tongue can stay on the roof of your mouth. 

Personally, I always assess the neck area and treat it as appropriate. 

I also incorporate IMS, which can be used to release tension in the massater, temporalis, and lateraly Pterygoid muscles. 

I’ve had lots of success treating clients who come to me with jaw pain. 

Personally, I no longer get intense neck and trapezius muscle tension and jaw pain stapled with the brutal headaches I used to get. 

 IF YOU’RE MOTIVATED:

We’re online in every place imaginable! Surf our website www.startlinephysiotherapy.com, then be our friend by moseying on over to our Facebook or Twitter sites by hitting the link there. To book an appointment at Start Line, call the clinic at 250-746-7463.

This was one of the questions from someone reading one of my earlier blogs. 

It’s a great question, but unfortunately there is not a simple answer. 

Some victims claim it lasts as long as there is litigation. I know this will ruffle a few feathers and by no means am I attempting to discredit those experiencing the pain of a neck injury following an accident. 

The second is that 99 per cent (my estimate) of the time treatment is only sought by the person who wasn’t at fault. 

There is a ton of literature available on whiplash associated disorders and predictors surrounding recovery.  

WHIPLASH IS CATEGORIZED INTO FOUR GRADES

Grade I: there is soreness when touched but no loss of neck motion, range of movement (ROM)

Grade II:  there is tenderness and loss of ROM

Grade III:  there is tenderness, loss of ROM and evidence of neurological involvement

Grade IV:  there is evidence of fracture 

WHAT’S THE SCOOP?

As you may already be aware (if you have read earlier blogs of mine on spinal degeneration), that our spines do wear out as we age, some faster than others depending on how we have treated our bodies. But you can argue that you did not have this pain before the accident. 

I am not sure what research article I read this in (sorry folks but I do not have a photographic memory for research, I only seem to remember pertainent facts, which won’t do me any good in a court of law), but people with pre-existing problems in their necks prior to the accident tend to have a worse prognosis when it comes to recovery. What this means in English is that if your neck is worn out (degenerated)–weak or tight prior to the whiplash injury–you’re likely to have a longer recovery time and may not recover completely. 

I did find, however, something in one of the reviews that proves I am not just making this stuff up as I go along.

“… neck pain and severe headaches are more prevalent in subjects with a history of neck injury due to a car collision.”3

WHY IS THIS SO?

If there’s spinal degeneration, you may experience more trauma to the joints as your neck is thrown backwards (jamming the joints). 

If your neck is weak, you are less likely able to protect the neck during the whiplash injury. 

If the muscles are tight, the muscle is not able to stretch and is more likely to experience trauma (strain). 

WHAT’S THE BEST TREATMENT

The answer from my clinical experience is that first and foremost you must be an active participant in your own

recovery. 

People who keep moving and get involved in exercises seem to recover much better. 

Manipulation (by a qualified physiotherapist or chiropractor) if you are comfortable with this technique has been shown to be effective (both clinically and in the literature) for stiff joints.  

There is a great deal of controversy around the use of neck manipulations.  There’s some research that indicates adjustments to the upper back without adjusting the neck can be just as effective in helping restore mobility.

I personally use IMS (www.istop.org) very effectively for relaxing the tight, tense and ropy muscles. 

I am very pleased to say that I have been using IMS on a number of clients who, for several years after their car accidents, were still experiencing muscle soreness and tightness often resulting in tension headaches. 

Just like the Buckley’s saying, “it is painful but it works”. 

“A recent Cochrane review concluded that dry-needling, added to other conventional therapies such as exercise, is more effective at relieving pain than conventional therapies alone in non-specific low back pain.

This combined approach to management has never been investigated in whiplash.” 1

“Adequate information and successive mobilization without a collar as early as possible supported by a physiotherapist are the best treatments for reducing pain and increasing ROM at six months follow-up according to one study.”3

Once muscles are relaxed and joints are moving, you must re-strengthen the muscles (see my Neck Stabilization Blog). 

HOW LONG WILL IT LAST? 

“The evidence suggests that approximately 50 per cent of those with WAD will report neck pain symptoms one year after their

injuries.

Greater initial pain, more symptoms, and greater initial disability predicted slower recovery.

Few factors related to the collision itself (for example, direction of the collision, headrest type) were prognostic; however, post injury psychological factors such as passive coping style, depressed mood, and fear of movement were prognostic for slower or less complete recovery.

There is also preliminary evidence that the prevailing compensation system is prognostic for recovery in WAD.”2

It is estimated that five to eight per cent of people who sustain a whiplash injury will continue to experience problems beyond six months post accident (depending on what study you look at). 3

IF YOU’RE MOTIVATED:

1. Michele Sterling, Stephanie Valentin, Bill Vicenzino, Tina Souvlis, and Luke B Connelly. Dry needling and exercise for chronic whiplash – a randomised controlled trial. BMC Musculoskelet Disord. 2009; 10: 160

 2. Linda J, Can-oil, PhD  et al. COURSE AND PROGNOSTIC FACTORS FOR NECK PAIN IN

WHIPLASH-ASSOCIATED DISORDERS (WAD) Results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders 

3. Ylva Sterner and Bjorn Gerdle. ACUTE AND CHRONIC WHIPLASH DISORDERS – A REVIEW. J Rehabil Med 2004; 36: 193-210

We’re online in every place imaginable! Surf our website www.startlinephysiotherapy.com, then be our friend by moseying on over to our Facebook site by hitting the link there. To book an appointment at Start Line, call the clinic at 250-746-7463.

STABILIZATION FOR THE NECK

All the rage these days is doing stabilization exercises for the lower back.

Did you know that you can reduce headaches by strengthening the correct neck muscles? 

 The muscles at the front of the neck include: 

• Rectus Capitus Anterior  
• Lateralis Capitus
• Longus Cervicus

These muscles at the front of your neck lie deep along the spinal vertebrae. 

These are like your deep abdominal muscles. 

When you have poor posture (forwards head where your chin is poking forwards) the muscles at the back of the neck

get short and tight, compressing the back joints of the neck bones, while the muscles at the front of the neck get long

 and stretched. Both short and long muscles can be weak as they are not in the optimum position for working. 

Whiplash injuries may contribute to the improper use of the deep neck muscles.

The more superficial muscles, Sternocleidomastoid (SCM) and Scalenes will compensate for the weak, deeper

muscles. These muscles are the movers of the neck and are not great stabilizers.   

Over time, because of poor stabilization the neck joints can wear (often considered as arthritis).

Nerve impingements at the neck, either where the nerve comes out between the bones, or as the nerves pass

through the scalene muscles, under the collar bone and over the ribs, can cause symptoms into the shoulder, elbow

and wrist/hand. 

The neck often has a roll in conditions such as “tennis elbow,” “carpal tunnel syndrome,” and “thoracic outlet syndrome.”

Testing of the deep neck muscles is done by a physiotherapis with you lying on your back and the head

and neck in a neutral spinal position. A chin nod is performed. A Pressure Feedback Cuff (PBU) can be used to help

measure the force of the contraction (superficially). The therapist will monitor the more superficial muscles (SCM,

 Scalenes and Suprahyoid) to determine if you are using these more superficial muscles through 2/3^rds of the motion

 versus just the deep muscles. The ultimate goal is to be able to sustain the proper contraction during the chin nod

exercise 10 seconds for 10 repetitions before fatiguing. 

Research has shown people who suffer from headaches have weakness of the deep neck muscles. 

Supervision by a physiotherapist is required initially to determine if you are recruiting the correct muscles.  

There is no sense in doing the exercise incorrectly, as it will then only serve to reinforce the incorrect movement pattern

and may contribute to more discomfort.

IF YOU’RE MOTIVATED:

Carol Kennedy of Treloar Physiotherapy (www.treloarphysio.com) is leading the way in the area of neck pain and

 exercises. It was Carol who instructed myself through my manual therapy levels and introduced me to the concept of

Deep Neck Flexion exercises.

We’re online in every place imaginable! Surf our website www.startlinephysiotherapy.com, then be our friend by moseying on over to our Facebook site by hitting the link there. To book an appointment at Start Line, call the clinic at 250-746-7463.