Neck pain is the second most common reason for visiting a chiropractor. However, many people with neck pain actually have temporal mandibular dysfunction (TMJ)—not a cervical problem.
Posted in Clinical Risks on Wednesday, January 31, 2018
People who have TMJ that presents as neck pain don’t always receive relief the first time they see a chiropractor. As a result, they seek out care from other healthcare providers before the problem is identified.
Karl Lewit, the father of manual medicine, stated that 80 percent of all neck pain patients have TMD or temporal mandibular dysfunction. It is estimated that 60 to 70 percent of general population have at least one sign of temporal mandibular dysfunction.1
Evaluating and treating the TMJ can be the key link to resolving chronic neck pain.
The Temporal Mandibular Joint consists of the temporal bone, a biconcave intra-articular disc, and the head of the mandible, which creates a modified ovoid bicondylar joint. The intra-articular disc is comprised of fibrocartilage, not hyaline, and has attachments to the medial and lateral collateral ligaments, posterior mandibular fossa, and lateral ptyergoid muscles.2 These anatomical features lead to increased mobility and an inherently unstable joint, relying on ligamentous stability.
The muscle of mastication, or prime movers of the jaw, are the Temporalis, Masseter, Medial and Lateral Pterygoids. The Temporalis and Masseter primarily close the mouth, where the ptyerygoids work to protrude and deviate the jaw to the opposite side.3 Dysfunctional movement of the TMJ leads to stress due to overuse and pain. One common example of TMJ dysfunction presents as:
Decreased mouth opening due to masseter stiffness including clinching à the cervical extensor and suboccipital muscles are recruited to extend the skull increasing mouth opening à cervicogenic headaches and neck pain occur over time à suprahyoid muscles are inhibited à dysfunction cycle continues
Trigger points in the muscles of the TMJ can refer pain to many areas of head, neck and skull. The Masseter commonly refers pain to the cheek and ear, as well as pain traveling from the mandible to the forehead. Temporalis pain presents as lateral head or skull pain mimicking tension headaches, as well as pain traveling from the maxilla bone to forehead. The Medial and Lateral Pterygoids create a pain pattern presenting from posterior mandible to the TMJ, and from the cheek to the TMJ respectively. The Digastric muscles can refer pain from the lateral cervical spine to the posterior lateral skull.
Many pain patterns associated with the muscle of mastication present as common headaches and cervical spine pathologies. With proper screening and evaluation, cervical pain disorders can be alleviated or aided with temporal mandibular treatment.
- Is there pain with opening (extra-articular) or closing (intra-articular)
- Does the patient breath through the nose or mouth
- Crepitus or clicking
- Early (developing dysfunction), late (chronic)
- Missing teeth
- Hearing, vision, swallowing problems, other ear problems, voice problems
- Headaches or dizziness
There are many tests and screens available to evaluate the TMJ, but having a few quick screens to rule in or out possible dysfunction can help guide if further evaluation is necessary. The three-finger or two-knuckle test is a quick screen for restricted ROM. Can the patient place three fingers or two knuckles in their mouth? Many measuring tools are available that can give a quantitative number for the amount of jaw opening available. Typically, 35-55 mm of opening is considered within normal limits.
Treatment consists of passive and active care, although Medicare and ACA guidelines for passive care do apply. Transitioning to active care as soon as the patient can tolerate will increase outcomes. Active care techniques, such as myofascial release and instrument assisted soft tissue manipulation applied to the muscles and ligaments, can decrease muscle rigidity. Gentler techniques, such as post isometric relaxation, can help decrease trigger points.
Additionally, mobilizations to the restricted joints can free up motion. In many cases, a biopsychosocial approach may be needed to address yellow flags found in the exam.
A high percentage of neck pain patients present with dysfunction in the jaw and many individuals in the general population have at least one sign of temporal mandibular dysfunction. The muscles of mastication can produce pain patterns mimicking cervicogenic headaches and neck pain.
Jaw dysfunction can lead to overuse or recruitment of cervical muscles. Proper evaluation and treatment of the TMJ may aid or alleviate chronic neck pain.
1 Lewit K: Manipulative Therapy in Rehabilitation of the Locomotor System, 2nd edition, London: Butterworth, 1991.
2 Neumann, Donald A. Kinesiology of the Musculoskeletal System: Foundations for Rehabilitation. St. Louis, MO: Mosby/Elsevier, 2010.
3 Neumann, Donald A. Kinesiology of the Musculoskeletal System: Foundations for Rehabilitation. St. Louis, MO: Mosby/Elsevier, 2010.
4 Travell, Janet G., and Lois S. Simons. Myofascial Pain and Dysfunction: The Trigger Point Manual. N.p.: Williams & Wilkins, 1999.