Hi, my name is Emily Conard. I'm a physical therapist and I work at the University of Minnesota in the TMD, Orofacial Pain and Dental Sleep Medicine Clinic. I have been treating exclusively facial pain, orofacial pain, and temporomandibular disorders for 17 years. And I have treated a number of patients for side effects after having a mandibular advancement device for sleep apnea. And the first topic I want to talk with you today about is how to assess whether pain is coming from the joint or from the muscle. There can be a lot of different mechanisms of pain. One of the things we do know is that there is a common convergence point in the spine at the trigeminal nucleus, and that pain can come from many different locations. So the brain sometimes has trouble identifying whether the pain is coming from one specific muscle or from the joint or from someplace else. And then once we have central sensitization, which is a common symptom that a lot of our patients experience, it starts to become very confusing. And if we don't have the right diagnosis for our patients, then our treatments are not going to be as successful. Dentists are taught to look at mechanical restrictions first. But muscle pain is more variable. There's no gold standard for diagnostic assessment. We definitely need to start by looking at range of motion to know if we are restricted or not. But once we determine whether there is restricted range of motion, the next question to answer is, is it coming from the joint or from the muscle? We use this information to tailor our exercises and our interventions. Because that oral appliance therapy can irritate both joint and muscle pain, we want to make sure we have the correct intervention in order to proceed appropriately. So we have specific diagnostic criteria that has been validated as part of the diagnostic criteria for temporomandibular disorders that differentiate between joint and muscle pain. We have to make sure that elements of the subjective history align with whether it's a joint or a muscle problem. And we ask them, where do you feel your pain? Have them point to it. If it is joint pain, they will usually point directly in front of their ear, right where that lateral condyle is. If it's muscle pain, they will point a little further forward toward their cheek, maybe across the zygomatic arch or complain about sinus pain. It can come all the way down here to the mandibular angle. They might have tooth pain as a referral process from the masseter muscle. If it's the temporalis, they will point up here. And they might talk about having a temple headache. Often, the anterior part of the temporalis can refer to teeth. So they can complain about having teeth or tooth pain if it's coming from that part of the muscle. When we do our objective assessment, we need to make sure that we are palpating the appropriate area and that we are reproducing their familiar pain. So right here, directly in front of the ear, is the lateral pole of the condyle. And we'll demonstrate that with palpation in just a moment. And you need to make sure when you're palpating it that it reproduces their familiar pain for us to classify that as joint pain. Up here, the temporalis muscle and then the masseter muscle down here are the other areas that we palpate in order to fulfill our diagnostic criteria. And we have to find a positive report of pain from the patient in any of these areas. It can be either one. And we also need to make sure that this is their familiar pain in order for us to make that appropriate diagnosis. One of our most reliable tests for differentiating between joint and muscle pain is called static and dynamic testing. The static testing really only assesses the muscle structures because we are not moving the joint through its range of motion. Whereas our dynamic testing does move through. And so we start looking at the articular structures instead. So first, I'm going to be doing some testing to see if it's your muscle or your joint causing the pain. The first one is our static test. I'll have you just hold a position. I'll be adding pressure in some different directions. And I'll be asking you if it hurts and if it reproduces your familiar pain. So the first direction is just to drop your jaw slightly open, please. So this is static testing in resisted opening. And I'm going to add some pressure upward, but don't let me move you. And relax. So we hold it for five seconds. Is there any pain or discomfort with that? A little bit. A little bit. Okay. Where did you feel it? Can you point and show me? Okay. Right there. Is that your familiar pain? Mm-hmm. Okay. So a positive test would be that it reproduces familiar pain. If she had said, oh, it's painful, but that's not really my actual pain, it's not considered a positive test. So then we do that in additional directions. Next I'm going to test resisted closing. So for this, it'll be the same position, but I'm going to be pushing down. And don't let me move you. Okay. So go ahead. Drop your jaw open. Okay. And then don't let me move you. Okay. Any pain or discomfort with that? A little bit. Okay. Where did you feel that? Over here. Yeah. Over here? Yes. Okay. All right. Next we'll be doing resisted to the side. So I'm going to lay my finger on the side of your chin here. Move your jaw toward my finger, but don't let me move you. Okay. And then go ahead and relax. Any pain or discomfort with that? A little bit. Even in my neck. In your neck and your shoulders? Yeah. So the neck and the shoulders wouldn't be a positive test because that's not her familiar jaw pain. But it's also telling me that she's overcompensating with her neck muscles when she uses her jaw. Okay. And then we'll do the opposite side. So with my finger over here, go ahead and move your jaw toward and then don't let me move you. Okay. Any pain or discomfort with that one? Not as much as the other. Not as much as the other side. Okay. Good. And then the last direction is moving your chin forward toward me. Good. Okay. You can relax your jaw back into that neutral position. So relax totally for me. There you go. Bring your chin slightly into my finger. Good. And then don't let me move you. Okay. Five seconds there. Any pain or discomfort with that? Okay. Right in there. Is that your familiar pain as well? Yeah. Yeah. Okay. So that's our static testing where we're not moving through her full range. Now we're going to test those same five directions. I'll be adding about a fingertip's worth of resistance and I'm going to have you move three times into each position. And as before, I'll be asking if it's discomfort, pain, or clicking. That's the new thing now that we'll look at. So the first movement is resisted opening. I'll have you open three times. One, two, three. Any discomfort, pain, or clicking with that? A little bit. Okay. Where did you feel that? I don't know if I can feel that. Yeah. Look where that is. Yeah. That's okay. Was it a familiar discomfort to you? Yeah. Yeah. Okay. So familiar discomfort. She didn't necessarily tell me it was the joints, but I'm going to store that in my brain as we move to our next movements that we test. So next I'll have you start with your jaw open and I'm going to resist your closing. So three times. Close. One, two, and three. Any clicking, pain, or discomfort with that? Not that a lot. Okay. It's familiar, but I can't identify it. Okay. All right. So now I'm going to have you move into my finger this direction, but I'm not going to stop you this time. Go ahead all the way. Good. And back to the middle and then to the side again. Any discomfort, noise, or pain there? There was a funny noise. Yeah. How did you feel that noise? Kind of back inside. Okay. Deeper inside? Mm-hmm. Okay. So then I'm going to store that away and make sure I assess her joint for some clicking later, but I might call that a positive sign. Okay. Now we're going to go to the opposite side and for this I want you to move toward my finger here whenever you're ready. Yep. And then back to the middle and one more time to the side and back to the middle. Any noise, discomfort, or pain there? Mm-mm. Okay. We're going to flare you up here today. And then finally you'll be moving forward into my finger like before, except this time you'll actually move. So whenever you're ready, move that chin forward into my finger. Good. And then back and then forward, back, and one more time forward and back. Noise, discomfort, or pain? No. Okay. She also jutted her head a little bit forward, which is why it's important to stabilize because people will make those compensations and that will get in the way of assessing the test. But once again, a positive test for dynamic testing is reproduction of noise, discomfort, or pain that is more toward the joint as opposed to the muscles. Now when she said she felt kind of a click back there, I would call that positive on the left side. Our palpation testing is what we need in order to fulfill our diagnostic criteria for the muscle versus the joint conditions. And the procedure does need to be standardized according to our criteria. So you palpate with one finger, laying flat against the muscle, and you hold sustained pressure for three seconds at about two to three kilograms of pressure. More practically, you can think of that as pushing hard enough for your fingernail to blanch. And it's important to hold it for three seconds because that's where we'll start seeing if we get any referral to other areas. So I will first be palpating the joint directly in front of the ear, and I'm going to add my pressure for three seconds. Any pain or discomfort with that? Okay. And is that your familiar pain? Yes. And once again, we need that designation of familiar pain in order to fulfill a diagnosis of joint pain, which that would be, because I'm on the lateral part of the joint, or muscle pain. The other joint structure that we can palpate from the outside like this is the posterior part of the joint. So for this, I'll have you open your jaw, please. I'm going to put my finger back here, and I'm going to add that pressure for three seconds. Any pain or discomfort with that? A little discomfort. A little bit. Yeah. The other way you can get at this is with your pinky finger inside the ear pushing forward against the joint. Next, I'm going to move to palpating the temporalis and the masseter. Both of these are so large that we tend to break it up into different portions of the structure. The first part of the masseter, which again goes from the cheekbone down to the jawbone, is the deep masseter directly underneath the joint. So I'll find my spot, and I'll add my pressure. All right. Any discomfort or pain with that? Okay. Do you feel it moving anywhere or staying right under my finger? Staying under the finger. Okay. All right. So from there, I'll move forward to the anterior part of the masseter, kind of right on the border, and I'm going to add my pressure there. Oh, that's sore. So we've already got our positive test there. Familiar pain? Mm-hmm. Okay. Moving down to the inferior part, right by the mandibular angle, and I'll be pushing my three seconds here. Not so much. Yeah. Not too much. And I always stabilize with my opposite hand, because otherwise, I would just push her right this way. That wouldn't be very practical. The other muscle we palpate is the temporalis. For this, I'll ask you to take your glasses off, please. Thank you. So the temporalis is so large, we break it into an anterior, middle, and posterior. So the tendon is right here. We can palpate that, and I'm going to start here. Oh. Is that uncomfortable? Yeah. Yeah? Any familiar pain? Yeah. Okay. So then I'm going to move up to the anterior part, and I will sometimes just feel around first to make sure I'm on it. If I'm not sure, I'll ask them to clench. Clench your teeth just a little bit. Yep. If it pops right into my fingertip, do that one more time. Yep. And you can even kind of see it twitching. Okay. So then I'm going to add my pressure. Any pain or discomfort with that? Not as much. No? Okay. Then I'll move to the middle section and add my pressure. Any pain there? Yeah. That hurts a little more. A little more. Yeah. Okay. And then back here to the posterior. No. And sometimes people feel headache pain here, too. So that's an important thing for us to differentiate. So if you are going to refer your patient to a physical therapist, it is helpful to share any assessment information that you have come up with, whether they have restricted range of motion. If you have gone through to determine whether this is joint or muscle pain, that's very helpful to guide the physical therapist. They will be doing their assessment to figure out on their own, so it's okay if you don't know. But any information you can give them that helps guide their diagnosis will help in the long term. If you decide to manage conservatively with your patient first, and you've already gone through to determine if it's joint or muscle pain, you can use the exercises in order to help them appropriately start their care. If they're having muscle pain, then you can counsel them to use heat or ice in order to decrease the tension. You can tell them to feel their tight muscles, do some gentle self-massage. Make sure you tell them not to force any stretching beyond what feels comfortable because overstretching can actually flare up the muscle pain. If you think that the joint is the primary limitation, then you want to make sure you train them to protect their opening so they don't open too far and strain their joint because that can make that pain worse. If they keep their tongue up on the roof of the mouth, they can open in that protected range, and opening that far for yawning and for functional activities during the day can be protective for their joint and help to decrease their pain. No matter whether it's muscle or joint pain, make sure to counsel them to let their tongue rest up on the roof of their mouth, like they're saying the letter N. That tongue up, slightly teeth apart position is important to take strain off of the joints and the muscles in order to help decrease pain so that they can be successful with any therapy that you are going to do after that.

joint pain

muscle pain

temporomandibular disorders

diagnosis

treatment