Headache/Temporal region - Referred pain from trigger points in temporalis muscle can cause temporal headache and pain

in the teeth of the upper jaw. The various trigger points in the temporalis refer pain in distinct "rays" upward into the head and eyebrow and with the exception of TrP 4, downward toward the teeth. Portions of this pain pattern resemble that of other muscles such as the sternocleidomastoid, the trapezius, the splenius cervicis and the semispinalis capitis. Careful attention to the entire referral pattern and examination of this group of muscles will help in differential diagnosis. For instance, the pain of the splenius cervicis typically radiates from the upper neck and rear of the head through the head toward eye, ie, the pain is more internal. Pain of the semispinalis capitis may also be quite intense in the temple but feels almost as if a tight band is wrapping around the head from the rear of the skull to the temple. The diagonal "fingers" of the temporalis referral pattern is quite different. However, multiple TrPs in the temporalis can cluster to form patterns not unlike those posterior neck muscles but involvement of the upper teeth, local tenderness and palpable taut bands in the temporal region tend to point towards the temporalis. Examination is typically done with the mouth dropped open revealing TrPs in the belly of the muscle. The temporalis acts primarly on the jaw and like the masseter, can also refer pain in the TMJ and involvement of the teeth can include sensitivity to heat and cold. Unlike masseter TrPs, patients are typically unaware of the modest reduction in ROM (5-10mm or about 3/8") associated with temporalis TrPs. Note that care must be taken with patients with active TMJ derangement/displacement of the articular disc in the TMJ. Precipitating factors include direct trauma to the head, immobilization such as cervical traction, excessive gum chewing, clenching of the teeth/bruxism. As with many of the neck muscles, temporalis TrPs can be activated by cold drafts and head forward posture. In some cases, infection or inflammation in the teeth/gums or pre-existing TMJD can cause temporalis TrPs that become selfsustaining, even after the inflammation has been resolved. Temporalis TrPs can also be activated indirectly due to the stress and/or TrPs of the hyoid, SCM and upper trapezius muscles and if present, these must be resolved before treating the temporalis. Following the release of temporalis TrPs and those in related muscles, self care includes self-stretch of the temporalis muscle in which the patient fully opens the mouth to a comfortable position and with the fingers spread apart and placed on both sides of head presses firmly up while taking a long, deep breath. Application of warm compress prior to this stretch can be helpful, especially before bed. As progress is made, this can be augmented with an active-resistive mouth opening exercise utilizing reciprocal inhibition.

dolor masetero TMJD/Restricted Opening The pain of temporomandibular joint disorders is often due to associated TrPs in facial and neck muscles. The masseter is the

muscle most likely to also cause severely restricted jaw opening. The trigger point pain referral pattern of the superficial layer includes the eyebrow, maxilla and mandible as well as the upper and lower molars. The deep, or inner, masseter TrPs refer pain deep into the ear and the region of the TMJ. TrPs high in the inner masseter muscle can also cause unilateral tinnitus. Secondary TrPs in muscles such as the medial pterygoid and temporalis can also cause significant TMJ pain. However, the primary masseter TrPs, if present, should be inactivated before these secondary TrPs are addressed. The masseter muscle, in turn, can develop satellite TrPs secondary to the sternocleidomastoid (SCM) and upper trapezius, suggesting that the SCM and trapezius should be evaluated first in most cases of TMJ pain. TrP activation and perpetuating factors include gross trauma, microtrauma such as bruxism or gum chewing, acute overload, emotional distress, holding the mandible in other than a rest position for prolonged periods, poor posture generally and head forward posture specifically. Patient examination may reveal a restriction of mandibular opening a quick test is whether the patient can easily pass two of their own stacked knuckles between their teeth with the mouth comfortably wide open. Mandibular range of motion should be assessed gently and never forced. Trigger point examination is more effective if the jaws are partially open. The superficial anterior fibers are most accessible with pincer palpation but some of the posterior, deeper fibers can be reached through flat palpation against the mandible. Restoration of normal posture, particularly normal head positioning, is the crucial first step in the management of almost any chronic head or neck condition. Treatment also requires correction elimination of TrPs in related neck muscles. Abusive chewing, cracking of nuts, ice or hard candy should be avoided. Patients should be taught proper tongue posture to reduce bruxing and clenching. When the tongue is at rest, including sleep, it should be gently placed against the roof of the mouth, behind the incisor teeth. Both trigger point pressure release with gentle stretch throughout the comfortable, pain-free range of motion and spray and stretch are effective for the masseter muscle. Forceful stretching should be avoided but a gentle reciprocal inhibition exercise can be helpful. The patient sits with the mandible propped up on the palms and the mouth comfortably wide open. The patient gently depresses the mandible (not the head) isometrically, against their own hands, for at least five seconds. While inhaling, the hands take up any slack in the jaw muscles as the mouth opens wider and the process is repeated up to 3 times. dolor pterigoideo lat TMJD/Diffuse throat or ear pain The pain of temporomandibular joint disorders is often due to associated TrPs in facial and neck muscles. The referred pain of the medial pterygoid muscle can appear as a vague ache at the back of the mouth and pharynx, behind and below the TMJ and deep in the ear. Views A, B and C are all of the same central TrP in the medial pterygoid, from the skin

surface (A), illustrating the muscle with the overlying masseter and mandible removed (B) and from behind the mandible (C). Together with the masseter on each side the medial pterygoids suspend the mandible in a sling. Unilateral contraction of either medial pterygoid causes lateral deviation of the mandible to the opposite side. Bilateral contraction assists in elevation and protrusion of the mandible. The primary symptoms of trigger points in the medial pterygoids are throat pain, difficulty in swallowing and painful, moderately restricted jaw opening. Patient examination often reveals deviation of the incisal path, typically to the contralateral side, as maximum jaw opening is approached. Trigger point palpation of central TrPs is only possible intraorally. Attachment TrPs can be palpated externally, along the ramus of the mandible. Medial Pterygoid TrP activation is often secondary to TrPs in the masseter and/or lateral pterygoids and rarely occur alone. Perpetuating factors include poor posture and specifically head forward posture, anxiety or emotional tension or microtrauma such as bruxism, clenching or gum chewing. In the past, occlusal imbalance was considered one cause for activation of medial pterygoid TrPs. It is now thought that the abnormal muscle tension caused by TrPs in masticatory muscles including the medial pterygoid often cause the occlusal abnormalities. Masticatory muscle TrPs should be inactivated prior to beginning any prosthodontic treatment. Restoration of normal posture, particularly normal head positioning, is the crucial first step in the management of almost any chronic head or neck condition. Treatment also requires elimination of TrPs in related neck muscles. Trigger point pressure release of the medial pterygoid muscle is most effective when performed by the patient intraorally-not an option for most therapists to perform this work directly. For effective external release consider devices such as the cold laser or extracorporeal shockwave therapy. Spray and stretch (gently) can also be effective. A gentle reciprocal inhibition exercise can be helpful. The patient sits with the mandible propped up on the palms and the mouth comfortably wide open. The patient gently depresses the mandible (not the head) isometrically, against their own hands, for at least five seconds. While inhaling, the hands take up any slack in the jaw muscles as the mouth opens wider and the process is repeated up to 3 times. Travell and Simons, Vol 1, pages 365-377.

pterigoideo lat Key to TMD The lateral pterygoid is frequently the key to understanding many craniomandibular disorders, including TMD. Referred pain is felt strongly in the maxilla and often in the TMJ region. Active trigger points in this muscle are

likely to disturb the position of the mandible, its incisal path while opening and closing the jaw and the coordination with other muscles. The superior division attaches anteriorly to the sphenoid bone but posteriorly to the medial surface of the neck of the mandible just below the articular disk. The inferior division originates from the lateral pterygoid plate and attaches to the neck of the mandible next to the superior division. The proximity these attachments to the articular disk is part of what makes the lateral pterygoids so important. The inferior division opens and protrudes the jaw working bilaterally. Unilateral contraction of either lateral pterygoid causes lateral deviation of the mandible to the opposite side. Bilateral contraction assists in elevation and protrusion of the mandible. The superior division has been identified as specifically supporting the apposition of the condyle, disc and eminence during closure of the jaw. So the two divisions of the same muscle are actually antagonists. Myofascial pain on chewing tends to be proportional to the vigor of movement. Clicking sounds from the TMJ can result from TrPs in the lateral pterygoids. Other symptoms can include tinnitus or sinus problems. Range of motion is not usually not dramatically affected by TrPs in this muscle alone but TrPs in the lateral pterygoids often occur along with TrPs in the masseter or medial pterygoids with significant impact on ROM. Trigger point release of the lateral pterygoids is difficult since the therapist cannot typically provide intraoral treatment. The tools and instructional DVDs provided by TMJ Solutions (http://www.tmjpainsolutions.com/) can be useful for teaching patients release of this muscle with self care. Both divisions of the lateral pterygoids can also be reached externally through extracorporeal shockwave therapy. Elimination of head forward posture and poor tongue posture, if present, are necessary first steps. Perpetuating factors include anxiety or emotional tension or microtrauma from abuse such as bruxism, clenching or gum chewing. A gentle reciprocal inhibition exercise can be helpful. The patient gently protrudes the mandible (not the head) isometrically, against their fingers, for at about five seconds. Breathe out, relax and allow the chin to drop back, towards retrusion of the mandible. The process is repeated 3-5 times. Travell and Simons, Vol 1, pages 379-394. digastrico Headache/Back of head, below ear - Referred pain from trigger points in the posterior belly of the digastric muscle are projected into the upper part of the sternocleidomastoid (SCM) muscle and can be considered pseudo-SCM pain. This referred pain persists even after inactivation of true SCM TrPs. The anterior belly of the digastric projects pain into the four lower incisors.

Patients with TrPs in the posterior digastric often complain of difficulty swallowing and a sensation of a lump in the throat. The patient is likely to point to the SCM muscle on the involved side. Although ROM of rotation of the head may not be reduced the patient is likely to avoid turning the head to the involved side. The posterior digastric pain referral concentrates in the upper area of the SCM but the patient may not be aware of the referral until after the SCM TrPs on the same side have been inactivated. Active TrPs in the posterior belly are a common problem when the ability to open the mouth or protrude the mandible has been restricted due to masseter, temporalis or pterygoid TrPs. Mouth breathing can activate or perpetuate digastric TrPs. The primary symptom from TrPs in the anterior belly of the digastric is pain the lower incisor teeth. One test of anterior digastric TrP involvement is to ask the patient to pull the corners of the mouth down vigorously enough to engage the anterior neck muscles. When positive this Anterior Digastric Test activates the toothache and indicates the likelihood of TrPs in the anterior belly of at least one digastric muscle. Tension of the digastric muscle can be assessed by finding abnormal resistance when trying to shift the hyoid muscle from side to side. Examination is done with the patient supine and the head extended. The posterior belly is palpated by rubbing across the fibers behind the angle of the mandible and sliding the finger upward toward the ear lobe along the anterior border of the SCM while pressing inward. Initial pressure on active TrPs elicits exquisite local tenderness and sustained pressure may reproduce the more distant neck and head pain. To palpate the anterior belly examine the soft tissues just beneath the point of the chin on both sides of the midline. A tender nodule may be felt on the muscle belly at the point of TrP tenderness. Trigger point pressure release is effective for both bellies of the digastric. Head forward posture and mouth breathing should be corrected The digastric muscle can be treated with postisometric relaxation while sitting at a table, chin supported by one hand and using the other hand at the hyoid bone. Patients can also do an active jaw protrusion exercise lying supine. If the mandible deviates to one side during active opening and closure, the patient should rhythmically resist, pushing the mandible to the opposite side with the fingers while the jaw is less than half open. This helps to stretch the posterior belly. Self-stretch of the anterior digastric belly can be performed with one of the patients fingers placed inside the mouth with another outside.