The importance of temporomandibular joint, oro-facial and cervical/trapezial palpation findings in the TMD exam (including screening for hypersensitivity, malingering and false complaint).
This is very important information for any practitioner who is examining, referring and/or treating patients who present with headache, neck pain, dizziness, tinnitus, primary ear symptoms and/or TMJ/orofacial pain. If you are curious about why I list these particular symptoms (and you should be) you might want to read through the this research paper.
More detailed information can be found in the “Examination & Diagnosis” link on my website www.whiplashandtmj.com. I have bolded the key points in this blog version. All reference numbers found here correspond to references found in the website version. The palpation portion of the examination is demonstrated at 29 minutes 51 seconds on my TMD Training DVD.
All your comments are welcome on this blog!
The six parts of the standard TMD office examination should include at least:
1. Case history
2. TMJ Range of motion
3. Mandibular tracking
5. TMJ auscultation
6. TMJoint/masticatory muscle challenges (provocations)
This list does not include radiology and special tests which may need to be ordered pending review of the findings documented during the exam above.
Of particular interest is that the most telling findings may well come from the palpation exam when the findings are reviewed in light of the case history and symptom report.
palpation: the act of feeling with the hands or fingers – a phase of the examination procedure in which the sense of touch is used to gather information essential for diagnosis.
palpation, bilateral: a method of examination in which both hands are used to simultaneously examine and compare symmetrical body structures on opposite sides of the body.
Palpation is perhaps the most undervalued and misunderstood of the TMD exam procedures. Palpation findings for muscles, joints, ligaments and tendons are often considered equally reliable or unreliable and lumped under the heading of “subjective” data. In fact, with regards to muscles and joints, inter-examiner and serial intra-examiner reliability is different for each tissue. This includes studies of the cervical, lumbar and masticatory regions (19, 44, 60,90).
The effectiveness of palpation for differentiating patients from non-patients has not been thoroughly validated, however palpation findings have proven very valuable in developing an accurate diagnostic impression when examining a symptomatic patient.
Interpreting palpation findings:
1. Cervical and/or masticatory muscle tenderness is not a reliable indicator of local muscle pathology as tenderness may represent the affect of a CNS process stimulated by peripheral pathology (90, 105, 115).
2. Identification of trigger points by palpation is reliable (111). Just keep in mind that while trigger points are a source of pain that is expressed elsewhere, they themselves may exist because a neural trigger is stimulating abnormal and perpetuated muscle contraction. This is what drives the peripheral symptom expression of temporomandibular joint specific disorders and why so many TMD cases are misdiagnosed as myogenous when, in fact, they are arthrogenous.
3. In a TMD patient population tenderness over the lateral poles of the temporomandibular joint condyles identifies capsular inflammation accurately especially if the tenderness is equal to or greater than 2 on a 0 to 3 scale and the condyles are as tender or more tender than the ipsilateral masseter and temporalis musculature (105).
4. Palpation of the lateral and posterior capsule of the temporomandibular joint with an algometer shows acceptable inter and intra-examiner reliability and can identify patients from non-patients (13).
5. Females report temporomandibular joint capsule pain at a lower pain pressure threshold than males when tested by algometer (13).
Many difficult questions are now being asked which challenge our ideas about myofascial disorders. In the field of TMD this is very troublesome as a “myofascial” diagnosis is one of the most commonly assigned in clinical practice. Results from four surgical studies and two temporomandibular joint anesthetic injection studies challenge the idea that we can identify myogenous disorders exclusively by the presence of muscular tenderness to palpation. These studies have demonstrated remission of both masticatory and cervical myofascial tenderness when the temporomandibular joints are injected with an anesthetic and/or operated (17, 68, 70, 105, 113). This is not to say that all myofascial presentations are driven by joint inflammation, but rather that muscle tenderness alone cannot rule in a true primary myogenous disorder, cannot rule out an arthrogenous disorder and cannot rule in a mixed arthrogenous/ myogenous disorder as the arthrogenous disorder is capable of driving the entire muscular component (105). Joint tenderness as an isolated finding may not be an accurate inclusionary factor for symptomatic capsulitis as it has been noted that joint receptor discharge increases with muscle activity (66). In fact, comparing locations, patterns and relative degrees of tenderness in the muscles and joints of the head and neck may give us the most useful diagnostic impression (105). It should be noted that the presence of cervical muscle tenderness in patients expressing symptoms in the head and neck has been identified as indicating a high probability of TMD (40, 109, 115).
Palpation of the masticatory and cervical/upper shoulder regions is necessary and important in the TMD examination. These tests are necessary to satisfy the demands of standard of care and can provide useful information in the following ways. First, identification of trigger points and muscle hypertonicity provides targets for treatment in true non-arthrogenous myofascial conditions (112). Second, certain patterns of muscle tenderness and hypertonicity can be informative diagnostically when temporomandibular joint tenderness is present concurrently (105). Third, when temporomandibular joint pathology is suspected of being the driving force behind the symptoms, specific areas of muscle tenderness and hypertonicity can serve as target areas for anesthetic temporomandibular joint injections and/or joint-specific treatment trials (17, 105, 107).
TEMPOROMANDIBULAR JOINT PALPATION – TECHNIQUE
To palpate the temporomandibular joints most effectively have the patient move the chin to the side opposite the joint palpated. When the joint is palpated with the teeth together or the mandible at rest there is approximately 5-10 min of tissue between your finger and the joint capsule. Having the patient maneuver the chin to the opposite side will surface the condyle for more accurate palpation findings.
Palpate the condyle with three to five pounds of pressure with the pad of the index finger.
Palpate the entire condyle accessible to you as the lateral capsule is complex and certain areas may be tender while others remain nontender. Any tender areas of the capsule should be recorded.
IMPORTANT PALPATION FINDINGS
1. Condyle tenderness which is equal to or greater than 2 on a 0 to 3 scale and which is more pronounced than ipsilateral anterior temporalis and superficial masseter tenderness indicates temporomandibular joint capsulitis. Patients with this finding are very likely to express TMD symptoms which are driven by temporomandibular joint-specific inflammation and/or mechanical deformation.
2. Tenderness of the belly of the sternocleidomastoideus and/or upper trapezius may be produced by inflammation of the temporomandibular joints. This can be unilateral, bilateral or ipsilateral to the involved joint. These muscles are almost always hypertonic as well as tender if temporomandibular joint inflammation is the driving force behind this finding. This indicates that this is not just referred pain, but a muscular reaction to heightened neurologic activity produced by joint inflammation. This has been confirmed by retrospective surgical testing (70,105) and anesthetic injection studies (17, 105).
3. Temporomandibular joint inflammation produces substantial hypertonicity and tenderness of the paracervical musculature especially in the suboccipital region. It may also cause hyper-contraction and tenderness of the scalene muscles with associated pain and paresthesia in the upper extremities.
4. Temporomandibular joint inflammation does not usually cause isolated tenderness of the spinous processes and interspinous spaces in the cervical region. This helps to differentiate primary cervical injury/pathology from temporomandibular joint-cervical affect.
5. The stylomandibular ligaments and the temporal tendons at their coronoid attachments should also be palpated. Referred pain from the coronoid attachment includes the eye, bridge of the nose, temporomandibular joint and ear (101). Stylomandibular ligament inflammation refers pain to the preauricular region, ear, neck and head (101).
6. The mastoid processes are useful control areas for palpation. Except for mastoiditis or a direct blow to the area, this region is nontender in most all patients (severe temporomandibular joint inflammation may produce slight tenderness in a few patients). This area is above the sternocleidomastoideus insertion and lateral to the upper trapezial insertion. This is an area of thinly covered bone and, while not identical to the temporomandibular joint condyle, is similar. It thus provides an ideal area for comparison of palpation responses. The area should be palpated two to three times during the examination with the same pressure (3-5 pounds of pressure applied with the pad of the pad of the index finger). This allows the doctor to check for consistency of response. This is a valuable screening test for hypersensitivity, false complaint and malingering.