Jaw pain can be suprisingly debillitating. It often can cause headaches, stress, neck pain, and sometimes shoulder pain. ⁣It can make it so things like happy hour with friends no longer enjoyable because not only does it hurt to eat, but the pain is distracting and you never feel present. And unless your friends have experienced jaw pain, they often don't understand. ⁣It can affect work and cause headaches, especially if you stare at a computer screen all day. If you have to have face to face interactions, it can again be distracting when an acute flare up hits that can come on simply from opening your mouth. ⁣And if you’re a normal active gym goer, you’ll likely find yourself not wanting to go as often when it’s flared up, or at least not do push/pull motions.

The good news is it’s often healed conservatively, no surgical intervention needed.

Dysfunction of this area can happen with a lot of different things, as we’ll go over in a bit. Sometimes the muscles are overworked, sometimes the ligaments (not pictured) get stressed, and sometimes the disc in the picture above gets out of place due to trauma.

My Story

Let’s start with my jaw pain story, which may resonate with anyone who has dealt with or is dealing with jaw pain:

When I was 18 and graduated high school, some friends and I celebrated at the lake. We took turns tubing behind the boat, while our friend’s dad tried to throw each of us off. My friend Erin and I were the only ones that had stayed on, so we got the brilliant idea to go at the same time. In hindsight, this already sounds like a bad idea. But it was a lot of fun! Until it wasn’t. We hit a series of big wakes and we both went airborn. Right into each other. Except it had happened so fast, that we each though we’d just hit the water hard. But when our heads popped back up, I turned to see her face covered in blood. Turns out my chin had rammed her forehead (and head wounds bleed like a mother). We both went to the ER (no open wounds on my end, but I did feel some jaw pain and a headache. Plus, looking at the damage I did to her head, I figured it was worth getting checked). She ended up with 15 stitches in her head and I got sent home after being told it must just be inflammed and that I’d be fine. They hadn’t seen anything on the regular film Xray they’d taken. So I figured I just needed to suck it up and it would go away eventually. Except it didn’t. It just got worse. It started as a nagging pain on both sides, more on the right. Especially when I chewed on that side. Then it progressed to not being able to chew on that side and painfully popping if I did (also hurt chewing on the left, but tolerable). And I started to get right sided headaches more frequently, my range of motion for opening my mouth became limited, and I had constant face and neck pain on the right. So after a few months of dealing with this, I finally went and saw a specialist. There, they took a panoramic Xray which showed 2 fairly major fractures in my jaw. One on the right up through the condyle (top of the joint) and on the left a long one through the mandible (the big jaw bone).

The doctor explained that the Xray in the ER likely missed these as they took images straight though from one side of the face, allowing the bones on the opposite side to be directly behind the ones being imaged, thereby hiding any fracture. I was told that since the bones were not displaced, I did not need to be wired shut, but I did have to be on a liquids only diet for 6 weeks to allow the bones to heal. Nowadays, this would still suck, but it’d be a lot easier with the products available and the smoothie and juice bars. 15 years ago, none of that was around yet. Heck, I don’t even remember easy access to protein powders. Anyways, I digress. After those 6 weeks, the doctor cleared me without getting another Xray (in hindsight, I should have been adamant about requesting one). I slowly integrated solid foods back in. The pain was significantly better, and I assumed the residual pain was from the muscles not being used much during that time.

It took me about a year to realize I was still avoiding chewing on the right side, never chewed gum due to pain flare ups, and only had about 50% range of motion. But like most people, I just dealt with it. For years. I would have flare ups of the headaches and jaw/neck pain a few times a year, but it would always eventually go away. And it progressed to this painful click/clunk with opening and closing my mouth beyond that 50%. Over the next several years it progressed to constant pain that would increase to the point of affecting my social life and causing bouts of depression. It wasn’t fun to go out to eat with friends. The pain made me not want to be social in general. And I noticed when my jaw pain was bad, my neck and shoulder would hurt more with lifting. While I treated a lot of jaw pain (they often came in with neck or shoulder pain that turned out to be referred from the jaw), my colleagues weren’t as comfortable treating this area. It’s not something we learn much about in school (unless you’re like me and currently experiencing it, therefore do tons of extra research on your own). And I never made time to take care of myself. I did try acupuncture and many splints, to no avail. The splints did help bring the pain down some, but nowhere near gone. What did help? Finally taking the time to treat myself as best as I could with mobilizations, dry needling, and strengthening. Is it completely gone? No. Admittedly, it will occasionally flare up. But now, it’s rare, never debillitating and is short lived when it does happen. And I have to think that if I’d done this stuff sooner than 15 years after the fact, it may be completely gone because I wouldn’t have had the time to develop compensation patterns.

Terminology

Let’s start with just clearing up some terms that could otherwise make this confusing to read: TMJ stands for tempromandibular joint. It is the anotomical structure itself, not a condition. TMD on the other hand, is tempromandibular dysfunction and refers to any issue involving the TMJ, supporting musculature, and surrounding structures. That’s the term I’ll use from here on out when talking about any pain or dysfunction.

A few little facts about TMD:

• It’s more common than you think. TMD signs/symptoms (including, but not limited to, jaw pain) happen is 31% of the population.

• More common in women age 20-40

• It can refer pain to the head, neck, and sometimes even the shoulder (nagging headaches are fairly common with TMD)

• If you get that painful click/clunk when opening your mouth, it’s the disc in the joint sitting too far forward, causing the bone that’s supposed to move with it to get stuck and then suddenly “clunk” over the disc into place. Same idea with closing the mouth, but in the reverse. (sometimes this will progress, like it did with me, where it just gets stuck and never gets past that point, limiting range of motion)

  • If you have some small joint sounds occur with moving your mouth, but no pain, you may not have a dysfunction. Some sounds can be normal, like nonpainful clicking in your knee with standing up. Every case varies, so if you’re concerned, talk to a provider.

• Multiple possible causes, including trauma to the area, dental procedures, teeth grinding, jaw clenching, nail bitting, and gum chewing (last 4 can end up being an overuse injury)

Pain Patterns

Ok, so I mentioned referred pain. Almost always, head neck stuff goes along with TMD (though the converse isn’t always true). This is because there are some shared nerve pathways between them. Specifically, the nerve that supplies the movements of biting and chewing is the same that supplies sensation to the side of the face, even above the ear into the temporal area. Hence why headaches in that area or behind the eye can occur. And then to further complicate things, that nerve pathway converges with the pathways from C1-3, aka your upper neck (so in the picture below, it follows the red path down, and then the blue path back up to reach the brain). So when the jaw sends signals that something is wrong, that signal can get mixed up before it gets up there. So then the brain can’t always discern if it came from the muscles of the jaw versus the neck versus any of the other structures the trigeminal nerve supplies.

As for the shoulder/shoulder blade pain: that typically comes from the jaw muscles being overloaded, causing stress on the muscles of the head and shoulders. And you may not even necessarily realize you have jaw pain. More than once I’ve had someone come see me with complaints of shoulder pain, and after a thorough evaluation, it turned out to be coming from the TMJ.

And as I kinda alluded to in the beginning, there are a lot of stressors that can build up when you frequently experience TMD. In fact, there was a study done (Carlson 2001) that found that “People with chronic TMDs are physiologically overreactive to their environment and tend to have substantial psychological stressors compared to people without TMD.” So no, you’re not crazy. This is normal to experience with TMD. Believe me, I’ve been there.

Ok, so now what?

First off, I know a lot of people try orthotics/splints (think like a specialized mouth guard or like a retainer, but for the inside of your jaw). Heck, I myself actually tried this before trying PT because it’s what a dentist recommended. And while I think it did help a little, the ROI just didn’t make sense. I had treated the person who made it for me, so I got a steep discount…and it was STILL $1,000! It wasn’t comfortable and after a couple of months, my pain was maybe about 30% reduced and plateaued at that point. Don’t get me wrong, a 30% reduction was still welcome, but I had a hard time believing that was it. Especially at that cost. In the end, the amount of physical therapy I did was 5 sessions (we’ll just use what I charge for sessions to come up with an amount - $675) over 2 months and by the end of it, I felt 90% better. And still do. Yes, I have occasional flare ups, but they are only maybe 30% of what a flare up used to be, they happen infrequently, and don’t last long. I will absolutely take that after YEARS of progressing pain that was debillitating. Much better ROI if you ask me. So if you’re reading this and thinking you may have some TMD happening, I’d say the first step is go see a physical therapist. In fact, a study done by Shaffer et all found that “Physical therapy is the preferred conservative management approach for TMD.”

Now, when I say go see a physical therapist for this, there are a few questions I want you to ask the provider you see:

How many TMD cases have you seen/treated? And if not many, how much education/information have you taken on this topic since graduation? Are you comfortable going inside my mouth to assess and treat this? Do you dry needle the lateral ptyerigoid?

I’m not saying don’t see a provider just because they haven’t seen many cases or don’t do dry needling (though as I explain in a bit, it does help tremendously in a lot of cases). But they do need to be comfortable going intra-oral and have more understanding of this that the minimal we get in actual school versus continuing education. Hell, tell them to jump on a call with me for an hour if it’s someone you really want to see, but they aren’t comfortable with the jaw.

So what does treatment look like?

It should be a combination of mobilizations, some soft tissue mobilizations, possibly some dry needling, and then (I’m sure this is a shocker for those that have been treated by me or have read my stuff before): EXERCISE!! Strengthening up the surrounding area, particularly the neck and shoulder stabilizers, will be tremendously helpful in actually solving the issue and keep jaw pain from just coming back. If you’ve had treatment for TMD, it’s very likely you have done the Rocabado 6x6 exercises. These have honestly not been shown to be that helpful long term via research, but they are the most popularly used by clinicians. While I do like using them, both myself and with patients, for a “quick fix” to calm down a flare up when you’re somewhere where you have limited options (at a work meeting or such), there is actually more long term benefit in actual strengthening exercises like cervical flexion holds, weighted shrugs, and others that we’ll get into later…

Mobilizations should absolutely include one for the TMJ itself, but also the neck and maybe even the upper back. In fact, one of the things that has really helped my jaw pain is cervical manipulations followed by strength exercises. Your therapist can show you how to perform self-mobilizations at home to help as well.

Dry needling is what I honestly think helped the most, specifically the lateral pterygoid for any anatomy nerds wondering (and it’s what I’m needling in Tuesday’s IG post if you saw that). And that plus keeping up strength is really all I do to maintain the progress made during those 2 months of PT - The few times I have a flare up, I toss a needle in there for a couple minutes and then do some specific drills. Over the next few days, the pain progressively dissipates. Admittedly, it does help that I can perform this on myself, but for the once every so often flare ups, I’d argue the relatively small cost of this (I charge $70) is well worth it. For any practitioners reading this, I’m aware that research on dry needling for TMD is iffy, but if you look at how the research was conducted, they rarely actually performed it in the muscles of the jaw, so I’m really not sure what they were expecting to find.

Moral of the story: Don’t be like me and take 10 years to do something about jaw pain, and go down the right path the first time around.

DM/comment with any questions!

NEXT WEEK: You know how multiple times through this blog I mentioned having exercises that really helped me? That’s what I’ll be going over next week! Sorry if it felt like I teased you with those, but there’s already a lot of info in this blog, and I didn’t want to turn it into a novel