0196-601 1/82/0304-0193$02.

00/0
THE JOURNAL
OF ORTHOPAEDIC
AND SPORTSPHYSICALTHERAPY
Copyright 0 1982 by The Orthopaedic and Sports Physical Therapy Sections of the
American Physical Therapy Association

The Evaluation of Facial, Head, Neck,

and Temporomandibular Joint Pain
Patients
TERESA A. ATKINSON, BS, PT, SARAH VOSSLER, BS, PT,* DENNIS L. HART, MPA, PTf

The purposes of this paper are 1) to present an evaluation procedure for patients
with signs and symptoms of temporomandibular joint (TMJ) pain dysfunction
syndrome (PDS) and 2) to describe the findings of the evaluation procedure on 12
patients with TMJ PDS. The evaluation emphasizes the collection of subjective
and objective data. Records from 12 patients with facial, head, and neck pain
were reviewed. The most frequent symptoms were: headache (1 00%), neckache
(83.3%), and ear pain (58.3%). The most frequent signs were: muscle tenderness
(100%) and mandibular deviation on opening (66.7%). Subjects with lateral
pterygoid muscle tenderness had digastric muscle tenderness as well. Subjects
with medial pterygoid muscle tenderness had masseter and hyoid muscle
tenderness. Masseter muscle tenderness was strongly related to
sternocleidomastoid and mylohyoid muscle tenderness and neckache.

Temporomandibular joint (TMJ) pain dysfunction syndrome (PDS)4' is a nonorganic disorder

of the complex stomatognathic system including
the bilateral TMJs, the articulating maxillary and
mandibular teeth, the periodontium, and the
muscles of ma~tication.~'The four cardinal
elements of the syndrome are pain, joint
sounds (clicking or crepitus), dysfunction of jaw
movements, and tenderness of the muscles of
mastication.7.17,20,22.33,34,41.44
According to
S~hwartz,~'
the pain patterns commonly include
a unilateral dull ache in the TMJ, ear, and jaw
with radiation to the head, neck, and shoulder.
Clinical studies tend to relate signs of muscle
tenderness to
particular
referred
pain
patterns.6323
However, specific pathologies for
patients with facial, head, and neck pain frequently elude the ~ l i n i c i a n .l7
'~~
To organize the clinical approach to patients
with facial, head, and neck pain, a thorough
musculoskeletal evaluation is required. The evaluation should include an examination of the TMJ,
the muscles of ma~tication,'~and the entire
spine, including the sacroiliac joints.' The ex-

* Staff Physical Therapist. Gracewood State School and Hospital.

Gracewood, GA 30812.
t Assistant Professor, Division of Physical Therapy, West Virginia
University Medical Center, Morgantown, WV 26506.

amination of the sacroiliac joints is presented

elsewherei2. " and will not be included here. The
purposes of this paper are 1) to present an
evaluation procedure for patients with signs and
symptoms of TMJ PDS and 2) to describe the
findings of the evaluation procedure on 12 patients with TMJ PDS.

REVIEW OF LITERATURE
The theories of TMJ PDS etiology have been
classified by De Boever." The first classification
is the mechanical displacement theory. This theory states that the posterior displacement of the
mandibular condyle results in pain in the posterior joint structure^.^ Malocclusion or loss of
posterior teeth may be the etiological factors of
this condylar di~placement.~
Second, the muscular theory emphasizes the myofascial source
Of
15, 25,47
The muscular pain may be induced by the stimulation of hypersensitive trigger areas, leading to muscle shortening, painful
spasms,5i and possible contractions. Patterns of
referred pain and concomitant symptoms also
have been d e s ~ r i b e d . ~ ,Similar
~'
patterns of
muscle tenderness have been described in
"normals."23
The third classification is the neuromuscular
concept. This concept stresses the influence of

194

ATKINSON ET AL

inhibitory and facilitatory impulses from periodontal proprioceptors, muscle spindles, and
joint receptors."* 55 Major etiological factors related to the neuromuscular concept are parafunctional oral movements, such as bruxism and
clenching. These oral habits may be caused by
occlusal interference^,^' especially when coupled with emotional
49. 58 Fourth, the
psychophysiological theory emphasizes the role
of emotional tension in producing parafunctional
oral habits. Occlusal disharmony is considered
to be a sequela of the chronic muscle spasms
associated with tension-relieving habits.26136
Last, the psychological theory examines personality profiles of patients with TMJ PDS to determine the possibility of psychological predisposition.", 31
In light of the debate concerning the etiology
of TMJ PDS, several authors warned against the
rigid acceptance of one c o n ~ e p t ' . ' ~ ~42 Thus, a
broad approach to the evaluation of a patient
with head, neck, and facial pain is recommended.
Review of the physical therapy literature includes several studies describing the management of oral problems'~', ', 38'
56 but did not
reveal a specific evaluation procedure that addresses subjective and objective information. In
a clinical research study, Trott and G O S Seval~~
uated and treated 34 patients with myofascial
PDS using physiotherapy techniques. The physical therapy evaluation consisted of: three tests
for the muscles of mastication, three tests for the
TMJ, and two tests for the cervical spine. Trott
and Goss did not report a collection of subjective
information which is essential for the management of any pain problem. Thus, there is a need
for a thorough physical therapy evaluation format
which will serve the following purposes: determine the specific acute signs and symptoms and
chronic structural problems of patients with TMJ
PDS; provide individualized baseline data on
which to judge the effectiveness of treatment;
and provide data for clinical research.
277

533

PHYSICAL THERAPY INITIAL EVALUATIONS

An outline of the physical therapist's evaluation is seen in Table 1. The first step of the
physical therapy evaluation was to ask th'e patient to complete a self-administered questionnaire to determine information concerning the

$ Based on the work of R o ~ a b a d o , ~Gelb,16-l8

'~~
and E v e r ~ a u I . ' ~ . ' ~

JOSPT Vol. 3, No. 4

chief complaint, medical and dental history, and

other subjective data.37After reviewing the questionnaire, the therapist conducted an interview
to clarify the patient's answers. During the interview, the therapist observed the patient's general posture, state of health, affective qualities,
and signs of orofacial dysfunction such as voluntary or involuntary facial habits or speech
defects.
Facial measurements were performed to determine any decrease in vertical dimension and
to check for developmental problems such as
micrognathia or ma~rognathia.~'
Hypertrophy of
the facial muscles, redness, or swelling were
also checked.40
An active range of motion test was then performed. The patient was asked to move the mandible in elevation, depression, protrusion, retraction, and lateral movement to each side. During
active range of motion, the therapist checked for
limited movement, hypermobility, incoordination,
or evidence of pain. At maximal opening, the
midline interincisal distance was measured. The
normal value for this distance is 35-40 millimet e r ~ During
. ~ ~ jaw opening and closing, mandibular and maxillary midlines were observed to
determine lateral or zigzag deviations.
The occlusion was then checked. Overbite,
crossbite, presence of orthodontic appliances,
dentures, or missing teeth were noted and recorded.
The TMJs were palpated both on the lateral
surface and with the therapist's fingers in each
external auditory meatus. The patient was asked
again to open and close his mouth several times
so that clicking on opening or closing or crepitus
could be noted.
The muscles of mastication were palpated bilaterally both extraorally and intraorally. The degrees of tenderness were graded subjectively as
follows: 0 = normal; 1 = tender; 2 = painful.

METHOD OF SURVEY
Twelve records of patients from the office of
Physiotherapy Associates, Augusta, GA, were
selected nonrandomly for the study. The selection of the records was based on the following
criteria: 1) a complete history questionnaire; 2)
a chief complaint of head, neck, or facial pain;
3) no history of recent trauma or surgery of the
face or head; 4) no history of an organic disorder
of the TMJ; and 5) the same therapist (T. A. A,)
performed all initial evaluations.
Following the acquisition of a written informed

JOSPT Spring 1982

EVALUATION OF TMJ PATIENTS

TABLE 1
Outline of physical therapy evaluation of the patient with facial, head, or TMJ pain
I. Self-administered questionnaire*
A. Chief complaint
B. Past treatments to correct the problem and success
C. Patient's opinion of a solution to the problem
D. Symptoms and history
1. Location(s)
2. Onset (time and circumstances)
3. Duration
4. Aggravating or relieving factors
5. Consultations, diagnoses, medications
6. Specific symptoms
a. Jaw dysfunctions
b. Signs of inflammation
c. Symptoms of autonomic nervous system involvement or endocrine problem
d. Parafunctional oral habits
e. Dental signs and symptoms
f. Headaches and neckaches
g. Ear symptoms
h. Pain
1) Type
2) Intensity
3) Frequency
II. Patient interview
A. Dietary history
B. Dental history
Ill. Examination
A. General posture evaluation
B. Inspection of the head and face
1. Anterior view
2. Profile
C. Mandibular movements
1. Active range of motion
2. lnterincisal distance on maximal opening
D. Lip closure39
E. Lingual position3'
F. Occlusion
G. Bony palpation
1. Lateral joint surface
2. External auditory meatus
H. TMJ auscultation
I. Palpation of the muscles of mastication and of the neck
J. Respiration (mouth or nasal breather)16
K. Phonetics (his house, church, judge, zebra)I6

* Summarized from George EversaulO, P.O. Box 19476, Las Vegas. NV 891 19.

consent, each patient's chart was reviewed to

obtain subjective and objective data from the
initial physical therapy evaluation. The data were
analyzed for means, standard deviations, and
Pearson product-moment correlation coefficients for each pair of signs and symptoms. The
signs and symptoms were totaled to determine
the ranked order of frequency of occurrence.

RESULTS
Two men and 1 0 women, ages 35 to 77 with

a mean age of 50.5 years (median of 48 years),

consented to participate in the retrospective

study. Eight patients were referred from otolaryngology, one from cardiology, one from internal
medicine, and two from dentistry.
Tables 2 and 3 present the raw data from the
survey. The most frequent symptom was pain:
headache (1 00%), neckache (83.3%), and ear
pain (58.3%). The most frequent signs were:
muscle tenderness (100%) and mandibular deviation on opening (66.7%).
Significant correlations of r 2 0.70 (P 5 0.05)
for various signs and symptoms are presented
in Table 4. Subjects with lateral pterygoid

196

ATKINSON ET AL

JOSPT Vol. 3, No. 4

TABLE 2
Sians and svmDtoms of TMJ ~atients
-

Patients
Total
1

Age
Sex
Oral
TMJ pain
Limited mouth opening
Deviation
TMJ noise
Bruxism
Clenching
Ear symptoms
Tinnitus
Popping
Stuffiness
Pain
Itching
Hearing loss
Hearing sensitivity
Concomitant symptoms
Headaches
Neckache
Dizziness

40
F

77
F

35
F

37
M

68
F

50
F

36
F

60
F

X
X

X
X

X
X

65
F

52
M

46
F

X
X
X

X
X
X

40
F

6
3
8

X
X

X
X
X

X
X
X

X
X

X
X

X
X

X
X
X

X
X

X
X
X

X
X
X

X
X
X
X

X
X
X

X
X
X

X
X
X

X
X
X

X
X
X

X
X

X
X

4
3
3
7
1
2
2

X
X

12
11

TABLE 3
Results of muscle palpation*
Patients
1

9 . 1 0

External palpation
Temporalis
Masseter
Medial pterygoid
Digastric
Sternocleidomastoid
Hyoid

2
2
2
2
2
2

0
2
2
2
2
0

0
2
2
0
2
2

2
2
2
2
2
2

1
0
0
2
0
0

2
2
1
2
2
1

2
2
2
2
2
2

2
2
1
2
2
2

1
1
2
2
0
0

1
1
0
2
2
0

Internal palpation
Masseter
Medial pterygoid
Temporalis tendon
Lateral pterygoid

2
2
2
2

0
0
0
2

2
2
0
1

2
2
2
2

0
0
0
2

2
2
0
2

2
2
2
2

2
2
1
2

0
0
0
2

0
0
1
2

0
0
0
2

0
0
0
1

* Muscle palpation values: 0 = normal; 1 = tender; 2 = painful.

tenderness also had digastric muscle tenderness. Subjects with medial pterygoid muscle
tenderness also had masseter and hyoid muscle
tenderness. Masseter muscle tenderness was
strongly related to sternocleidomastoid and
mylohyoid muscle tenderness and neckache.

DlSCUSSlON
An evaluation procedure for patients with TMJ
PDS was presented, and the records of 12 nonrandomly selected patients with histories of TMJ
PDS were reviewed. The clinical findings were

TABLE 4
Correlations of signs and symptoms
r*

Lateral pterygoid-digastric
Medial pterygoid-masseter

1.oo
1.00

0.001
0.001

Medial pterygoid-hyoid
Masseter-sternocleidomastoid
Masseter-neckache
Masseter-mylohyoid
Sternocleidomastoid-neckache
Mylohyoid-temporalis tendon

0.96
0.95
0.93
0.85
0.77
0.73

0.001
0.001
0.001
0.001
0.003
0.007

bledial pterygoid-dizziness
tendon-c1enching teeth

0.72
0.70

0.008
0.01

Variables

* r = Pearson product-moment correlation coefficient.

EVALUATION OF TMJ PATIENTS

JOSPT Spring 1982

197

TABLE 5
Comparison of surveys of the symptomatology of TMJ PDS with percentage of occurrence
Investigators
Signs and symptoms

Atkinson
et al.

Greene
et a1."

Sheppard and
Shepparda5

Gelb
et al."

Ne133

Pain
Joint sounds
Muscle tenderness
Limited motion
TMJ pain
Ear symptoms
Headache
Tinnitus
Dizziness
Muscle palpation tenderness
Lateral pterygoid
Masseter
Temporalis
Medial pterygoid
Ratio of women to men
Total N

similar to previous studiesi8*

43, 44*
57
(Table 5) even though the total number of subjects was much smaller. One hundred percent of
the patients in the present study reported tenderness in at least one muscle. All subjects had a
history of headaches which was a higher inci.~~
dence than previously r e p ~ r t e d . ' ~However,
since headache is such a difficult symptom to
quantitate, headache data should be cautiously
compared among studies. The relationship between tension headaches and tenderness of the
muscles of mastication have been reported elsewhere."
The incidence of ear symptoms in the present study was high in comparison to the other
StUdieS5.
18.30.32.33.45
and may be attributed to the
fact that the majority of subjects (67%) were
referred by otolaryngologists. Myrhaug3' postulated that, since the innervation of the muscles
of mastication, tensor tympani, and tensor palatini was the same, a generalized condition of
muscle spasms involving all of these muscles
may be present in patients with TMJ PDS. The
sustained contractions of the tensor muscles
may lead to tinnitus, hearing sensitivity, temporary deafness, and ear stuffiness or fullness. In
an EMG study, Block4 identified a relationship
between spasm of the medial pterygoid muscle
and ear stuffiness.
In the present study, a correlation of r = 0.72
(P = 0.008) was found between medial pterygoid tenderness and dizziness. Some authors
have reported an association between dizziness
and tenderness on palpation of the sternoclei3
"

339

453

domastoid muscle,44.50. 54 but no explanation of

either of these phenomena has been offered.
Mryhaug3' suggested that dizziness may be associated with TMJ dysfunction because of the
myospasm of the tensor muscles.
The high incidence of muscle tenderness and
low incidence of oral habits in the symptom
survey appears to contradict the concept of the
neuromuscu~ar~
1,35,48,49,55.58 and psychophystheories of etiology. However,
further studies of more than 12 subjects are
necessary to clarify any discrepancies or correlations.
The common symptoms found among patients
with TMJ .PDS have been described. Since many
patients with TMJ PDS are referred to physical
therapy with other diagnoses, commonly acute
or chronic neck and head pain syndromes, a
thorough examination of the stomatognathic system is necessary to determine the appropriate
approach to treatment. If a diagnosis of TMJ
PDS is suspected following an accurate evaluation, the patient should be referred to a dentalocclusion specialist for necessary intraoral support. In our experience, the combination of dental splinting ;therapy and physical therapy has
successfully alleviated many chronic pain complaints and permitted patients to return to normal
function.

SUMMARY
A physical therapy evaluation procedure for
patients with signs and symptoms of TMJ PDS

198

ATKINSON ET AL

has been presented. The clinical profiles of 12

patients presenting with head, face, or TMJ pain
were compiled from their physical therapy evaluations. The clinical findings were descriptively
analyzed to determine the most frequently observed signs and symptoms and any possible
correlations between these signs and symptoms.
Additional research is required to determine the
effectiveness of the physical therapy evaluation
format presented in this report.

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JOSPT Spring 7 982

EVALUATION OF TMJ PATIENTS

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