MSK 3 Mod 3 TMJ Joint PDF

MSK 3 mod 3: TMJ joint TMJ anatomy and Biomechanics -​ The temporomandibular joint is the articulation between the temporal bone of the skull and the mandible or the lower jaw. movements of the joint are described by what the mandible is doing. -​ mandibular elevation is the same a...

MSK 3 mod 3: TMJ joint TMJ anatomy and Biomechanics -​ The temporomandibular joint is the articulation between the temporal bone of the skull and the mandible or the lower jaw. movements of the joint are described by what the mandible is doing. -​ mandibular elevation is the same as closing your mouth from an open position. mandibular depression is the same as opening your mouth. -​ protrusion and retrusion are sliding the jaw anteriorly and posteriorly, as if to create an underbite and an overbite -​ Chewing ( mastication) and grinding are composite motions that do not occur in one plane, but these are extremely important functions of this joint Arthrokinematics Mandibular depression -​ the early phase of mandibular depression primarily involves rotation at the joint, and the later phase involves primarily translation. -​ to open mouth: posterior rotation or depression and anterior translation (glide/ protrusion) happens simultaneously -​ to close mouth: anterior rotation ( close) and posterior translation ( Glide/ retract) happen simultaneously. Knowledge check: -​ the lateral temporal mandibular ligament prevents excessive opening of the mouth. true or false? false, it prevents excessive anterior/ posterior and lateral motions. -​ To chew gum on the right side of your mouth, the left medial and lateral pterygoids protract on the right posterior temporalis muscle retracts. true or false? true. Patient History and subjective exam -​ The subjective interview for patient history includes Gathering pertinent information that is often referred to as the fundamental four -​ the fundamental four includes: 1.​ present illness ( Chief complaint) -​ sacred seven 2.​ past health history -​ confounding, intervening factors -​ response to previous interventions 3.​ family held history (risk factors) -​ congenital issues/ heredity 4.​ personal or social history ( risk factors) -​ fear avoidance behaviors ​ Present illness/ Chief complaint -​ the seven attributes/sacred seven include: 1.​ setting or onset -​ Mechanism of injury: how, what, when? -​ traumatic: direct blow, application of force position of body -​ non-traumatic: postural, repetitive motion, overuse -​ Insidious: no known mechanism 2.​ location/ radiation -​ Local, referred, radicular, or Regional? -​ Chief complaint: described by the patient in their own words -​ pain mapping or body diagrams may be helpful 3.​ Severity -​ The intensity of pain, assessed with pain scales 4.​ Quality -​ Descriptors of symptoms: stabbing, burning, aching, stiffness, etc. -​ nature of symptoms: constant, variable, intermittent 5.​ chronology/ timing -​ Time of day: worse or best in AM? worse or best in PM? -​ are symptoms worse with activity/ relieved with rest? mechanical pain -​ unprovoked by activity? non-mechanical pain 6.​ Associated symptoms/ modifying factors -​ Associated symptoms: swelling, weight-bearing status, functional status -​ modifying factors: factors that improve status, factors that worsen status 7.​ current medical management -​ Medication: taking as prescribed? -​ Diagnostic Imaging: report, images available? -​ medical plan/ prognosis: expectations, goals? -​ response to interventions: any changes in status? ​ Red flags -​ Post-trauma: -​ upper cervical instability -​ Fracture  -​ myelopathic symptoms -​ 5 Ds ( dizziness, drop attacks, diplopia, dysarthria, dysphasia) -​ 1A: ataxia -​ 3 Ns: Nausea, numbness, nystagmus -​ bone density compromise/ significant osteoporosis -​ prior history of cancer Exam ​ Forward head posture and TMD -​ changes the resting position of the mandible: -​ May result in mal-occlusion ( bad bite pattern) -​ may result in muscle guarding around TMJ because patient doesn't know where to hold jaw at rest -​ malocclusion may require increased muscle activity to get mandible back into proper position for chewing -​ all of these factors exposed TMJ to abnormal stresses and may result in TMD kyphosis ​ posture -​ General: forward head, rounded shoulders, thoracic kyphosis -​ symmetry of mandible in resting position -​ symmetry of facial muscles -​ is not open or closed in resting -​ Evidence of protrusion/ retraction in resting Observation ​ overall posture -​ in waiting room and during exam ​ Forward head posture -​ head lies anterior to plumb line ​ rounded shoulders -​ acromion is anterior to plumb line, scapula tend to be abducted ​ spinal curves ( cervical, thoracic, Lumber) -​ do not limit to just head and neck -​ increased thoracic kyphosis ​ muscle symmetry, atrophy, hypertrophy, or spasm ​ observable deformity or asymmetry -​ fracture/ dislocation, splinting, or torticollis ( twisted/ tilted neck) Upper quarter screen ​ upper quarter screen -​ dermatome/sensory testing -​ Deep tendon reflexes (biceps brachii: C5, brachioradialis: C6, triceps brachii: C7) -​ Myotome testing ​ additional neurological tests  -​ Upper motor neuron signs -​ Hoffman’s reflex -​ Babinski test -​ Hyperreflexia (tonic DTRs, clonus) -​ Upper Limb tension testing -​ Cranial nerve tests -​ Other neurological tests as appropriate -​ A neurological screen is relevant to a comprehensive upper quarter screen due to the possibility of the nerve root and or spinal cord compression Palpation ​ Boney -​ TMJ -​ Ramus, angle, and body of mandible -​ Condylar heads laterally (with mouth closed and during opening and closing movements) -​ Posterior aspect of TMJ through auditory meatus (mouth closed and during opening and closing movements) -​ Zygomatic arch -​ Hyoid bone ​Muscles -​Temporalis:side of the temporal bone above the zygomatic arch -​ can access the insertion on the coronoid process with the mouth open -​Masseter -​ superficial belly: face -​ deep belly: interior -​ inferior head of lateral pterygoid -​ Medial pterygoid -​digastric: feel under the chin for the pencil with muscle as your partner opens their mouth against gentle resistance ROM, MMT, end feels, and accessory motions ​ Motion -​ Available ROM in opening, closing, lateral deviation, protraction, retraction (normal, limited, excessive) -​ deviations from normal tracking  -​ locking, clicking during movement ​ Strength ( isometric) -​ opening, protrusion, lateral deviation ​ Accessory motion -​ caudal traction -​ Protrusion -​ lateral Glide Special tests -​ Notice in the image which joint is gapping and what is/ could be compressed when loading of one joint 1.​ loading of one joint/unilateral loading -​ Bite down on a tongue depressor just on one side (right), getting gapping on right side and compression on the left -​ If this alleviates pain, this tells us a distraction alleviates, It Might be a pathology with disc or inside joint -​ If he has pain with distraction on right, could indicate irritation of joint capsule or soft tissues around there as they get tensile loading 2.​ posterior loading of both joints/ bilateral loading -​ Patient bites down on a tongue depressor -​ Reproduction of pain in medial and central structures (masseter, pterygoid, ligaments) 3.​ distraction of joint -​ Stabilize the forehead and palpate TMJ, mobilizing hand is placed on the mandibular molars, applying a straight distraction force -​ Inferior glide -​ Looking for reproduction of pain, reduction of symptoms, reduction of anterior dislocation Conditions ​ TMJ referral to PT and epidemiology 1.​ Prevalence of referral to PT -​ survey to members of American Dental Association -​ PT referral among top 10 interventions -​ 10 to 17% of patients referred to PT 2.​ Classification of TMJ pathology -​ developmental abnormalities: hypo/hyperplasia, chondromas -​ Diseases: OA, RA, infections -​ macro trauma: fractures, dislocations of the TMJ -​ Dysfunction: -​ abnormal condition not resulting from developmental, disease, or trauma resulting in fracture/ dislocation -​ PT treats mostly dysfunction/ impairments ​ symptoms of TMD 1.​ Common complaints -​ pain in the immediate area of TMJ with mandibular movement during chewing, talking, yawning -​ pain in the muscle of mastication -​ referred pain around eyes, ears, zygomatic arch, Temple areas -​ Tinnitus -​ crepitus and clicking in TMJ 2.​ elicited complaints -​ Palpation -​ Mouth closed: lateral poles, behind lateral poles, along lateral ligament -​ mouth open: same as closed, also an external auditory meatus (retro discal tissue) -​ loading unilaterally -​ Unilateral loading applied by having patient bite down on gauze, cotton, etc placed on one side -​ get ipsilateral distraction and contralateral compression of TMJ with this technique -​ no pain means relief of compression -​ pain on ipsilateral side of gauze May mean capsule is irritated from tensile loads -​ loading bilaterally -​ bilateral loading may be done by biting down on one tongue depressor to load both joints -​ compresses Central and medial structures of the joint 3.​ other Associated impairments -​ Limited mouth opening -​ lateral deviations of the mandible during opening and closing -​ upper quarter postural deviations -​ limited cervical spine IV motions -​ swallowing abnormalities -​ Hyoid bone tenderness -​ anxiety and depression ​ types of dysfunctions 1.​ TMJ disc derangement: anterior displacement with reduction -​ Loud click during opening that indicates disc has relocated -​ during closing, subtle click indicates discounts displaced anteriorly -​ job position of opening click usually different than closing click -​ retro discal tissue is what pulls disc back -​ trick motion: S curve like, lateral movement May reduce disc after click -​ Case study -​ in this case, as the patient is opening their mouth, the meniscus translates to for anteriorly and it stretches the biloaminar zone. however the disc does not stay in that anterior position the whole time - at a certain point in the opening range of motion, the Redford the school tissue stretches enough to pull the disc back to its normal position between the mandibular condyle and the temporal bone. when that return to normal position occurs, the patient will often hear or feel a click or pop. during the reverse, when the mouth is closing, you will often hear a second click or pop as the disc flips over the mandibular condyle a second time 2.​ TMJ disc arrangement: anterior displacement without reduction -​ No clicking, get series of reproducible restrictions during movement of jaw -​ restrictions due to disc blocking translation -​ Example: R dislocation: -​ deviation to R on opening with less than 40 mm of ROM -​ deviation to R during protrusion -​ Decreased L lateral movements -​ may have passed history of trauma -​ may have had passed history of clicking, but no clicking now -​ Case study -​ because of this, the disc's position actually blocks further translation of the mandible, so people with an anterior displacement without reduction will often have limited opening range of motion -​ this is quite painful -​ the disc does not have nerves, so when the disc is between the mandible and the temporal bone you are fine -​ but when did this remains displaced anteriorly, the bilaminar tissue, which does have nerves and blood supply, gets pinched between the mandible and the temporal bone as you open your mouth 3.​ TMJ subluxation ( too much translation) -​ Excessive mandibular opening -​ palpate lateral poles to see if they move too far forward -​ may hear noise at beginning of closing or at end range of opening  -​ with unilateral subluxation, may see quick deviation to contralateral side at end of opening -​ typically, in the chart document, you write this as s- deviation when there is a motor control issue where the jaw is moving from side to side. it can occur with subluxation issues, but does not always occur with subluxation. the motor control issue is the person over correcting when there is pain or dysfunctional motion, and the person creates an S pattern with their jaw -​ translation occurs too soon during opening ( within first 11 mm of opening) -​ jutting of jaw forward during the onset of opening -​ places more strain -​ subluxations and early translations are related to muscle imbalances -​ may not immediately cause TMJ dysfunction but will over time -​ treatment will focus on neuromuscular re-education 4.​ TMJ capsular restrictions ( example: right TMJ) -​ Deviation to R with less than functional opening (