Head, Jaw & Cervical

TMD

Temporomandibular Dysfunction — “Client presents with jaw pain, clicking, clenching, and headaches.”

Safety first

Before applying any manual techniques to the jaw region, check for a history of jaw dislocation or significant TMJ instability. Clients with these histories require extra caution with opening movements and MET.

Intraoral work requires gloves and clear client consent — some clients will decline, and that must be respected.

TMD is one of the most common presentations involving the jaw. It affects approximately 5–12% of the population and is the second most common musculoskeletal condition after chronic low back pain (Schiffman et al., 2014). The temporomandibular joint (TMJ) is where the mandible articulates with the temporal bone — a complex joint involving both hinge and sliding movements, controlled by the muscles of mastication. When these muscles are hypertonic, restricted, or contain trigger points, the joint mechanics are affected.

Many clients also clench or grind their teeth, particularly during sleep or periods of stress, which perpetuates the cycle of muscle overload and joint irritation.

Clients may report some or all of the following:

Jaw pain, localised to the TMJ or spreading into the face
Clicking, popping, or grinding sounds with jaw movement
Limited opening or deviation of the jaw on opening
Headaches, often temporal — sometimes mistaken for migraines
Ear pain or fullness, often without ear pathology
Tooth pain, without a dental cause
Facial tension or fatigue

Not all symptoms will be present, and pain is not always the primary complaint — some clients present mainly with clicking, restricted movement, or referred symptoms.

Contributing factors Bruxism (teeth grinding or clenching) · Stress and anxiety · Postural dysfunction (forward head position shifts the mandible and increases jaw muscle tension) · Prolonged dental work or mouth opening · Trauma to the jaw or face · Chewing habits (gum, hard foods, unilateral chewing) · Breathing dysfunction (mouth breathing affects tongue and jaw posture)

Trigger point referral areas — muscles of mastication:

Temporalis	Temple, eyebrow, upper teeth, behind the eye
Masseter	Jaw, lower teeth, eyebrow, ear, cheek; deep layer may cause tinnitus
Medial Pterygoid	Jaw, tongue, hard palate, ear, TMJ area
Lateral Pterygoid	Cheek, TMJ, deep ear

Research shows TMD clients have significantly more active trigger points in masticatory muscles than healthy individuals, with larger referred pain areas (Fernández-de-las-Peñas et al., 2010).

Muscles involved

Temporalis Masseters Pterygoids

Subjective — case history:

Where is the pain? Localised or spreading?
When did it start? Was there a trigger — stress, dental work, trauma?
What aggravates it? Chewing, yawning, talking, clenching?
What relieves it? Rest, heat, massage, medication?
Do they clench or grind? During the day? At night? Do they wake with jaw pain or headaches?
Any clicking, popping, or locking?
Ear symptoms: pain, fullness, ringing (tinnitus)?
History of dental issues, orthodontics, or TMJ treatment?
Stress levels? Sleep quality?

Observation:

How does the client hold their jaw at rest? Mouth slightly open? Teeth clenched?
Visible asymmetry in the face or jaw?
Head and neck posture — forward head position is common in TMD
Do they favour one side when talking or at rest?

Range of motion — assess active jaw movements:

Opening	Normal ~40–50mm (three finger-widths). Note restriction, pain, or deviation. Deviation to one side on opening may indicate Lateral Pterygoid involvement or disc displacement.
Lateral excursion	Side-to-side. Normal ~10mm each direction. Pain or restriction may indicate Pterygoid involvement.
Protrusion	Jaw forward. Pain or restriction suggests Lateral Pterygoid involvement.

Passive ROM Gently guide the jaw through range without the client’s active effort. A soft, springy end feel suggests muscular restriction. A hard, abrupt stop suggests joint or capsular involvement. Not always necessary, but useful when active range is limited or the origin of restriction is unclear.

Special tests (if indicated):

Joint-loading test	Place fingers over the TMJ. Ask the client to clench. Pain suggests joint involvement.
Resisted opening	Ask the client to open against gentle resistance. Pain may indicate Lateral Pterygoid dysfunction.
Resisted closing	Ask the client to close against gentle resistance. Pain may indicate dysfunction of the elevator muscles (Temporalis, Masseter, Medial Pterygoid).

Palpation — palpate externally first:

Temporalis	Across the temporal fossa. Ask the client to clench to confirm location. Note tone, tenderness, trigger points.
Masseter	From the zygomatic arch to the angle of the mandible. Assess both superficial and deep layers. Ask client to clench to confirm. Note hypertrophy (common in bruxism), tenderness, trigger points.
Lateral Pterygoid	Just anterior to the TMJ in the soft tissue depression behind the zygomatic arch. Ask the client to open slightly or protrude the jaw. Direct palpation is difficult due to depth — tenderness with these movements suggests involvement.
Medial Pterygoid	At the inner (medial) angle of the mandible, just inside the inferior border. Use gentle pressure. Ask client to clench lightly to confirm. Significant tenderness or familiar pain reproduction suggests involvement.

Compare sides. Note asymmetry. Full assessment of the Medial Pterygoid requires intraoral access.

When to consider intraoral assessment Consider if: external treatment produces limited change · pain with opening, protrusion, or lateral deviation · deep diffuse pain around the TMJ or into the ear · clicking occurs early in opening.

Intraoral work requires gloves and clear client consent. Explain what you’re doing and why. Some clients will decline — respect this.

Choose techniques based on what you find. The clinical reasoning loop continues: feel, interpret, decide, apply, reassess.

Hypertonic, restricted tissue	FMT — passive first, then active if tolerated
Localised tender spots with referral	TPT — sustained pressure, don’t overwork
Muscle won’t relax, limited opening	MET — contract-relax to reset tone
Adhesions at tendon attachment	Frictions — use sparingly on jaw muscles

Full technique protocols, per muscle: see Temporalis, Masseters, Pterygoids.

Reassess after each intervention Has tone changed? Has tenderness reduced? Can the client open wider or more comfortably? Use this feedback to guide your next step — the loop continues throughout the session.

Cautions:

Jaw muscles can be extremely tender in chronic clenchers. Start lighter than you think necessary. Build trust before depth.
Parotid gland: located anterior to the ear, overlying the Masseter. Avoid direct pressure on this structure.
TMJ instability: if the client has a history of jaw dislocation or significant joint hypermobility, proceed cautiously with opening movements and MET.
Refer: if symptoms persist despite treatment, or if there is significant joint dysfunction (locking, severe clicking, pain with all movements), refer for dental or medical assessment.
Ear symptoms: if ear pain, fullness, or tinnitus is significant or persistent, consider referral to an ENT specialist to rule out other causes.

Evidence: Systematic reviews support manual therapy as an effective intervention for TMD — positive effects on pain intensity, maximum mouth opening, and disability, though effect sizes are often small to moderate (Armijo-Olivo et al., 2016; Asquini et al., 2022). Combining manual therapy with exercise produces the most consistent results.

Manual therapy is part of the solution, not the whole picture. Clients may also benefit from stress management, dental assessment, postural correction, and self-care strategies.

Jaw awareness and relaxation:

Resting position: Lips together, teeth slightly apart, tongue resting on the roof of the mouth. Many clients with TMD hold tension without realising it — bringing awareness to this position throughout the day can reduce habitual clenching.

“N” position: Say the letter “N” and hold. This naturally places the tongue in the correct resting position. Use as a cue throughout the day.

Controlled opening: Place the tip of the tongue on the roof of the mouth. Slowly open the mouth only as far as the tongue can maintain contact with the palate. This limits opening to a safe range and encourages controlled, centred movement. Repeat 10 times, 2–3 times per day.

Postural correction:

Chin tucks: Sit or stand tall. Gently draw the chin back without tilting the head up or down. Hold 5 seconds. Relax. Repeat 10 times. Reduces forward head posture, which contributes to TMD.

Heat application:

Moist heat over the Masseter and Temporalis for 10–15 minutes can help relax hypertonic muscles. Avoid if there is acute inflammation, recent trauma, infection, or skin irritation in the area.

Clinical connections

Posture	Forward head position changes mandible alignment and increases tension in the jaw elevators. Clients with TMD often present with tightness in the upper trapezius, levator scapulae, and SCM. See Scenario 3: Postural / Tension Pattern.
Headaches	TMD is a common contributor to tension-type headaches and can overlap with cervicogenic presentations. See Scenario 2: Headaches.
Stress	Clenching and grinding are often stress-related. This connects to breathing dysfunction, scalene involvement, and overall nervous system state.
Ear symptoms	Ear pain, fullness, or tinnitus can be referred from Masseter and Pterygoid trigger points. Always consider ENT referral if significant or persistent.

Headaches Postural / Tension Cervical Radiculopathy

Session 2 — Shoulder & Thoracic Spine

Posture and breathing connect TMD to the thoracic spine and ribcage — addressed in Session 2, which covers the upper trapezius, levator scapulae, and scalenes. This content is part of Session 2.