Patient History
Jane Doe presents for evaluation of chronic left-sided periorbital headache. A complete review of her history reveals that she has also had left-sided upper molar pain and right ear aching/fullness for which she has multiple evaluations. Over the years, dental, primary care, and ENT specialists have evaluated the tooth and ear symptoms and ruled out dental, sinus, and ear disease. She gets some relief with application of a hot towel on her face at night. She’s tried muscle relaxers and NSAIDs to transient benefit. At this point she is frustrated, confused, and hopeless about her continued orofacial pain.

Case Description
Physical examination revealed restricted intersegmental motion at the upper cervical spine, suboccipital muscle tenderness, masseter muscle tenderness, and restricted mouth opening range of motion. Further evaluation of masticatory function revealed overactivity of the lateral pterygoids, as demonstrated by early jaw protrusion upon mouth opening, resulting in probable derangement of the temporomandibular discs and an audible click. Yet, the TMJs did not demonstrate findings consistent with significant articular derangement or capsulitis. Pressure at the masseter, temporalis, and suboccipital muscles reproduces the symptoms of ear, tooth, and frontal head pain, respectively.

Treatment Plan
We began a two month course of manual therapy and rehabilitative exercise to improve temporomandibular and craniocervical motion and stability patterns. She demonstrated excellent performance of exercises to improve suprahyoid and deep cervical flexor muscle activity during mouth opening. She was given a home exercise program and self-care techniques to maintain improved masticatory function.

Outcome
At three month follow-up, she maintained resolution of orofacial pain. She was no longer limited by her pain and felt empowered by her important role in correcting this major problem.

Discussion
This case describes the rehabilitative management of temporomandibular joint dysfunction. As with many other types of functional, musculoskeletal pain, the etiology and perpetuating factors are varied. TMD may be a constellation of capsulitis, myofascial pain syndrome, psychosocial confounders, and functional alteration extending beyond the masticatory system. Masticatory, respiratory, and spinal stability mechanics are fully integrated, and functional impairments may be found across any of these systems. Our philosophy of rehabilitation is that provider and patient work together to remediate the functional movement impairment found to be overloading the pain generator.

In this case, the pain generator was found to be the myofascial trigger points, chronically perpetuated by faulty biomechanical stability systems. Careful examination to identify both the pain generator and key perpetuating factors is necessary successful rehabilitative management of temporomandibular joint dysfunction.