A collaboration between dentist Charles Crawford and physiotherapist Cathleen Lancelott-Redfern enabled boxer James Stanley to return to the ring after trauma caused severe myofascial pain.
Patient and boxer, James Roberts, arrived at Calm Dental Care and Physiotherapy’s jaw pain clinic in May 2014 suffering from severe jaw and facial pain that was radiating into his ear.
The patient presented having had a blow to the face whilst sparring during his boxing training. He was used to getting hit but this time was different. In the following days he developed a sharp pain behind his ear every time he clenched his teeth together. He was concerned that the injury may be serious enough to prevent him taking part in his fight the following week.
Charles carried out an examination of the articulatory system including the joints, the range of mandibular movements and the muscles of mastication. Some tenderness was discovered, particularly in masseter. Occlusion appeared to be unchanged. The fact that pain was caused on clenching indicated that an active (muscular structure) could be implicated. The lack of pain at rest made it less likely to be a fracture. There was also no tenderness to the body of the mandible. Charles asked Cathleen to come in to review the patient.
Charles had ruled out a number of potential sources of pain during the first part of the assessment, therefore Cathleen went on to assess the cervical spine as this can be a common site of referred pain into the orofacial region and whiplash type injuries are frequent with contact sports such as boxing. The cervical spine was clear and did not reproduce any symptoms. The upper cervical spine can also influence masseter activity that was suspected as the source of the pain and so assessment of the cervical spine is advantageous with jaw pain patients (Ballenberger et al, 2012).
The pattern of pain was consistent with a potential masseter trigger point and so it was felt that more in-depth masseter palpation was appropriate. A trigger point is a hyper-irritable band of taut muscle that on palpation reproduces local and referred pain (AAOP, 2008). A classic trigger point referral pattern for massester is pain into the ear. Cathleen reports to have found that the trigger point is not always obvious on initial palpation if the muscle is tense generally and it becomes more apparent after relaxing the muscle with heat or massage first. After five minutes of massage the trigger point was revealed. By pressing on the trigger point in the belly of the masseter muscle, the jaw and ear pain were reproduced indicating the likely cause of the pain.
Aware that the issue was myofascial pain caused by masseter, treatment options were soft tissue manipulation such as massage and trigger point release, heat treatment and stretching to promote muscle relaxation and acupuncture. Treatment began with applying heat to the area followed by soft tissue techniques including intraoral massage (see Figure 1) followed by gentle sustained ischaemic pressure on the trigger points. This worked very quickly to relieve a significant amount of pain. The patient was then instructed on some self management techniques in order to optimise recovery in the coming week. These techniques were: how to apply heat to the area, how to perform self-massage and trigger point release and how to stretch the affected area.
Figure 1: Treatment of the masseter muscle using a soft tissue release technique
Figure 2: Assessment of range of movement (in mm) of mouth opening using a sterile examination ruler
Figure 3: Masseter trigger points. The ‘X’ marks where the trigger point or knot can be palpated. The red shading is where the pain is typically experienced. This is particularly important for dentists as it can mimic tooth ache
Acupuncture can be highly effective for soft tissue tension and is often used successfully to treat TMD (temporomandibular joint dysfunction) problems. Cathleen opted to use soft tissue techniques due to the lower associated risks (although small) and side effects involved. Had the massage and trigger point release not been successful, she would have moved on to acupuncture as a second line of treatment.
Having arrived at the surgery with pain presenting a level seven out of 10, the patient reported that this had reduced to three out of 10 after 45 minutes of treatment. He reported that the area ‘felt looser’ and that he was reassured that the source of the pain was muscular and he would be able to participate in an upcoming fight just one week away. He went on to win.
The crucial element for this patient was knowing that it was safe to participate in his upcoming boxing match that was only one week away. Sharing knowledge and skills allowed us to provide detailed assessment and effective treatment. Rapid access to the service was also paramount in allowing this athlete to focus on training and not his injury.
The beauty of this collaboration is that Charles and Cathleen are able to discuss cases and treatment options immediately in-situ, perform joint assessments for complex cases and share knowledge to offer the patient a wider scope of treatment options without delay.
American Academy of Orofacial Pain (2008) Orofacial pain: Guidelines for Assessment, Diagnosis and Management. Ch 8. Ed Reny de Leeuw. Quintessence Books.
Ballenberger N, Von Piekartz H, Paris-Almany, A, La Touche R & Angulo-Diaz-Parreno S (2012) Influence on Different Upper Cervical Positions on Electromyography Activity of the Masticatory Muscles. Journal of Manipulative and Physiological Therapeutics. 35(4), p308-318.
For more information contact Calm Dental Care and Physiotherapy’s jaw pain clinic.