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Masticatory muscle disorders, such as myalgia, myospasm, and myositis, can cause significant discomfort and affect more than 40% of the population. To diagnose these disorders, clinicians use palpation techniques to assess muscle tenderness and pain. This involves sliding the overlying skin back and forth across the muscle to identify any taut bands and applying pressure to determine the level of tenderness. In this process, it is essential to introduce yourself to the patient, explain the examination's purpose, obtain consent, and maintain infectious control standards. This introduction will focus on the palpation techniques used to diagnose masticatory muscle disorders, ensuring patient comfort and understanding throughout the examination.
| Characteristics | Values |
|---|---|
| Masticatory muscle pain disorders | Similar to other skeletal muscle disorders; dull regional ache with the presence of trigger points when palpated which produces referred pain, that increases during the function |
| Masticatory myalgia | Characterized as a dull persistent ache overlying the jaw and temple muscles with occasional reference to other structures such as head, neck, ear, and teeth |
| Masticatory myospasm | Also known as muscle cramp; an acute condition resulting from a sudden, involuntary and continuous tonic contraction of the muscle |
| Myofascial contracture | Painless shortening of muscle as a result of fibrosis in and around the remaining contractile muscle tissue; follows an infectious process or trauma |
| Myositis | An inflammatory condition of the muscles caused by acute trauma or infection; characterized by swelling, redness overlying skin, and increased temperature over the affected area |
| Bruxism | Involuntary, aimless, repetitive, and stereotyped oral activity characterized by teeth clenching or grinding |
| Temporomandibular joint (TMJ) dysfunction | Can result from an imbalance of forces within the muscles of mastication |
| Taut bands | Palpate across the muscle with your fingers to identify any taut bands; apply firm pressure while asking the patient to report the tender point in the band |
| Relative tenderness assessment | Done using a standard anatomic location and a standard pressure level; ask the patient to rate the pressure as none, mild, moderate, or severe |
| Trigger point assessment | Palpate across the muscle with your fingers to identify any taut bands |
| Deep masseter muscle palpation | Point out the insertion and origin on a dry skull of the deep masseter |
| Superficial masseter muscle palpation | Point out the insertion and origin on a dry skull of the superficial masseter |
| Lateral pterygoid muscle functional exam | Point out the insertion and origin on a dry skull of the lateral pterygoid muscle anatomically; cannot be palpated but its function can be assessed by asking the patient to protrude the jaw |
| Medial pterygoid palpation | Point out the insertion and origin on a dry skull of the medial pterygoid muscle |
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What You'll Learn
Palpating the superficial masseter
To begin the palpation, locate the zygomatic arch and the muscle angled back towards the angle of the mandible. The superficial masseter is beneath the zygomatic arch. The palpation can be performed by pressing the muscle against the mandible with the patient's mouth open. This will help identify trigger points in the masseter muscle.
During the palpation, the examiner should use the padded aspect of the fingers or thumb, pressing them against the underlying tissue or bone. This involves sliding the overlying skin back and forth across the muscle to identify any taut bands. Once a band is found, move up and down the band, applying firm pressure while asking the patient to report the most tender point.
The medial pterygoid muscle, which is located opposite the masseter muscle, can also be palpated intraorally and extraorally. The origin of the medial pterygoid is on the inner surface of the pterygoid plate behind the maxilla, and its insertion is at the angle of the mandible. The lateral pterygoid muscle, on the other hand, cannot be palpated, but its function can be assessed by asking the patient to protrude the jaw.
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Palpating the deep masseter
The deep masseter muscle is located anterior and inferior to the lateral condyle pole, posterior to the posterior edge of the superficial masseter, and beneath the zygomatic arch. To palpate the deep masseter, begin by pointing out the insertion and origin on a dry skull. Then, use the index finger and thumb to feel the muscle's insertion. The masseter is located on the outside of the angle of the jaw.
When palpating the deep masseter, it is important to use the correct pressure and technique. Apply 2 kg of pressure with one finger for 2 seconds and ask the patient to rate the pressure as none, mild, moderate, or severe. The palpation technique involves sliding the overlying skin back and forth across the muscle to identify any taut bands. Once a taut band is located, move up and down the band, applying firm pressure, and ask the patient to report the tender point.
The presence of trigger points and taut bands in the deep masseter muscle can indicate masticatory myofascial pain. This condition is characterized by a dull, regional ache with trigger points that produce referred pain and increase during function. Palpation of the deep masseter can help identify and diagnose masticatory muscle disorders, such as myofascial pain, myalgia, myospasm, and other conditions affecting the jaw and masticatory muscles.
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Palpating the medial pterygoid
For the intraoral approach, the medial pterygoid muscle can be palpated at the inner aspect of the mandibular ramus with the patient's mouth open. The needle should be inserted at the medial aspect of the mandibular ramus and angled posteriorly and superiorly, approximately 20 degrees to the occlusal plane. EMG activity should confirm the correct insertion area during the mouth closing. This approach allows for the palpation of both the masseter and medial pterygoid muscle insertions.
The extraoral or mandibular approach involves pointing the needle from below and inserting it about 0.5-1 cm anterior to the angle of the mandible along the interior aspect of the mandible. The needle should be angled perpendicularly to the mandible until its position is verified by EMG with the patient clenching their teeth. This approach targets the medial pterygoid muscle specifically.
When palpating the medial pterygoid muscle, it is important to assess for muscle texture, tenderness, and myofascial trigger points. Tenderness in the facial muscles is a common finding in head and neck musculoskeletal disorders. Palpation should be performed at rest, during muscle contraction, and when the muscle is on a stretch to comprehensively assess its condition.
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Palpating the temporalis muscle
To begin the palpation of the anterior temporalis muscle, it is essential to locate its insertion and origin on a dry skull. The anterior temporalis muscle is best palpated at the hairline, directly opposite the eyebrow. During the procedure, the patient should be instructed to open their mouth to access the temporalis muscle tendon, which sits just beneath the zygomatic process.
The palpation technique involves using the padded aspect of the fingers or thumb. Apply pressure at a right angle across the muscle fibres, pressing them against the underlying tissue or bone. Move your fingers back and forth, similar to plucking a guitar string while maintaining contact with the surface. This technique helps elicit a local twitch response and is most effective near the trigger point with the muscle at a neutral length or slightly lengthened.
During the palpation, assess the relative tenderness of the muscle by asking the patient to rate the pressure as none, mild, moderate, or severe. This assessment provides valuable information about the presence and intensity of any pain associated with the temporalis muscle.
Additionally, the posterior temporalis muscle can be palpated by locating its insertion and origin on a dry skull. This site is just above the ear, with a posterior direction from the coronoid process.
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Relative tenderness assessment
The standard anatomical location will differ for each muscle. For example, the temporalis muscle tendon is at the coronoid process, just beneath the zygomatic process, and is accessed by having the mouth open. The medial pterygoid muscle's origin is located on the inner surface of the pterygoid plate, behind the maxilla.
The purpose of palpation is to elicit a local twitch response and is most effective when done near or on the trigger point with the muscle at a neutral length or slightly lengthened. Taut bands will be evident if they are present, and once found, the band needs to be compressed to see if the pain radiates or refers.
Masticatory muscle pain disorders are similar to other skeletal muscle disorders. They are characterized by a dull regional ache with the presence of trigger points when palpated, which produces referred pain that increases during the function.
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Frequently asked questions
Palpation is a technique used to assess muscle tenderness and pain.
Masticatory muscles, or muscles of mastication, are involved in mandibular movements and can be a source of pain and pulsating sensation in the masticatory apparatus. Palpation of these muscles can help identify any dysfunction or disorder, such as temporomandibular disorders (TMD), myositis, myofascial taut bands, trigger points, hypertrophy, or spasms.
The superficial masseter muscle is located beneath the zygomatic arch, and the muscle is angled back towards the angle of the mandible. To palpate this muscle, apply firm pressure and ask the patient to report the level of tenderness on a scale from none to severe.
If a patient presents with symptoms such as jaw pain, restricted jaw opening, fatigue, stiffness, or tooth wear, palpation of the masticatory muscles may be indicated to assess for potential disorders or dysfunctions.
