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17 Articles in Volume 19, Issue #7
Analgesics of the Future: Inside the Potential of 3 Drug Delivery Systems
Balancing Pain Care - and Opioids - in the Aging Adult
Book Review: A Useful Guide for New Pain Practitioners
Correspondence: Opioid Tapering & Discontinuation
Effective Interventions for Post-Stroke Shoulder Subluxation and Pain
Family: Their Role and Impact on Pain Management
Introducing the "Phoenix Sign:" Improved Vascular Perfusion of the Dorsalis Pedis Artery after a Subanesthetic Dose of Lidocaine
Medication Management of Chronic Pain in Patients with Comorbid Cardiovascular Disease
Multisite Pain May Be Associated with Fractures in the Elderly
Reconciling the New HHS Opioid Tapering Guideline with CDC and State Policies
Research Insights: Impaired Motor Imagery in Chronic Pain Conditions
Tapentadol: A Real-World Look at Misuse, Abuse, and Diversion
Temporomandibular Disorders in Performance Artists (Part 2)
Thoracic Outlet Syndrome Presenting as an Acute Stroke Mimic
Untangling Chronic Pain and Hyperarousal with Heart Rate Variability: A Case Report
What topicals exist for post-herpetic neuralgia pain?
When to Keep Your License: Older Physicians and Boundary Issues

Temporomandibular Disorders in Performance Artists (Part 2)

How to apply an osteopathic approach to assessing and treating orofacial pain in instrumentalists.
Pages 60-64

This is the second part of a series focusing on performing arts medicine for the instrumentalist. Part 1 reviewed1 the history of and treatment approaches for managing the unique musculoskeletal problems experienced by musicians.

Most musicians have encountered or will encounter pain or discomfort while playing their instruments. These problems may arise from musculoskeletal pain caused by holding an instrument, dermatological issues from skin contact, neurological dysfunction from overuse or repetition, and respiratory difficulties from infection or asthma.

Instrument-specific problems may also develop. Woodwind and brass instruments have an increased incidence of orofacial pain and other head and neck problems due to the physical demands and biomechanics of performance. While the positioning of each instrument’s mouthpiece differs, several disorders are commonly found in wind instrumentalists and are either directly or indirectly caused from playing the instrument. These include temporomandibular disorders (TMDs), as well as herpes simplex virus of the mouth; orthodontic problems; problems with the perioral musculature; embouchure dystonia; asthma and breathing problems; and high-pressure induced subconjunctival hemorrhage.2

Prevention of performance-affecting medical problems is the first and most crucial step to the care of the instrumentalist, as discussed in Part 1. This paper will focus on the osteopathic management of TMDs in instrumentalists.

Epidemiology, Prevention, and History

Woodwind and brass instrumentalists must position their lips, facial muscles, teeth, tongue, and jaw in such a way that is conducive to the creation of sound, known as setting the embouchure. As setting an embouchure involves potential strain of several facial structures, problems associated with playing can be especially detrimental to professional musicians, which can lead to emotional and psychological distress, impeding the physical rehabilitation and healing process.3

Several studies have shown that upwards of 70% of musicians suffer performance-related injuries at some point in their career.4-11 Therefore, a comprehensive treatment approach should consider all possible causes of injury and utilize a multidisciplinary team. For example, musicians dealing with orofacial problems have often sought help from professional music instructors who have been found to be valuable in the rehabilitation process.12 Most performing artists do not realize that playing through the pain can lead to an exacerbation of their problem, and recommending rest at the first recognition of a problem is crucial.

TMDs in Woodwind/Brass Instrumentalists

TMDs is a collective term that includes a number of clinical complaints involving the muscles of mastication, the temporomandibular joint (TMJ), or associated orofacial structures.13 They are considered a subclassification of musculoskeletal disorders,14 and typically run a recurrent or chronic course, with substantial fluctuation of signs and symptoms over time.15,16 Studies have shown that playing a musical instrument (eg, woodwind or brass) may cause a repetitive overuse injury on the muscles of mastication, as well as the orofacial skeletal system. This injury may cause or worsen a TMD, or cause other orofacial pain syndromes. Some researchers have suggested that professionally playing certain musical instruments (eg, trumpet, trombone, French horn, tuba) contributes to TMD.17

Playing a wind (or brass) instrument, in particular, is a complex neuromuscular task, requiring increased respiration and orofacial muscle activity.18,19 Specific techniques involve upward and backward movement of the mandible, which may directly impact the TMJ and compress it, contributing to the development of a TMD.20 In one study of Lebanese musicians, TMD was found in 23% of 360 woodwind instrumentalists.21

Temporomandibular palpation and motion testing may provide the physician with a particular diagnosis. For instance, by placing their first and second fingertips at the TMJs, just anterior to the lower earlobes, a clinician can palpate for tenderness and asymmetry. The patient should then slowly open their mouth as far as possible. The mandible should open symmetrically and without crepitus (grating) in the joints.

Any deviations of the mandible to one side during opening may indicate TMJ restriction on the same side. This restriction may involve somatic dysfunctions of the medial and lateral pterygoid muscles, masseter, cervical muscles such as the sternocleidomastoid, or sphenomandibular ligament. Intraoral palpation assists in further identifying which of these soft tissues is restricted or tight. After appropriate diagnosis, osteopathic manipulation treatment (OMT) can be performed to treat the soft tissue restriction.22

Osteopathic Manipulations

A variety of options are available for musicians seeking treatment for TMD (see Table I). Traditional approaches may include physical or occupational therapy, medications such as diclofenac gel for localized inflammation, injections, and surgery. However, these modalities are sometimes insufficient to restore patients back to health due to the consistently high demands of their performance. The use of osteopathic manipulation treatment (OMT) offers a non-invasive treatment option that may be considered for TMD as well as other musculoskeletal and fascial dysfunctions.

TMJ Muscle Energy

Once a patient is diagnosed with a restriction of the TMJ secondary to soft tissue or muscle restriction, muscle energy may be performed based on the side of restriction. Here, the patient lies supine and the physician sits at the head of the table. If the patient has a left mandibular deviation, or left restricted TMJ, the physician’s right hand supports the right side of the patient’s head and cups the chin. The left hand supports the left side of the head over the parietal bone.

The patient is then instructed to slowly open their mouth and stop when the physician palpates or observes left mandibular deviation. The clinician then applies a gentle force along the patient’s mandible, pushing it slightly toward the right into a restrictive barrier of increased tissue tension (see Figure 1). The patient is then instructed to push their jaw to the left while the physician provides an isometric counterforce to the right (see Figure 2). This isometric contraction is maintained for 3 to 5 seconds until the physician instructs the patient to stop and relax. The physician then gently repositions the patient’s mandible to the new restrictive barrier, and the isometric contraction-relaxation steps are repeated 3 to 5 times. The patient’s mandible is then returned to the neutral position and is reevaluated by the physician for symmetry of TMJ motion.

Figure 1. Initial muscle energy setup for TMJ restriction, physician-applied force designated by red arrow.

Figure 2. Patient-applied isometric contraction (green arrow) using muscle energy for TMJ.

Figure 3. TMJ compression using myofascial release.

Figure 4. TMJ decompression using myofascial release.

Figure 5. Masseter tender point location.

Figure 6. Masseter tender point counterstrain treatment.

Figure 7. Lateral pterygoid tender point location.

Figure 8. Lateral and medial pterygoid tender point counterstrain treatment.

Figure 9. Medial pterygoid tender point location.


Direct Myofascial Release

Another technique of note is myofascial compression/ decompression of the TMJ. This approach is indicated in TMJ restriction related to pain, mandible restriction, neck pain, and other problems. The technique consists of the physician gently pushing and holding the mandible superiorly toward the TMJs until a slight give is equal on both sides, compressing the joints and relaxing the tight tissue (see Figure 3). This compression is then followed up by pulling and holding the mandible inferiorly away from the TMJ until a slight give is equal on both sides, decompressing the joints and stretching the tight tissue (see Figure 4). The physician’s treatment force is applied over a minute or two to allow for the relaxation of tight tissue, followed by gentle and slow creep of the restricted tissue. Mobility can be retested to note any improvement in restrictions.

If mobility improves, the physician may consider prescribing TMJ self-mobilization.22 TMJ self-mobilization may be performed by the patient 2 to 4 times a day. Here, the patient places the back of their knuckle using one or two fingers inside the mouth between the upper and lower teeth. The patient then gently bites down into the fingers for 5 to 15 seconds, repeating 2 to 3 times as needed.22


Counterstrain is an indirect method of manipulative treatment in which muscle tenderness or hypertonicity is treated by positioning the muscle away from the restrictive barrier into a direction of ease for at least 90 seconds to reset muscle spindle activity and reduce gamma motor neuron activity before slowly returning to the neutral position. Effectiveness is based on the significant reduction of tender point pain rated on a scale of 1 to 10.

The masseter muscle tender point is located on the anterior border of the masseter muscle and over the anterior edge of the ascending ramus of the mandible pushing posteriorly (see Figure 5). The counterstrain treatment position shortens the masseter by cupping and pushing the patient’s jaw toward the side of the tender point until pain is reduced maximally (see Figure 6). After holding the position for 90 seconds, the physician slowly returns the patient’s jaw to the neutral position and reassesses the tender point.

The lateral pterygoid muscle tender point is located over the coronoid process of the mandible and inferior to the zygomatic arch (see Figure 7). The counterstrain treatment shortens the muscle by cupping the patient’s chin and pulling the open jaw laterally to the side opposite the tender point while stabilizing the patient’s head (see Figure 8). The physician holds the patient in this position for 90 seconds, while gently monitoring the tender point, and then slowly returns the patient to the neutral position. Effectiveness is based on the rating of pain after treatment.

Lastly, the medial pterygoid muscle is located on the medial surface of the ascending ramus of the mandible, just superior to the mandibular angle (see Figure 9). The medial pterygoid is treated similarly to the lateral pterygoid by pulling the open jaw laterally to the side opposite the tender point.


An understanding of the physical demands of performance, instrument-specific injuries, and physical examination findings is crucial to providing a comprehensive treatment plan for patients presenting with temporomandibular disorders. A complete evaluation involves spending adequate time with the performing artist to obtain the patient’s history, with a focus on the performer’s lifestyle, practice habits, exercise routine, nutrition, stress level, and associated medical problems. Physicians should consider a multidisciplined approach that utilizes multiple modalities (see Table I). Since an injury to a performing artist can be physically, emotionally, and financially devastating, these patients require a treatment plan designed to meet their unique needs. In soft tissue and muscle- related problems of the TMJ, osteopathic manipulation using such techniques as listed above can provide relief by decreasing tissue restrictions and restoring motion.


All figures are courtesy of the author David Shoup.

Last updated on: December 9, 2019
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