What is Torticollis – Congenital and Acquired

Common conditions, Health, Injury, Pain

MAIN WRY NECK

What is Torticollis?

Torticollis is derived from the Latin word tortus, meaning “twisted” and collum, meaning “neck”.  It is an abnormality, where the muscles in the neck that control the position of the head are affected causing the head to tilt and/or rotate to one side or be pulled forward or backward. This condition is also known as “Wry neck” or “Cervical dystonia”.

What happens in torticollis?

Acute injury to the soft tissue structures of the neck is the most common presentation that causes inflammation, spasm and shortening of the muscles of the neck. Characteristic head tilt with the ear moved toward the shoulder happens from an increased tone in the neck muscles. 

Most commonly, the trauma is to one of the neck muscles called sternocleidomastoid (SCM). This muscle is present in front of the neck on each side and runs diagonally from the collar (clavicle) and breastbone to the mastoid process and the base of the skull bone as shown in Fig 1.

sternocleidomastoid FRONT VIEW

In torticollis, there is shortening or excessive contraction of the SCM on one side of the neck. The head is typically tilted sideways towards the affected SCM and rotated with the chin facing to the opposite side as shown in Fig 2. 

CT

Pathophysiology of torticollis

As shown in Fig 2, Torticollis can be of two types.

  • Congenital
  • Acquired

Congenital Torticollis

“Congenital” means a physical abnormality present from birth. Congenital torticollis is an abnormal positioning of the neck caused due to the damage of the nerves or the blood supply of the neck. This occurs due to various reasons such as, 

  • Intrauterine (inside uterus) malposition of the baby 
  • Trauma while undergoing breech or difficult forceps delivery, fracture to the collar bone (clavicle) of the child during birth. 
  • Genetic birth defects: For example, webbing of the neck deformity seen in various syndromes, including Turner’s, Klippel-Feil, or Escobar-Syndrome. Brachial cleft cysts, vertebral bone problems, odontoid hyperplasia, spina bifida, hypertrophy or absence of neck muscles, and Arnold-Chiari syndrome.

Acquired Torticollis

This condition clinically presents because of other problems that affect the musculoskeletal structures of the neck. It typically occurs in the first 4 to 6 months of childhood or later affecting both children and adults. 

Reasons for Acquired Torticollis

  • Idiopathic or Unknown cause: Also classified as “Dystonia” which is a disorder characterized by involuntary muscle contractions that cause slow repetitive movements or abnormal postures. It is unclear but believed to occur due to lesions in an area of the brain (thalamic lesion). 
  • Postural problem: The problem with neck muscles can arise from a prolonged incorrect posture of the neck. It may appear overnight when, for example, a person has slept with his/her neck in an awkward position. Other activities like holding the telephone between the head and shoulder, or playing an instrument, such as the violin, for long periods.
  • Vision problem: Problem with vision in one eye can cause the individual to tilt his or her head to see better affecting the neck muscles on one side.
  • Trauma: Sudden accidental bend or twisting of the neck too far. Whiplash injury of the neck.
  • Infection: Inflection of upper respiratory, ear, or sinus lead to inflammation of the cervical lymph nodes that can irritate the nerves supplying the neck muscles causing torticollis. It can also damage the soft tissues and cause improper alignment of the neck bones.
  • Arthritis of the neck joints: Inflammatory joint conditions like cervical spondylitis, intervertebral disc problems of the neck can also cause torticollis.
  • Side effects of certain medications: Inflammation caused by many antipsychotic and antiemetic medications can cause Spasm or dystonia of the neck muscles.  
  • Neurogenic abnormalities: Spinal cord tumor or progressive spinal cord diseases can cause problems in the neck region. 

Signs and Symptoms of Torticollis

  • Inability to move the neck with limited range of motion
  • Chin tilted to one side
  • Headaches
  • Head tremor
  • Neck muscle spasm and pain
  • One shoulder is higher than the other
  • Spasms in other areas of their head such as their eyelids, face, or jaw, as well as in their hands
  • Stiffness of the neck muscles
  • Swelling of the neck muscles (possibly present at birth)
  • Other neurological signs: Difficulty in speaking, drooling, respiratory problems, swallowing difficulty (trouble initiating), tingling sensation in the neck, upper back and arm due to nerve problems, depression, self-consciousness.

When to seek medical care?

Congenital torticollis can be easily identified after childbirth and determine  the severity of the condition related to its neurological involvement. If a child or an adult suffers from neck problems, it is best advised to seek treatment immediately to prevent worsening of the pain and to prevent the development of torticollis.  

How is torticollis diagnosed?

A thorough assessment of the condition related to the history of the individual will be taken. Any injuries to the neck can be detected by certain diagnostic tests like an X-ray, computed tomography (CT) scans, and magnetic resonance imaging (MRI).  However, it’s unlikely that the exact cause of the muscle spasm can be isolated.

In children and infants, experts can detect neck muscle damage that may cause torticollis through routine physical examination. Newborns will be assessed for the presence of neck and/or facial or cranial asymmetry within the first 2 days of birth through visual observations.

How can torticollis be treated?

Treatment should begin immediately for infants with torticollis. At this stage, it is most successful in reversing the deformities caused by torticollis. For example, as the child grows with torticollis, the face on the tilted side may become flattened. This flattening can be reversed while the bones are young and soft but after one year of age it is most likely that the bones get fused and the deformity may become permanent. 

Other problems with delayed treatment 

  • Difficulty learning to walk and frequent falls seen because the head tilt causes unequal weight bearing and loss of balance.
  • Open mouth posture with the tongue pulled to one side or the other.
  • Suck/swallow may be affected leading to feeding issues.
  • A permanent trunk and facial asymmetry can occur.

 Chances of torticollis relapse

Most cases of muscular torticollis have good outcomes, however, there is a chance of relapse with both non-surgical and surgical treatments. Sometimes even if the recovery is spontaneous with continued treatment, there may still be a possible head tilt of small degree.

The outcome will also differ depending on the severity of the injury to the soft tissue and joint structures of the neck.

General goals for treatment,

  • Reducing pain, spasm and muscle strains of the neck.
  • Improving mobility and flexibility of the soft tissue structures affected.
  • Reducing stiffness in the neck and mobilizing the joints of the neck.
  • Postural correction and awareness by changing or selecting positions that will be beneficial for the neck.
  • Functional exercises to the neck muscles to restore stability, strength, and mobility of the neck.
  • Reassurance and education to prevent emotional stress, providing support to cope with social embarrassment.

There is no sure way to prevent wryneck and congenital torticollis; however, utmost care should be taken to avoid trauma to the child as much as possible during delivery. 

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Common Injuries of the Achilles Tendon

Ankle, Common conditions, Exercise, Foot, Injury, Lifestyle, Pain

Achilles tendon injury

The thickest and the strongest tendon in our body is the tendon of the calf muscles of the leg also known as the “Achilles tendon”. 

achilles Tendon main

Fig 1: Calf muscles and Achilles tendon

As shown in Fig 1, the calf muscles of the leg include the gastrocnemius and the soleus muscles that tapers and merges with a tough connective tissue of the Achilles’ tendon. The Achilles tendon then inserts into the heel bone (calcaneus).  Functions of the Achilles Tendon

  • Downward Movement of the foot: When the calf muscles contracts and pulls the Achilles tendon it causes the foot to push downward. This contraction enables: gait, standing on the toes, running, and jumping.
  • Bending the knee: The gastrocnemius muscle helps in bending the knee (flexion) during walking and running.
  • Transferring body weight: With each step of walking each of the Achilles tendon help to distribute the person’s body weight. Depending upon the speed, stride, terrain and additional weight being carried or pushed, each Achilles tendon may be subjected to approximately 3-12 times a person’s body weight.
  • Ankle stability: Along with the other muscles of the leg the Achilles tendon contributes to the stability of the ankle joint.

What surrounds the Achilles tendon? The Achilles tendon is protected by the Achilles tendon sheath and bursae. The sheath is the covering of the tendon that protects the tendon from friction and allows smooth movements. Similarly, the bursae around the Achilles is a thin fluid-filled sac that help to reduce friction between tendon and other tissue areas of the heel.

achilles Bursas

Fig 2: Bursae around the Achilles tendon

As shown in Fig 2, there are two bursae present at the heel. One of the bursae is present in between the surface of the tendon and the surface of the calcaneus at the distal attachment of the Achilles tendon. It is called the “retrocalcaneal bursa”. The other bursa is present between the calcaneum and the skin and is called as the “subcutaneous calcaneal bursa”. 

Brief History on Achilles tendon injuries

Because of the Greek Achilles legend, the Achilles heel is known as a vulnerable part for injury. Hippocrates described that “this tendon if bruised or cut causes the most acute fevers, induces choking, deranges the mind and at length brings death”. It was first reported that a ruptured tendon was to be wrapped with bandages dipped in wine and spices. Since then the cause and treatment of Achilles tendon injuries have brought growing interests among many researchers. 

What causes an Achilles tendon injury?

  • Overuse injuries

This is mostly sports related and is due to overuse of the calf muscles causing an injury to the Achilles tendon. Overdoing or rapid action of the calf muscles or resuming too quickly after a layoff can stress the Achilles tendon. For example, while running or walking faster, up and down on steeper hills or stairs  more powerful movements such as lunges, jumps, or push off.

  • Misalignment and muscle imbalances

Short or tight Achilles tendons or calf muscles, unequal leg length, over or under arched foot, disproportionally weak calf muscles.

  • Improper Footwear 
  • Side effects of certain medications  

Medications (Quinolone / Fluoroquinolone and Cortisone) can weaken the Achilles tendon and this may lead to an injury. Cortisone shots in or near the Achilles tendon may reduce pain in the Achilles tendon, but the weakness in the tendons persists which can an injury during activities.

  • Accidental trauma
  • Inflammatory conditions

Achilles injury may occur in relation to inflammatory illnesses, such as ankylosing spondylitis, reactive arthritis, gout or rheumatoid arthritis.

  • Genetic 

Individuals with a genetic predisposition like hypermobile people are reported to be more at risk of developing Achilles tendon problems. This is because they have excessive laxity in  ankle joints that lead to the wear and tear of the Achilles tendon. 

Achilles tendon injuries

achilles tendon injury locations

Fig 3. Locations of injury

As shown in Fig 3, different types of Injuries to the tendon can occur along different locations of the tendon. 

Musculotendinous junction: This explains the junction between the calf muscle and the Achilles tendon.

Mid portion of the tendon: This explains an injury midway between the top and bottom of the Achilles tendon.

Insertional Achilles tendon injury is an injury at the bottom of the Achilles tendon, where the Achilles tendon connects with (inserts into) the heel bone.

Non-insertional Achilles tendon injury means an injury to any part of the Achilles tendon except at the Achilles tendon – heel bone connection.

Types of Achilles injuries

The spectrum of Achilles injuries ranges from an acute inflammatory irritation to severe cases of rupture of the tendon as shown in Fig 4. The types of condition may co-exist depending on the severity of the injury.

Achilles Tendon course of injury

Fig 4: Types of Achilles Tendon Injuries

Tendonitis and tenosynovitis

Achilles tendonitis is an acute inflammation of the Achilles tendon as shown in Fig 5. Tenosynovitis is an inflammatory condition of the Achilles tendon sheath, rather than an inflammation in the Achilles tendon itself.

Tendonitis insertion

Fig 5: Achilles Tendonitis

Achilles Tendinosis (Tendinopathy): This is the degeneration and micro tears of the Achilles tendon that occurs over time due to overuse of an already inflamed and weak tendon (Refer Fig 6).

Both Achilles tendonitis and tenosynovitis can occur in parallel with, or lead to Achilles tendinosis.

Print

Fig 6: Tendinosis of Achilles tendon

Tendon Ruptures (Partial or complete tendon tear) Achilles tendon rupture is often described as an abrupt break with instantaneous pain that is felt in the foot or heel area. It occurs rapidly while performing activity like running or standing on the toes, which generates intense force on the tendon, leading to partial or complete rupture as shown in Fig 7.

Rupture complete

Fig 7: Complete and partial tear of the Achilles tendon

What can happen if you have an Achilles tendon injury?

  • Pain and tenderness along the Achilles tendon and at the back of the heel that worsens with activity.
  • Thickening of the tendon
  • Bone spur formation at the insert of the tendon
  • Bruising and Swelling around the tendon area.
  • Fibrosis and scarring may be seen in Achilles Tenosynovitis and tendinosis.
  • Restriction of Achilles tendon’s motion within the Achilles tendon sheath.
  • Bursitis: Inflammation of the bursas around the Achilles tendons.
  • Snapping or popping noise can indicate a tendon rupture.
  • Difficulty in moving the foot or pointing your toes (in complete tears of the tendon)
  • A limp may be seen on weight bearing immediately after an Achilles tendon rupture
  • Ankle instability
  • Nerve or blood vessel damage: Signs include numbness, tingling, pins-and-needles sensation in your foot and bruised skin.

How is an Achilles tendon injury diagnosed? An initial examination of the ankle can help differentiate a tendon rupture from other types of injury. When an Achilles tendon rupture occurs, it will not be possible for the individual to stand on toes as shown in Fig 8.

achilles tendon rupture and normal

Fig 8: Achilles tendon rupture of the Left heel

 An MRI or X-ray investigation can also be taken to further confirm the severity of the injury and differentiate the type of injury to the tendon. For example, an MRI scan of a ruptured Achilles tendon is shown in Fig 9.

Complete tear MRI

Fig 9: Achilles tendon rupture

When to seek expert care?

If you felt a sharp pain like a direct hit to the Achilles tendon or if you heard a distinct snap at your Achilles tendon, it calls for a medical emergency. If you have just begun with pain in the back of heels with swelling or discomfort in the Achilles tendon, it would be wise to seek expert assessment and treatment care. What may seem like a mild inflammation may lead to degeneration and rupture. Thus, an initial treatment for tendonitis will not only reduce problems of the tendon but will restore its strength and function which is important to prevent worsening and recurrence of the condition.  

Ankle Injuries – Sprain, Strains and Fractures

Common conditions, Exercise, Injury, Lifestyle, Pain

Ankle sprain main

An ankle injury is the most common type of injury that may involve the bones of the ankle and other soft tissue structures. Three are three types of injuries that are observed at the ankle:

  • Sprains
  • Strains
  • Fractures

Sprains are injuries to the ligaments that connect one bone to another. An ankle sprain may involve an injury to one or more ligaments that stabilize the ankle and the foot. 

Strains are injuries that involve musculotendinous (muscle and tendon) structures. Both sprains and strains can occur due to over-stretching or tearing of the ligaments and tendons due to sudden twisting of the ankle joint or when excessive forces are applied on them.

Fractures are injuries that involve bones of the ankle joint. It ranges from a simple break in one bone to several fractures, which causes your ankle to move out of place and puts you in great pain.

Who could be at a risk of an ankle injury?

Ankle injuries may occur among,

  • Dancers
  • Sports persons- Gymnasts, basketball players, players participating in jumping sports etc.
  • Women wearing unstable high heels
  • Hypermobile people who already have laxed ankle ligaments 

Types of Ankle injuries

  • Lateral ankle injury

This is the most common injury to the ankle. Often, an inversion sprain could be an associated with a fracture and a strain to the peroneal tendons.  

An inversion sprain happens when the ankle in twisted inwards with an inward rolled foot as shown in Fig 1.

inversion injury

Fig 1: Lateral ankle injury

  • The Medial ankle injury

This type of injury occurs at the inner aspect of the ankle. Like a inversion sprain, the eversion sprain may also be associated with fractures of lower ends of the leg bones and strains to the tibialis anterior muscle.  

Eversion sprain happens when the ankle is twisted out with the foot rolled outwards as shown in Fig 2.

eversion injury

Fig 2: Medial ankle injury

High Ankle Injury

This type of injury is very rare. A high ankle sprain happens when the tibia bone rotates injuring the ligaments that hold the lower end of the two leg bones (tibia and fibula) as shown in Fig 3.

Severe injuries may cause fracture to the lower ends of the leg bones.

syndesmosis injury

Fig 3: High ankle injury

Severity of an ankle sprain 

An ankle ligament sprain can be graded according to the severity of the tear in the ligaments as shown in Fig 4.
 
lateral ankle sprain

Fig 4: Grades of ankle sprain

Sign and Symptoms of Ankle Injury
 
    • Swelling: Increased fluid in the tissue due to inflammation and soft tissue damage.
    • Pain:  Depending upon the severity of the injury and the structures involved, pain intensity can vary. 
    • Redness/ Warmth/ Tenderness: Caused by increased blood flow to the area.
    • Unstable ankle: The affected side feels weak and difficult to weight-bear.
    • Deformity: Severe injuries can cause fractured bones to move out of place and make the ankle look deformed.
Causes of Ankle Injury
Trauma
  • Stepping in a hole or a stone
  • Running on uneven ground
  • Fall or slippage on wet floor
  • Contact injury during sports like basketball, when a player is accidentally hit by an opponent causing the foot to roll inwards as shown in Fig 5.
Basketball

Fig 5: Lateral ankle sprain during basketball

Muscle imbalances

Lack of flexibility in muscles can hamper joint movement. For example, if the calf muscles are very tight, it will affect the stability and mobility of the ankle joint. In such a state, if one engages in any physical activity like running there could be a potential risk of twisting an ankle. Sometimes even lack of warm-up and stretching could be the cause of muscle imbalances.

  • Lack of Postural control

Postural control is defined as the act of maintaining, achieving or restoring a state of balance during any posture or activity.

It helps to maintain a good base of support for balance so that the force of gravity can act on the center of mass (COM) of the body. Centre of mass is the point in the body where the entire body weight is concentrated (located in the lower end of the spine) as shown in Fig 6.

Figure_10_03_05

Fig 6: Line of gravity and base of support

During sports, sudden quick body movements or external forces like a push or a contact by an opponent will affect your balance. If you lack postural controlm you may lose balance and risk hurting your ankle. 

Diagnosis of an ankle injury

Most ankle injuries are usually straightforward ligament strains. However, the clinical presentation of subtle fractures can be similar to that of a ankle sprains and these fractures can be easily missed on initial examination. Fractures are usually detected via X-ray scans. If any fracture is left untreated, it may cause excessive pain and disability to an extent that you may not be able to bear weight on the joint. Therefore, an X-ray or an MRI scan is often recommended to understand the severity of the injury.

For example, a lateral ankle sprain showing fractured bones in an X-ray is shown in fig 7. 

ankle sprain with bone fracture

Fig 7: Lateral ankle sprain with fracture of the lower end of fibula bone

Ankle Injury management

Usually, ligament injuries heal in about 6-12 weeks and fractured bones take about 3-6 months to heal. This is however largely dependent on the severity of the injury and lifestyle of the individual so complete healing time frame may vary. 

Even after the healing process, ankle injuries may cause long term instability if not healed correctly. This may also be the cause of recurrent ankle sprains. An expert assessment of ankle mechanics is very important to decide on how long to protect and rehabilitate an ankle after an injury. The treatment plan will aim to restore the normal functions of the ankle and make return-to-play decisions based on the stability of the ankle thus preventing recurrent ankle injuries.

Common Knee Ligament Injuries

Common conditions, Injury, Lifestyle, Pain

17vike0510.jpg

A ligament is a band of connective tissue composed mainly of collagen fibres. The knee joint ligaments connect the femur (thighbone) to the tibia (leg bone) at the knee joint to improve its stability and to limit the amount of mobility in the joint.

The four main ligaments of the knee joint are,

  • ACL: Anterior Cruciate Ligament
  • PCL: Posterior Cruciate Ligament
  • MCL: Medial Collateral Ligament
  • LCL: Lateral Collateral Ligament
knee ligaments

Fig 1: Ligaments of the knee joint

Functions of the knee ligaments

  • Stability to the knee joint

The ligaments of the knee are responsible for preventing the tibia (shin bone) from sliding out of the femur (thigh bone). During rotational movements, knee ligaments work together to prevent both valgus (knee moved inwards) or varus (knee moved outwards) stresses to the knee.

According to their attachments in the knee, the ligaments prevent tibial displacements. For example, ACL prevents forward displacement of the tibia while PCL prevents backward displacement of the tibia. Similarily, the MCL provides support on the inner side of the knee while the LCL provides support on the outer side of the knee.

  • Locking the knee during walking

Apart from supporting the bones, the knee ligaments contribute to the “screw-home” mechanism, a process that locks the knees during walking. For example, just before you strike the heel to the ground your knee is slightly flexed (about 20 degrees bent) then the screw home mechanism works to straighten the knee as your body moves over the planted heel as shown in Fig 2.

swing to stance

Fig 2: Screw-home mechanism

What does a ligament Injury mean?

A ligament injury is the over-stretching or tearing of the ligaments of the knee. A tear may be partial or complete.

mcl injury BY GRADES

Fig 3 Grades of  Ligament injury

What can cause a Knee Ligament Injury?

Extreme movements at the knee joint forcing the knee to move beyond its normal motion can injure a ligament. Most of the injuries occur during weight-bearing activities, as the ligaments resist against perturbations at the knee.

Types of people who usually get them

  • Sports people like football players, basketball players, skiers etc.
  • Hyper-mobile individuals who engage in high-impact sports may have an injury due to excessive laxity in the knee ligaments.
  • Accidental fall on the knees or hit on the knees during contact sports like rugby, football etc or automobile accidents (in which the knees can hit the dashboard)

Mechanism of an injury

hyperextension

Fig 4: Causes of knee injury

  • Hyper extension injury

Extending the knee too far by over straightening of the knee. This can happen when you stop suddenly while running.

  • Flexion and Hyperflexion injury

Jumping and landing on a flexed (bent) knee or falling on your knees with over overbent knees.

  • Rotational injuries

Valgum (inner) or varum (outer) stress on the knees due to twisting of your knee inwards and outwards. Sudden shifting of weight from one leg to the other.

  • Contact Sports

Accidental hit on the knee during sports as shown in Fig 5

PCL INJURY

Fig 5: Direct hit on the leg

Other Reasons that contribute to a Ligament Injury

  • Lack of force distribution

During movement, the body exerts a force on the ground and at the same time, an equal and opposite ground reaction force (GRF) is exerted by the ground on the body. This GRF is directed towards the center of mass (COM) of the body, a point in the body where the entire body weight is concentrated; in front of the tailbone.

If there is an imbalance, which means the athlete’s knee does not bend on landing and remains straight, the GRF creates a forward shear force that pushes the tibial forwards, stressing the ligaments. Hamstring muscles on the back of the thigh play a vital role in stabilizing the knee joint especially when the athlete lands. Normally, the knees normally bend slightly to absorb GRF as shown in Fig 6.

QUADS DOMINANCE

Fig 6: Hamstring action advantage for absorbing GRF

  • Lack of trunk control

Without trunk control, there will be greater movements in the trunk following a perturbation (disturbance) which could affect the distribution of the GRF.

Lack of control in the trunk motion happens because of diminished proprioception. In such a situation, if the trunk moves more on the side of the knee joint laterally, the GRF tracks the COG and follows the movement of the trunk. As the GRF tracks the COM, and if it progresses beyond the center of the knee joint, it results in a movement of the knee joint into a valgus alignment stressing the knee ligaments as shown in Fig 6.

Trunk dominance

Fig 6: Valgus alignment of the left knee

Signs and Symptoms of Ligament Injury

  • Popping sound at the time of injury can indicate a ligament rupture.
  • The knee swelling within the first 24 to 48 hours
  • Tenderness and possibly redness around your knee on touching. 
  • Knee feels unstable or may buckle during weight bearing. This may cause you to limp or feel wobbly at the knee during walking.
  • Bruising around the knee can develop. 

What to do if you think you have an injury?

If you are having any of the above signs or symptoms, seek immediate medical attention. What can appear to be a simple ligament or soft tissue strain may become something more if left untreated. Diagnostic tests such as an X-ray or MRI scan will be able to show any tears or rupture of the ligaments. According to the severity of the ligament injury, appropriate treatment care will be advised.

Temporomandibular (TMJ) Joint and its Disorder

anatomy, Common conditions, Injury, Pain

TMJ

What is the TMJ?

The temporomandibular joint (TMJ) or the jaw joint is a synovial hinge type of joint. This joint is responsible for the movements of our mouth that are needed for chewing, biting, talking and yawning.

To achieve the complex movements needed by the jaw, the TMJ has two articulating surfaces which include the head of the mandible (jaw bone) that fits in the articulating socket of the temporal bone of the skull. In order to prevent friction between the two bones, an articular disc sits between the articulating surfaces which moves with the head of the mandible as one unit.

TMJ disc

Fig 1: Normal TMJ when jaw closed

Apart from the disc and articulating structures, there are other supporting structures that provide stability to the TMJ:

  • Joint Capsule
  • Ligaments
  • Muscles

Joint capsule and Ligaments of the TMJ

The capsule is a fibrous cartilaginous membrane that along with the ligaments surrounds the TMJ and attaches all around the articular eminence of the temporal bone, the articular disc and the neck of the mandibular condyle. Both the capsule and the ligaments provide stability to the TMJ during movements. The four ligaments include (Refer Fig 2),

  • The Lateral Ligament (temporomandibular ligament)
  • Sphenomandibular Ligament
  • Stylomandibular Ligament
  • Stylohyoid Ligament
CAPSULE

Fig 2: Showing the attachment of joint capsule, lateral ligament and stylomandibular ligament.

Muscles around the TMJ

The are four main muscles (Refer Fig 3) of the TMJ are,

  • Temporalis
  • Masseter
  • Medial Pterygoid
  • Lateral Pterygoid
muscles of tmj

Fig 3: Prime muscles for TMJ movement

Movements at the TMJ

There is a combination of hinge and sliding motions that can occur in the TMJ due to the movements of the mandible.

  • Protraction (forward) and Retraction (backwards)
  • Elevation (upward) and Depression (downward)
  • Lateral deviation (Side to side movements of the jaw)
MOVEMENT PROTRACTION RETRACTION

Fig 4: The forward and backward movements of the jaw

ELEVATION DEPRESSION

Fig 5: Upward and downward movements of the jaw

lateral deviation

Fig 6: side movement of the jaw

Temporomandibular Joint Disorder 

  • Muscular problem: Pain and discomfort in the muscles of the face during jaw movements.
  • Disc problem: Usually comprises of displaced disc, dislocated jaw, or injury to the mandibular condyle.
  • Joint problem: Degenerative inflammatory joint condition like Arthritis at the temporomandibular joint.

Reasons for TMJ Disorder

  • Genetics

Individuals who have misaligned jaw or teeth which are hereditary can be affected with TMJ disorder.

  • Functional mandibular overload

Normally the jaw is free to move and make contact with the teeth in the right position, (centered occlusion), in anatomical and functional harmony.

Mandibular overload occurs when one sleeps in a wrong position (face down) where the load of the head pushes the mandible to compress the TMJ on one side and attenuation of the ligaments on the other side. Compression obstructs the blood circulation and moves the teeth to a lateral bad occlusion position. In such a situation, swallowing causes the masticatory muscles to overwork to centre the jaw and bring the teeth from forced lateral malocclusion to centred occlusion. This causes a disharmony between the upper and lower teeth. An imbalance of the jaw that can cause bruxism in an attempt to re-position the teeth.

The term bruxism is defined as an involuntary rhythmic or spasmodic non-functional gnashing, grinding or clenching of teeth. The rubbing causes tooth facet to wear out, structural and function damage to the capsulo-ligamentous and muscles around the TMJ. Stress and psychological problems could worsen the condition.

Sudden trauma

Whiplash injury occurs any time when the head is suddenly and unexpectedly distorted from the neck, causing overstretching of the muscles and ligaments that hold the neck and head in alignment. During a whiplash injury, there is also a potential secondary injury of whiplash in the jaw. Jaw dislocation in severe cases can also occur.

  • Inflammatory diseases 

Sometimes infection in the teeth or adjacent structures can cause a spread of infection in the TMJ leading to infectious arthritis.

TMJ could also be affected by osteoarthritis that causes damage in the articular cartilage of the joint and disc degeneration leading to friction between the bones causing inflammation and pain. It usually affects individuals above 50 years of age and is associated with trauma and other muscular and teeth problems.

TMJ disorder could also be present among individuals who are already diagnosed of rheumatic arthritic disease.

Symptoms of TMJ

  • Jaw pain: Pain and tenderness in the jaws. Increasing pain during chewing in the TMJ and in the muscles, radiating pain is also felt in the face, jaw, or neck.
  •  Limited or painful jaw movement: Swelling due to the inflammation lead to joint stiffness and limited movement, wear and tear of the disc leading to locking of the jaw and impaired jaw function.
  • Headache, Neck pain or stiffness: It is generally assumed that headache, neck pain, or painful jaw movement is suggestive of muscular problems. Masticatory and neck muscles may show muscle spasm and myofascial trigger points in the masseter or sternocleidomastoid muscles that refer pain to the head.
  • Clicking or popping: This occurs within the joint during mouth opening and may indicate displacement of the intra-articular disk during mandibular movement.
  • Ear pain and tinnitus (Ringing of the ear): Middle ear muscles have a common embryological and functional origin with masticatory (Chewing muscles) and facial muscles.Having said that, problems with muscles in TMJ disorder could affect the middle ear. In case, other ear problems are not the cause of ear pain and tinnitus a temporomandibular joint dysfunction may be the reason of these symptoms.

Prevention and Treatment

In order to relieve pain and restore the function of the TMJ, a thorough assessment is required to correctly determine the causative factors and to treat the involved structures. Personalized care interventions at an early stage that includes behavioural change and reassurance are important steps for prevention of TMJ disorder.

Rotator Cuff Injury

Common conditions, Injury, Pain

shoulder

Our shoulders are the most movable joints in our body. Most activities whether simple or strenuous engage both our shoulders. That is the reason why with a little bit of pain in our shoulders, we find it very difficult to do even the simplest of tasks like putting on a coat or carrying groceries. Sometimes there is a crunchy sensation or you may hear clicking and popping sounds while you move your shoulder or do weights. This pain can worsen making you feel frustrated, leaving your shoulders feeling weaker than normal and stiff to move. There could be many reasons for the cause of your shoulder pain but the most common injury that could possibly show these type of symptoms would be a rotator cuff injury.

What is the rotator cuff and how does it get injured?

Rotator cuff injury

The Rotator cuff is a group of muscles coming from the shoulder blade and ending in tendons that attach to the arm bone. These muscles cup the shoulder and are responsible for its stability during movement. The muscles of the rotator cuff muscles include:

  • Supraspinatus
  • Infraspinatus
  • Subscapularis
  • Teres Minor

“Centralisation”- Your rotator cuff is important

The function of the rotator cuff, in addition to generating torque, is to dynamically stabilize the shoulder joint. It keeps the ball of the shoulder centred over the small glenoid socket. Thus, stronger rotator cuff muscles result in the better glenohumeral joint stabilization and hold the humeral head into the glenoid by depressing it. This prevents impingement and decreased chances of shoulder dislocation when the deltoid abducts(arm sideways up) the shoulder. Without an intact rotator cuff, particularly during the first 60 degrees the ball of the shoulder would migrate up the glenoid cavity causing the rotator cuff attachments to get compressed by the acromion leading to impingement of the rotator cuff. In patients with large rotator cuff tears, the humeral head is poorly depressed and can migrate cephalad during active elevation of the arm.

Rotator cuff injuries

Sometimes sudden fall or high impact sports could be the cause of injury but in most cases, it is due to the repetitive injury over the tendons as they being pulled beyond their capacity to stretch. This gradually worsens causing partial or full tear of the tendons. Due to the way these tendons cup the shoulder by being closely spaced, they are more at risk of friction. Especially when you turn your shoulder or lift any weight at the end range of shoulder movement, the tendons in this tight space become taut and rub against the bony knob (acromion process of the scapula) above them or against a ligament at the front of the shoulder. This causes friction, pain and as a normal response, inflammation sets leading to pain, swelling and movement restriction.

Physiology of rotator cuff damage

1. Tendonitis (acute Inflammation)

Tendonitis can occur in a particular rotator cuff tendon causing pain, inflammation and irritation. If this condition becomes more chronic, more tendons can become involved or it may progress to a tendinosis (degeneration).

2. Impingement Syndrome (compression of the tendon)

The most common site of impingements is within the “supraspinatus outlet”. This outlet is a space formed by the acromion process of the scapula, the coracoacromial ligament and the upper rim of the humeral head. Subacromial outlet

Impingement within the outlet can be caused by:

  • Thickened Coracoacromial ligament: This can cause impingement by becoming thickened due to excess calcium deposits that will compress the supraspinatus tendon.
  • Hooked acromium: In repetitive overhead activities, the tendons rubs against the acromion process of the Scapula and gets damaged. When the inflammation spreads into the pocket of fluids (subacromial bursa) that lubricates the rotator cuff tendons under the acromion bone. This causes subacromion bursistis and the pain gets even worse on movements.
  • Abnormal Scapular Movement: With normal shoulder movement, the scapula moves outward and upwards helping the shoulder to move up

scaphumerorhythm movement

  • In the case of an unhealthy shoulder, the scapula does not move in the same fashion as the healthy shoulder and gets “stuck” in a lower position. This could lead to abnormal movement of the scapula during shoulder movement. Poor scapular movement will cause compression of the tendons in the supraspinatus outlet increasing the chances of impingement of the rotator cuff tendon that goes under it.
  • The picture below shows an unhealthy right shoulder at a risk of impingement, showing improper movement in the scapula.

chances of impingement

3. Rotator cuff tears

A tear is a result of the worsening of the tendon damage. Although an acute fall can tear the rotator cuff tendon, chronic inflammation and degeneration due to impingement is the major cause of tears. This tear can start small and get larger over time due to repetitive use or a re-injury. When a tear occurs, there will be severe weakness and atrophy(loss of muscle mass) of the muscles around the arm and loss of movements of the shoulder. impingement

How is Rotator Cuff Injury Diagnosed?

Pain in the shoulder could be caused by various other reasons like joint injury, capsule injury, nerve problems and many more. A thorough examination of the shoulder should be done to distinguish the injury type. If a tear is suspected in the rotator cuff an MRI or an arthrogram (X-ray of the shoulder joint after injecting a contrast dye) can be taken.

normal

Prevention and Management

A proper diagnosis and plan of management is necessary for the treatment and prevention of rotator cuff damage. Initial treatment would be pain relief, rest and avoiding any activity that aggravates pain in order to enhance the healing process. Further treatments will be decided upon the individual’s condition. Thorough assessment and planning by the experts with an application of knowledge of the condition and correct methods of treatment will promote recovery and prevent injury reoccurrence.