When a headache or a toothache is not about the head or teeth?

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When a headache or a toothache is not about the head or teeth?

By Zacharias Sifakis & Marios Papachristopoulos

Following a stressful day, many people suffer from a telltale pain that radiates from their neck and head and is only preceded by an ongoing stiffness in the jaw.  Pain from the temporomandibular joint (TMJ) can be easily mistaken for a common headache, mostly because the symptoms are so similar. It often causes for repeated dentist visits without any outcome however as the symptoms arise from a different structure even if you feel it around your teeth.

But there are a few key differences that set a TMJ-related headache or facial pain apart from a common tension headache. When the symptoms are associated with TMJ then the pain state is also known as a temporomandibular disorder (TMD). TMD is a broad term that encompasses disorders of the TMJ and its associated anatomical structures. A TMD can often be very painful and disabling. With an accurate and opportune identification of the type of pain you’re experiencing, you can find relief before the sensation becomes unbearable. But let us have an insight into what we know about one of the joints that we use more on our body.

The TMJs are complex structures made up of two bones, the temporal bone and condyle, which are separated by a fibrous disk, and surrounded by a capsule. The TMJ is mainly composed of fibers like those in ordinary connective tissue. This gives the joint the tendency to remodel. Injury to or disorders of these structures can all result in pain in the jaw area. Jaw pain may occur on one side or on both sides, depending upon the cause and may be associated with myofascial pain and headache.

A typical TMD consists of:

• Recurrent pain in one or more regions of the head and/or face.
• X-ray, MRI and/or bone scintigraphy findings that demonstrate TMJ disorder.
Important clinical evidence that pain can be attributed to the TMD are:
– Pain precipitated by jaw movements such as laughing, yawning and/or chewing of hard or tough food.
– Jaw stiffness and reduced range of motion or irregular jaw opening.
– Noises like clicking or popping) from one or both TMJs during jaw movements.
– Tenderness of the joint capsule(s) in one or both TMJs.
Temporomandibular disorders may occur following a direct trauma or secondary due to indirect mechanism of injury. Usually, direct trauma is a blow or a fall to the chin or jaw. Indirect mechanisms of injury may be triggered by numerous causes. Most common are whiplash injury following an accident, heavy chewing, teeth grinding (bruxism), clenching of the jaw, disorders of dental occlusion, loss of dental height due to worn down or missing teeth, prolonged periods of mouth opening such as a dental or a general anaesthetic procedure etc.

Common intra-articular temporomandibular disorders are inflammation, internal derangement conditions, and degeneration. These conditions are commonly related to a disk/condyle incoordination and noise can be detected on movements. This may progress to locking (where the condyle can’t ride over the forward located disk) where the mouth can not open causing symptoms and severe limitations in daily activities such as chewing, laughing or yawning. Overuse of the jaw muscles such as excessive gum chewing can inflame the TMJ, resulting in pain and stiffness. 

Arthritis can also occur in the TMJ as a result of age-related degeneration (usually seen in the over 50s), or secondary to trauma occurring at a younger age. In arthritis, crepitus can be felt or heard and changes can often be seen on a plain x-ray or on an MRI.
Muscle spasm of one or more muscles of mastication, is an extra-articular cause of TMD usually following prolonged dental procedures or anaesthetics or due to stress, bruxism etc. Muscle spam can also cause significant pain and limitation of the jaw movements. Mismanagement of fractures rehabilitation, at the mandibular symphysis or the condylar neck, as well as the dislocation of one or both condyles, can also be a cause for a TMD.

It is not always clear what triggers a TMD and there are numerous other conditions that can cause pain in the TMJ region. Pain in the areas of the face around the TMJ’s, jaws and ears, often derives from common disorders of the upper cervical spine.

Specialised clinical examination, as well as an interdisciplinary approach where needed, is required to ensure a reliable differential diagnosis & treatment is given, and that potentially serious problems such as trigeminal neuralgia, systemic diseases and other medical conditions are not overlooked.

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What is the treatment and prognosis for temporomandibular disorders?

TMD is a recurring, but self-limiting condition that tends not to be progressive and usually responds to conservative therapy. TMJ-related pain is commonly misdiagnosed as a regular stress-induced headache. TMJ-related pain in fact is a much more preventable source. Following successful treatment, headache resolves within 3 months and does not recur.

Satisfactory management requires a thorough clinical examination. The examination should include complete history of the patient, assessment of jaw/tongue/neck position, palpation of the TMJ, assessment of both active and passive range and quality of movement of the jaw and cervical spine, and assessment of the patient’s bite. Also, signs of sleep bruxism/grinding are checked. Important clinical signs including the presence of swelling, muscle spasm and stiffness or hypermobility of one or both TMJ. Complaints of limited mouth opening and other signs of joint dysfunction must also be interpreted and assessed in the context of age, gender, and general health.

Α personalised identification of the factors contributing to a TMD, can be decisive in establishing the most effective therapy. In some of the cases, a simple modification of lifestyle and oral habits may be sufficient to alter symptom intensity. Non-invasive, conservative treatments include physical therapy, occlusal adjustment, splint therapy (especially when symptoms are related to bruxism during sleep), medications etc.

Given the self-limiting nature of most TMD, surgical intervention is rarely the treatment of choice, but may be justified in cases where circumstances are extreme, and disability associated with joint disease impacts greatly on the quality of life.
Physiotherapy treatment is an effective and safe approach in the treatment and management of TMD, even when the symptoms are long-standing and severe. With the appropriate comprehensive approach, most patients will see a significant improvement in pain intensity and range of motion within 3 to 6 weeks. Individualized accustomed mobility exercise programmes and selection of manual therapy techniques have the most promising effects in people with TMD.
This article is intended to promote understanding of and knowledge about a common health topic and does not intend to be a substitute for professional advice, diagnosis or treatment. As the evidence cannot determine the most appropriate type, intensity, and duration of therapy, we recommend you to always seek the advice of your dentist, specialized physiotherapist or other qualified healthcare providers with any questions you may have regarding a medical condition or treatment on the TMJ area.






Daily Nightmare

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Persistent pain in sports performance. Α daily nightmare?

“Hurt doesn’t equal harm” is a common mindset, among people who exercise on a regular basis either for recreational purposes or elite sports performance. Phrases like “no pain no gain” or “the pain you feel today is the strength you feel tomorrow” are printed on fitness T-shirts & gym walls as the representation of the dominant mindset in the fitness world.

In general, for someone putting effort to improve sports performance in terms of aerobic capacity, muscle strength & endurance, flexibility, as well as other aspects of exercise, it is absolutely normal to put stress on the body into vigorous soreness and fatigue levels, during a workout session.

What happens when pain persists for a long time and doesn’t seem to be relieved with training, medication, physiotherapy, or even injections?

During a competitive training and the days following, a tissue adaptation process is triggered by different body systems in order to compensate for the new physical demands. When our body is healthy, it is expected to recover within a few hours following a vigorous exercise session and up to a couple of weeks in the case of marathon runners and other similar endurance sports.

For example, muscle tissue adaptation sensation (aka Delayed Onset Muscle Soreness) can be triggered even 24h following an exercise session and it shouldn’t persist for more than a few days to ease off. Regardless of how strenuous a training session is, it would become easier, for the same person to perform exactly the same exercise program a few days later, at least in some aspects of the program.


There are many cases of athletes who struggle to improve their performance without any significant success in the end due to recurrent or long-standing pain. When the occurrence of pain is directly related to the training sessions and there is no sufficient improvement in sports performance over time, it is most likely to be attributed to an overuse injury condition. Overuse injuries in sports participation have common behavioral characteristics like the recurrence or even gradual aggravation of debilitating symptoms with medium or minimal intensity training.


There are numerous underlying reasons for the trigger and progress of an overuse condition to an athlete. In general, such condition is mainly attributed to gradual insufficient tissue adaptation to training workloads, due to imbalance in load & rest analogy. There are also cases where an acute injury has occurred prior to the gradual turn into a chronic overuse state.

That is mainly caused by primary recurrent injuries on the same location or secondarily due to the excessive strain of adjacent musculoskeletal structures. Important contributing factors are training load modification, recovery time efficiency between the same training tasks or the whole training sessions, quality of sleep, pain behavior monitoring, pre-season design et al.


There are plenty of sports-related musculoskeletal pathologies & disorders with an overuse component on the sports performance. Some of the most known are reactive or chronic tendinopathy, medial Tibial stress syndrome, chronic fatigue syndrome, repetitive strain injuries on hamstrings, and other parts of the body.

Overuse is also one of the most common etiologic factors that lead to injuries in pediatric and adolescent athletes.


What is the solution to an overuse condition?


As the term “overuse” indicates the individual experiencing pain has done too much for too long, someone would assume that rest is all we need. Our body tissues (bones, muscles, tendons, ligaments, cartilage et al.) are always affected by training stimulus or immobilization in a never-ending process. For example, if you stop using a specific part of your body for a while, this will cause, muscle atrophy, bones will become less dense, cartilage will be triggered by a degenerative process, ligaments and tendons will lose some of their elasticity. Even in a painful condition, absolute rest in an athlete comes with undesirable side effects. In most pathologies, continuous training load adaptation (optimal load management) is the main rehab strategy in order to overcome an overuse condition.


Optimal loading means replacing rest with a balanced and incremental rehabilitation program. A comprehensive rehabilitation design should be based on a proper diagnosis, a thorough assessment, and recognition of contributing factors as well as the appliance of individualized exercise prescription. The solution may be just as simple to put into words, but as the injuries and biopsychosocial background of each athlete varies, it is hard to implement/apply a single “one size fits all” rehab strategy.


In conclusion, if you are experiencing persistent pain when exercising and you have been diagnosed with an overuse injury condition,  you would, then, probably need a modification on training loads. While processing your way back to sports participation, you should also consider if there are any contributing factors to be addressed as well for the prevention of injury recurrence.


The information provided by this article is meant to help you become more effective and robust when exercising, so as to be able to return to desired performance levels.

If you still struggle without any significant success, then you should refer to a clinical specialist for athletes (an orthopaedic surgeon or a sports physio) to assist & guide you on your way back to sports participation. The same principles are not applicable to athletes with acute trauma or in a post-surgery state, and the contribution of exercise in these conditions will be well-explained in another following article.











Rest Or Load?

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Should I rest or should I load? How to recover following an acute soft tissue injury

Soft tissue injuries (muscles, ligaments and tendons), are inevitable events during the career of almost every athlete. These injuries usually occur following an impact force from an external stimulus, when there is a contact-related history, or due to strain and/or compression load in the non-contact cases. Most of the non-contact injuries are related with doing too much too fast, after doing too little for too long.

Over the past decades, R.I.C.E.

  • Rest
  • Ice
  • Compression
  • Elevation

was the main approach to the management of acute soft tissue injuries, but its effectiveness is being questioned by researchers.

This article provides enriched updated recommendations for optimum and efficient acute soft tissue injury management (from rest & recovery phase to progress to exercise and return to performance), based on a recently published review of research.

What is necessary in an acute injury?

All injuries at their initial stage, have to undergo a healing process which is vital to enhance tissue remodeling & recovery. According to the recent data, soft tissue injuries on their immediate care simply need P.E.A.C.E. The acronym arises from

  • Protection
  • Elevation
  • Avoid anti-inflammatory modalities
  • Compression 
  • Education.

Protection over the first days of an injury is required to minimize bleeding, prevent distension of injured fibers and reduce the risk of injury aggravation by unloading the injured limb and restricting movements that would increase pain.

Elevation while resting (positioning the limb higher than the heart), promotes interstitial fluid flow out of the injured area.

Despite the lack of evidence of its use, elevation is still considered safe given its low risk-benefit ratio. Avoid anti-inflammatory medication (NSAID’s) and ice use over the first 48h as it may potentially disrupt the inflammation process and lead to impaired tissue regeneration in the long-term tissue healing.

As the various phases of inflammation contribute to optimal soft tissue regeneration, inhibiting such an important process using medication or ice is not recommended. When appropriate, NSAID’S dosage should always be prescribed by a licensed health care professional.

Compression (external mechanical pressure) on the injured area, with the use of taping methods, limits intra-articular edema & tissue hemorrhage.

Compression also improves quality of life in ankle sprain injuries. Patient information and education is a major contributing factor and should always be provided by a specialized health professional on these topics in order to raise realistic expectations on the rehabilitation times. Instead of looking for a magic treatment approach up on “Dr” Google, you should consult your physician or physiotherapist to learn more about the nature of your injury condition, recovery times, and how to apply load management.

How much rest is enough?

You should first worry about complete healing and then about the rest & recovery management, as these are key ingredients in any training program. If you don’t allow your body the time needed to recover properly, and instead you push it into exercise the injury won’t heal, while it is also likely to turn into an overuse/chronic condition with persistent symptoms.

Chronic pain is a much greater threat to your sports performance than resting! In general, it’s feasible to rest/protect against an injury while still maintaining fitness with modified exercise even from the first days.

How much rest is required prior to exercise introduction, is in general determined by the pain presence and the nature of the injury.

In a recent study, a group of athletes with muscle injuries, who were introduced to exercise sooner (2 days post-injury), shortened the interval from injury to pain-free recovery and returned to sports 3 weeks earlier compared to the athletes who rested for 9 days (see figure). No increased risk of injury recurrence was identified between the two groups. Most of the references set at least a 48h rest period for muscle strains.

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When can I progress to training? (loading phase)

When the acute symptoms subside and there is no aggravation in specific movements, pain behavior is guiding the removal of protection and gradual reloading. At this stage, rehabilitation must be driven by L.O.V.E. where the acronym consists of

  • Load
  • Optimism
  • Vascularisation 
  • Exercise.

Optimal loading during the subacute phase of recovery promotes the long-term tissue repair and remodeling, and the capacity of tendons, muscles, and ligaments. Optimal load, as well as persistent pain management for athletes, has been described in another article.

The mental status of the athlete has a key role in sports injury rehabilitation, as emotional distress can decrease significantly the recovery rate. A successful rehabilitation should be driven by consistency, optimism, and trust between the coach, the athlete, and the sports physiotherapist.

A pain-free aerobic exercise represents a cornerstone in the management of musculoskeletal injuries as it boosts athlete’s motivation while at the same time it increases blood flow and facilitates vascularisation to the injured structures. It has also been highlighted that it improves function, work status, optimism while reducing the need for painkillers. Cardiovascular activity is recommended to be introduced as soon as possible, although there are no guidelines on dosage.

In a conclusion, systematic exercise restores mobility, strength, endurance proprioception, agility, and other important aspects of fitness capability, in order to return to desired sports performance. Progression in any activity is been guided by symptoms behavior and comprehensive design.

Any implementation of the provided information should be individualized to fit the biopsychosocial profile of each athlete.


Back Pain And School Bags

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School bags as a cause of back pain. Myth or reality?

Back pain is among the most common musculoskeletal conditions of our time, with a continuous increase in incidence rates in the general population, and with frequent reference to age groups among children and adolescents.

Epidemiological studies over the world in these age groups have shown that 1 in 4, 1 in 3, and 1 in 2 children aged 11, 13 and 15 respectively will report at least once an episode with back pain.

Back pain is defined as the occurrence of symptoms spreading as height as up to the shoulder blades and low as the pelvic/sacral area.

Nearly 1 in 5 children reported having requested medical care for this episode, and nearly 1 in 10 children were absent from school for one or more days due to back pain. In a similar survey, 75% (3 out of 4 children) of children with non-specific (undefined source of pain that cannot be directly associated with pathology, both in clinical examination and/or with imaging) chronic back pain reported that the transportation of a school bag exacerbated their symptoms.

In many countries, guidelines have been adopted that set specific weight limits for school bags. These limits usually range from 10% to 15% of children’s body weight, but in some cases, they are set at 5% while there are guidelines up to 20% of body weight. While reviewing the scientific research on the topic, the question arises if all these “recommendations” are backed up by the data so far. Despite the apparent lack of reliable research data, school bags have been inseparably linked to the occurrence of back pain in children and adolescents.

For years, researchers globally have been trying to figure out the risk factors for such symptoms appearing in children and adolescents. Up until recently, there have been findings linking psychosocial factors (such as anxiety, emotional stress, family environment, etc.), female gender, and smoking with an increased risk of back pain in pupils. Several studies have also investigated load strain characteristics, such as contributing factors of biomechanics (eg technique, duration of loads, etc.) or anthropometric parameters (eg height, weight, body type etc.), that are considered to be contributing to the occurrence of such episodes. However, these claims do not appear to be adequately supported by current scientific evidence.

In particular, in a recent Australian survey, data from 69 studies, corresponding to over 72,000 children and adolescents, were collected and evaluated. Several parameters were recorded, evaluated, and analyzed, such as the weight of the bag, the duration of the transfer, the type of the bag (backpack, postman, etc.), the transfer method, and the referred schoolbag weight (as it is perceived from the child).

The results were published in May 2018 in the British Journal of Sports Medicine and are summarised as follows:

1) None of the studies included in the survey indicated sufficient evidence, that the use of school bags (in its various features) is a contributing factor associated with the occurrence of back pain in children.

2) One study has shown that a child’s likely report that the school bag he is carrying is heavy, is associated with the appearance of back or middle back pain symptoms.

3) In another study, children with pre-existing back pain and reported difficulty in transferring their bag showed an increased risk of symptoms aggravation and turning them into a chronic condition.

Based on the data analysis from the 69 studies available, it seems that the characteristics of the backpack (such as weight, bag design, transfer method, etc.) do NOT increase the risk of back pain occurrence in children and adolescents. Therefore, any relationship between the use of the backpack and the back pain is at best minimal and the researchers should turn their attention to other causes of symptoms in this population.

In conclusion, parents do not need to be particularly worried about what kind of bag they should choose, how the child should use it, and how heavy they should be, as there is no convincing evidence that these parameters increase the risk for pain occurrence on their children.

But there are well-grounded assertions that if the child himself reports that his schoolbag is “too heavy” or has difficulty in transferring it while already experiencing back pain, then it is best not to ignore it. In this case, we can reduce the load or make transportation easier for the child, until he feels able again to carry the full load.

Individualized education on optimal load management is currently the most effective method for people who deal with persistent or chronic pain. In particular, there is a substantial improvement in daily function as well as a significant reduction in the intensity of the symptoms. If the child suffers persistent symptoms which cannot be dealt with sufficient management, then we should contact a healthcare professional.