Managing TMJ Pain Holistically: The Barefoot Physiotherapy Approach
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Managing TMJ Pain Holistically: The Barefoot Physiotherapy Approach
Written for Clinicians by Sal Oliver Lange
Temporomandibular joint (TMJ) dysfunction is complex, often misunderstood, and rarely confined to the jaw alone. At Barefoot Physiotherapy, our approach to managing TMJ pain is grounded in a detailed understanding of anatomy, a strong connection to the cervical spine, and an integrated treatment pathway based on our signature Barefoot Plan.
We regularly review current research and integrate clinical insights from leaders such as Associate Professor Shaun O’Leary to ensure best practice. Below is an outline of our in-house TMJ management approach, shared to support other health professionals working with clients with this condition.
Understanding the Anatomy and Functional Interplay
Innervation
The TMJ is innervated by a branch of the trigeminal nerve (CN V)
Muscle Action
Muscles that close the jaw (and control opening eccentrically against gravity):
- Temporalis – also maintains resting jaw position
- Masseter – key chewing muscle
- Medial & Lateral Pterygoid – work as a sling for grinding and lateral movement
- Note: Superior lateral pterygoid is responsible for contralateral deviation
Muscles that open the jaw:
- Suprahyoid and infrahyoid muscles, requiring simultaneous upper cervical (UpCx) extension for effective range
EMG studies have shown increased masseter and temporalis activity with UpCx extension, due to the need to stabilise jaw closure.
Pain-Sensitive Structures
The retrodiscal tissue of the TMJ is highly innervated and vascularised, making it a common source of pain, especially in cases of compression or irritation.
TMJ–Cervical Spine Connection
The relationship between forward head posture (FHP), cervical tension, and TMJ dysfunction is significant. Tension in the hyoid muscles from FHP pulls the jaw open subtly, requiring the closers to work overtime to maintain closure—resulting in hypertonicity and fatigue.
A pivotal insight from Knutson (1999) described reflex contraction of upper cervical muscles with jaw dysfunction.
The Barefoot Plan in Practice: TMJ Management Step by Step
Step 1: Subjective Examination
Clients may or may not present with Jaw Pain as their primary concern. Jaw pain may be brought up in the Subjective but if not we often pick it up in the Full Body Assessment Step 5.
TMJ indicators in Subjective include:
- Difficulty chewing
- Pain during wide opening (e.g., at the dentist)
- Clicking/locking
- Morning jaw pain (bruxism)
- Stress-related tightness or grinding
Step 2: Referral Pathways
We refer out when pathology is suspected:
- Dentist – for splints or cracked teeth
- Orofacial surgeon – via dentist
- Medical specialists – for conditions such as RA or OA
Step 3: Neurodynamic Testing
NDT is used as part of our standard approach. We often find that jaw dysfunction can correlate with neural irritation or sensitivity especially on Upper Limb and Upper Cervical Neurodynamic Tests.
Step 4: Neural Treatments
If we have found nerves to be a contributing factor in the clients condition we need to treat them first.
The type of treatment we use will depend on which is the most effective for the client’s body as everyone is an individual. Neural interfaces not to be overlooked in clients with Jaw Pain: C1 PA, C2 and C3 AP or lateral glides.
Step 5: Detailed Assessment
We assess jaw function in all clients as part of our whole-body scan, using palpation. For clients needing detailed Jaw assessment this includes:
- Palpation
- Photos (frontal and lateral)
- Video of opening/closing
- AROM testing: opening, closing, protrusion, retrusion, lateral shifts
- Observation of translation patterns (e.g., contralateral deviation due to superior lateral pterygoid)
Retrusion, while often small, is provocative for retrodiscal tissue and should be noted.
Step 6: Treatment Direction Tests (TDTs) – Test don’t guess
Quoting Shaun O’Leary: “If they don’t move well, work out how to help them move well.”
Treatment techniques may include:
- MWM (Mobilisation with Movement) of the TMJ and relevant cervical/thoracic/rib segments
- MRWM (Muscle Release with Movement) for identifying contributing muscles
Step 7: Treatment Techniques
Interventions are tailored to what testing reveals, and may include:
- Neural interface glides (Cx/Tx/Lx)
- Cervical joint mobilisations
- Western Acupuncture and Dry needling – especially UpCx and jaw musculature
- Myofascial releases – including masseter, temporalis and pterygoids
- Education – particularly around relative rest and avoidance of aggravating habits
- Postural retraining – including workstation setup
Step 8: Self-Care Tools (As Appropriate)
Not every client needs every strategy—but here’s some from our toolkit that may be needed:
- Workstation setup and activity pacing
- Self-releases (trigger points, jaw massage)
- Relaxation practice (e.g., “breathe in, breathe out, relax jaw”)
- Stress and clenching awareness
- Splinting for night bruxism
- Ice or heat application
- Supported yawns
- Small/soft food choices
- Mirror-based motor retraining
We educate that habitual jaw relaxation can take up to 2,500 reps to become ingrained, so consistency is key.
Step 9: Tune-Ups
These are a really good idea as TMJ issues are often recurrent or cyclical, especially when linked to stress or tech use so it is important to have regular touch points to minimise flare ups. The great things about our objective tests being so specific means we can pick up when a body is tightening up BEFORE it is in pain!
Step 10: 😊 Living empowered
We remind our clients—and ourselves—to celebrate progress. Smiles, soft food wins, or finally yawning pain-free all count.
Conclusion: Collaborative, Connected Care
At Barefoot Physiotherapy, TMJ care is never siloed. We treat it within the context of the cervical spine, neural system, stress response, and lifestyle patterns. It’s a collaborative process between client and clinician, often involving other health professionals such as dentists, GPs and mental health providers.
If you’re a clinician working with jaw pain and are interested in learning more, we’d love to connect. Let’s keep sharing what works and learning together.
If you’re interested in more blogs written specifically for clinicians here is one on Anti-inflammatories
These insights were compiled by Sal Oliver Lange as part of clinical training in the clinic. With reference to:
Training on TMJ and the Cervical Spine with Shaun O’Leary BPHTY (Hon), MPHTY (Msk), PhD. Shaun is an Associate Professor in Physiotherapy between the School of Health and Rehabilitation Sciences at the University of Queensland, and the RBWH. He is also a Specialist Musculoskeletal Physiotherapist (as awarded by the Australian College of Physiotherapists (ACP) in 2008). Within that training the reference to Knutson as mentioned above: Knutson 1999 Journal of Manipulative Physiol Ther Jan;22(1):32-7.