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Case report

Derangement of the temporomandibular joint; a case study using Mechanical

Diagnosis and Therapy

C. Krog a, S. May b,*

a Faculty IMDT, Denmarkb Faculty of Health and Wellbeing, Sheffield Hallam University, Sheffield, UK

a r t i c l e i n f o

Article history:

Received 15 September 2011

Received in revised form

30 November 2011

Accepted 1 December 2011

Keywords:

Temporomandibular pain

Classification

Mechanical Diagnosis and Therapy

Derangement

a b s t r a c t

Mechanical Diagnosis and Therapy (MDT) is widely used for spinal problems, and more recently the

principles and mechanical syndromes have been applied to extremity musculoskeletal problems. One of

the most common classifications is derangement syndrome, which describes a presentation in which

repeated movements causes a decrease in symptoms and a restoration of restricted range of movement.

The case study describes the application of repeated movements to a patient with a 7-year history of

non-specific temporomandibular pain and reduced function, who had had lots of previous failed treat-

ment. Examination using repeated movements resulted in a classification of derangement, and the

patient rapidly responded in 4 treatment sessions, with an abolition of pain and full restoration of

function, and remained improved after many years. The case study demonstrates the application of

Mechanical Diagnosis and Therapy principles to a patient with a temporomandibular problem.

2011 Elsevier Ltd. All rights reserved.

1. Introduction

Mechanical Diagnosis and Therapy (MDT) (McKenzie and May

2000, 2003, 2006) is well known and commonly applied in the

management of musculoskeletal disorders worldwide, especially

patients with spinal problems (Gracey et al., 2002; Hamm et al.,

2003; Poitras et al., 2005; Byrne et al., 2006; Spoto and Collins,

2008). MDT uses a mechanical evaluation involving repeated

movements performed to end range while symptoms and

mechanical responses are monitored. The results of the repeated

movements are then used to classify the patients into one of three

mechanical syndromes: derangement, dysfunction or postural

syndrome. Based on the classification, different exercises and

postural concepts are employed to reduce derangement, remodel

dysfunction, or correct adverse postural loads. The mechanical

evaluation when used with spinal patients has demonstrated verygood to excellent reliability between trained clinicians (Werneke

et al., 1999; Razmjou et al., 2000; Fritz et al., 2000; Kilpikoski

et al., 2002); and improved outcomes (Clare et al., 2004; Cook

et al., 2005; Hettinga et al., 2007; Slade and Keating, 2007).

Furthermore, centralisation, which is a core component of the

approach, and describes the abolition of distal pain in response to

repeated movements, has demonstrated prognostic validity

(Werneke and Hart, 2001; Aina et al., 2004; Chorti et al., 2009).

When McKenzie (1981) described his original concept, he

maintained that the method could be applied equally well to

extremity problems, and an explicit description of how the MDT

principles could be applied to extremity conditions was published

more recently (McKenzie and May 2000). To date the relevant

literature is mostly limited to case studies at the shoulder and

thumb (Aina and May 2005; Littlewood and May 2007; Kaneko

et al., 2009), but in addition there was a reliability study (May

and Ross, 2009) that found good reliability, with kappa value of

0.83 amongst 97 therapists evaluating 25 case studies on McKenzie

extremity assessment sheets.

The purpose of this case report was to describe the assessment

and management regime, using the principles of MDT, as applied to

a patient with a non-specific temporomandibular joint (TMJ)problem. This patient was classified and treated as having

a derangement according to MDT principles. The patient gave

consent for the details of her case to be published in a medical

journal anonymously.

2. Case report

2.1. Patient history

Symptoms had started during a tooth operation at the dentist in

May 1997, during which her mouth was held wide open for about* Corresponding author. Tel.: 44 (0)114 225 2370.

E-mail addresses: ck@mckenzie.dk (C. Krog), s.may@shu.ac.uk (S. May).

Contents lists available at SciVerse ScienceDirect

Manual Therapy

j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / m a t h

1356-689X/$ e see front matter 2011 Elsevier Ltd. All rights reserved.

doi:10.1016/j.math.2011.12.002

Manual Therapy 17 (2012) 483e486

mailto:ck@mckenzie.dkmailto:s.may@shu.ac.ukhttp://www.sciencedirect.com/science/journal/1356689Xhttp://www.elsevier.com/mathhttp://dx.doi.org/10.1016/j.math.2011.12.002http://dx.doi.org/10.1016/j.math.2011.12.002http://dx.doi.org/10.1016/j.math.2011.12.002http://dx.doi.org/10.1016/j.math.2011.12.002http://dx.doi.org/10.1016/j.math.2011.12.002http://dx.doi.org/10.1016/j.math.2011.12.002http://www.elsevier.com/mathhttp://www.sciencedirect.com/science/journal/1356689Xmailto:s.may@shu.ac.ukmailto:ck@mckenzie.dk

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30 min by a dental wedge. During this time she felt a sharp pain in

the left jaw. Symptoms continued for approximately 6 months.

During this time she returned twice to the dentist who simply

advised her to give it time. Subsequently the joint pain slowly

abated but the jaw began to lock several times a day. If she opened

her mouth she could not close it again, unless she helped with her

hands. Chewing food, yawning and speaking loudly made the joint

locking condition worse.

In 1998, a second dentist began intra-oral splint therapy with

a maxillary appliance for night-time wear. In 1999 she had 5

sessions of chiropractic for the jaw pain and then in 2000 she

consulted another dentist. None of these interventions helped, but

over time the stiffness and pain become worse and she felt at times

her jaw coming out of place. She changed her eating habits,

preferring foods that did not need to be chewedor cutting food into

very small morsels. She also found that if she deviated the jaw to

the left she could open the mouth wider, and that if the jaw locked

she could unlock it by this same movement.

For a number of years she just tried to live with the problem, but

then it started to worsen, with pain radiating to her left ear,

becoming constant again, and increasing in severity from 1/10 on

a numeric pain rating scale to 8/10 at times. Because of the wors-

ening situation in 2004 her general practitioner referred her to anoral and maxillofacial surgeon at the hospital. However, she was

reluctant to contemplate further surgery, because of her previous

experience, and instead elected to contact a physical therapy

practice.

2.2. Physical examination

The 30-year old female presented to the physiotherapy clinic

with a complaint of left TMJ pain, which had been present for

nearly 7 years. At times, pain radiated to the left ear. Currently, her

functional ability was extremely limited and she was in constant

pain. Her sleep was disturbed nightly because of joint pain. Addi-

tionally, she suffered from extreme morning stiffness in the jaw.

A screening examination of the cervical spine, which consistedof single and repeated movements in sagittal and frontal planes,

revealed no restrictions of movements and no symptomatic or

mechanical responses. Involvement of the cervical spine was

thought to be unlikely. An examination of single movements of the

TMJ was conducted first to gain a baseline understanding of her

symptomatic and mechanical presentations. She reported an ache

at the left TMJ at rest of 2/10 on a numeric pain rating scale.

Opening the mouth demonstrated a moderate loss of movement

that was very painful at end range. MDTuses non-specific measures

for loss of movement: minor, moderate, and major, which though

imprecise are meaningful to MDTclinicians and relevant in the case

of individual patients. Both closing her mouth and clenching her

teeth increased local left TMJ pain. Retraction of the jaw and return

had no effect. Left lateral deviation was moderately limited andpainful throughout the range. Right lateral deviation was unre-

stricted but painful during the entire motion and she had the

feeling that the jaw would come out of place.

Both deviations were painful, but as the right also caused the

feeling of subluxation it was decided to explore this movement

further with repeated movements. Clinical practice has demon-

strated that the provocative movement can often be the most

informative. One set of 10e15 repetitions increased her symptoms,

made both the lateral movements more restricted, and made the

feeling of subluxation worse, until she could barely repeat the

movements. Given this negative response left lateral deviation was

the next movement to be explored. Her baseline symptoms were

recorded, with the numeric pain rating scale now at 6/10, and then

she was asked to perform 10e

15 repetitions. During the repetition

of left lateral deviation, she reported that the movement felt

increasingly easier to do and less painful. After completion of two

sets of repetitions, only end range pain remained, and she had no

pain at rest. On re-checking her baseline mechanical response of

mouth opening the range had increased to full range and was much

less painful. On right lateral deviation, the feeling of subluxation

was gone but pain was still present. When she repeated end range

movements to the right, the feelingof subluxation returnedand she

developed an obstruction again in left lateral deviation. Thus

through opposite lateral deviation movements, she was able to

both improve and worsen her symptoms and mechanical

presentation.

2.3. Initial clinical impression

Provisional diagnosis from the assessment was derangement of

the left TMJ, based on the rapid changes to symptoms and

mechanical presentation. The self-treatment strategies for the next

24 h were 10e15 repetitions of left lateral deviation every 2 h and

to try to avoid aggravating factors, such as chewing, speaking loudly

or yawning. She was instructed to perform the movement as far to

the end of range as possible on every repetition.

2.4. Visit 2

The patient was seen again the following day to confirm the

diagnosis and the application of mechanical therapy. She reported

she had performed her exercises regularly every 2 h while awake

and demonstrated accurate performance of the exercises. Waking

pain, pain on eating and joint stiffness was still present in the left

TMJ, but about a quarter of what they had been. She now demon-

strated minimal movement loss in all directions with end range

pain only except right lateral deviation where the feeling of

subluxation was still present. There was no pain at rest. The clas-

sification of derangement was confirmed.

She was now shown to progress the force by applying over-

pressure to the movement by using her hands to support the upperleft jaw and pushing with her right hand on the lower right jaw (see

Fig. 1). As a result, end range pain increased in the left jaw but did

not worsen as a result of repeated movements. She was instructed

to perform this exercise 10e15 times every 2 h and limit chewing

food.

2.5. Visit 3

The patient was seen again once more on the following day to

ensure that overpressure was having the desired effect. She

Fig. 1. Model demonstrating left lateral deviation with overpressure to the TMJ,

overpressure with right hand.

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reported she had performed the overpressure movement every 2 h,

and demonstrated that she had been performing them correctly. In

fact with each repetition she reported they had got easier and

easier to do. She reported that she had slept through the night

without waking due to the pain and had no pain on waking in the

morning. Also, she had no pain when eating breakfast and lunch

and no feeling of movement loss or stiffness as a result of eating. On

re-assessment, the patient demonstrated full and pain-free move-

ment in all directions except right lateral deviation where she felt

a slight pain at end range but no feeling of subluxation. Based on

the re-assessment, she was instructed to continue left lateral

deviation with overpressure every 2 h for another 24 h.

2.6. Visit 4

A week later the patient returned with no complaints of pain. On

examination, active ranges of all movements were full and pain-

free in all directions. It was no longer possible to reproduce the

feelingof subluxation with right lateral deviation by repeating side-

gliding to the right or by chewing or repeating mouth opening. She

was discharged with instructions to return if there was any re-

appearance of symptoms or problems.

2.7. Long-term follow-up

At follow-up by telephone one year later, the patient reported

that her condition had remained pain-free. She reported no func-

tional limitations and being able to freely chew food, sing, chew

gum, and sleep through the night. By chance the patient was

encountered on the street many years later. She reported no return

of TMJ problems or symptoms and full return of function, with

ability to eat anything she wanted, she could yawn fully, clench her

teeth, and sing loudly without fear of further problems.

3. Discussion

Thiscase study describes the successful management throughtheuse of MDT principles of a patient with TMJproblems who hadfailed

numerous previous management strategies. MDT does not seek to

make specific patho-anatomical diagnoses, but rather is based on the

symptomatic and mechanical responses to repeated movements.

According to these responses this patient was classified with

derangement syndrome and then demonstrated rapid improve-

ments in pain and function following regular application of active

repeated movements and active movements with overpressure. It

could be surmised that the source of the problem was related to the

articular discin the TMJ,and in deed internalderangement of the disc

is a commonly used classification for TMJ problems (Cook, 2007).

However according to Jones & Rivett (2004, pp 16e17) It is not

satisfactory simply to identify structures involved, as this alone does not

provide sufficient information to understand the problem and its effecton the patient, nor is it sufficient to justify the course of management

chosen.... of moreconcern is thatsolely tissue-basedreasoning tends

to promote inflexibility of management strategies. When therepeated

movement abolished her symptoms and increased the range of

motion, further examination was unnecessary as a treatment

strategy had been concluded. The MDT clinical reasoning process

firstly considers the presence of one of the mechanical syndromes,

namely derangement, dysfunction,or postural syndrome. Becauseof

the nature of the patients presentation and response to repeated

movements derangement was the only mechanical syndrome that

was possible. Full operational definitions are available for all the

mechanical syndromes, so it is not the point of this case study to

describe them (McKenzie andMay 2003). Althoughonly considering

3 options could be said to promote infl

exibility of management

strategies,if a patient does notfit the operationaldefinitions of oneof

the mechanical syndromes a number of other optionsare considered

(McKenzie and May 2003).

There are now several reports of the use of MDT principles being

applied to extremity problems (Aina and May 2005; Littlewood and

May 2007; Kaneko et al., 2009). A survey of 242 patients with

a range of extremity problems demonstrated that mechanical

syndrome classifications can be commonly applied to many

extremity problems (May 2006). Identification of the different

mechanical syndromes through the use of case studies has also

demonstrated very good levels of reliability amongst experienced

MDT clinicians (May and Ross, 2009). Further research is necessary

to demonstrate the effectiveness of MDT in extremity problems

with more rigorous scientific methodology.

4. Conclusion

This case report details the history and assessment of a woman

who presented with typically chronic non-specific TMJ pain. During

the physical examination the use of repeated movements, in line

with MDT treatment principles was able to reduce and later abolish

her symptoms and restore a full range of pain-free movement.

Movements in the opposite direction reproduced her symptoms

and caused a painful restriction in her range. Such a symptom

response is classified as derangement under MDT principles. This is

the first documented evidence of the application of these principles

being used as the only modality to assess and treat a patient with

a chronic TMJ problem.

Acknowledgement

Thanks to Dr Betty Sindelar for comments on the initial draft.

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