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The pterygoid (TEHR- uh- goyd) muscles are well hidden by the lower jawbone, which is very inconvenient, since their trigger points are a frequent cause of pain in temporomandibular joints of the jaw. The word “pterygoid” comes from the Greek for “wing- like,” a reflection of their shape. The root word is similar to that of “pterodactyl,” the name of the winged dinosaur.

The medial pterygoid muscle causes pain in the temporomandibular joint and the ear, which increases when you bite down on something (figure 4.43). It can also refer pain to the back of the mouth, hard palate, and tongue, and can make it hurt to swallow. Medial pterygoid

trigger points make it difficult to open the mouth wide. A sense of stuffiness in the ear can come from a tight medial pterygoid when it prevents the eustachian tube (in the middle ear) from opening. This may occur because of referred effects on the tensor veli palatini and salpingo- pharyngeus muscles in the back of the throat, which have more direct control over the eusta- chian tube. The medial pterygoid muscle helps close the jaw by attaching to the maxilla (upper jaw) outside and inside of the mouth (not shown). Its problems are therefore strongly associated with those in the masseter (Simons, Travell, and Simons 1999; Bell 1969).

Figure 4.42 Masseter massage with thumb and fingers (thumb inside the mouth)

Figure 4.43 Medial pterygoid trigger point and referred pain pattern. (Note that the jawbone is cut away to reveal this muscle deep to the bone.)

You can massage the medial pterygoid by pressing up with your thumb inside the inner edge of the back of your lower jaw (figure 4.44). Find the corner of your jaw by looking in the mirror. Place your thumb just an inch in front of this bony landmark and press up and out into the inside of the jawbone. Avoid pressing into the neck and onto the carotid artery here. Clench your jaw together to feel the medial pterygoid contract on the lower jaw. This can be an exceedingly painful spot. As with the masseter, massage of the pterygoids can leave you sore, so go easy at first.

The other pterygoid muscle, the lateral pterygoid, is the number one myofascial source of pain and temporoman- dibular joint (TMJ) dysfunction (figure 4.45). Constant trigger point– generated tension in the lateral pterygoids tends to pull the lower jaw forward and disarticulate, or partially dislocate, the joint. Popping or clicking in the jaw is the result of this and displacement of the meniscus, which is the articular disc that separates the jaw bone from the skull and allows for movement in the joint. As with the masseter, trigger points in the lateral pterygoid refer pain to the cheek, mimicking sinus pain. They can also stimulate sinus secretions. Many “sinus attacks” are simply the effects of lateral pterygoid trigger points (Simons, Travell, and Simons 1999; Reynolds 1981; Marbach 1972).

The function of the lateral pterygoid muscles is to help the digastric muscles open the jaw as well as project the lower jaw forward. When only one side of the lateral pterygoid contracts, it causes a lateral, or sideways, deviation of the jaw to the opposite side. Malocclusion, or mismatching bite of the top and bottom teeth, can occur with trigger points in these muscles. Trigger points are created in the lateral pterygoids when you have trouble breathing through your nose and must keep your mouth open in order to breathe. Satellite trigger points set up in the front of the face by the lateral pterygoids may account for much of the face pain that comes with allergies. Major dental work that stresses jaw muscles by requiring you to hold your mouth open for long periods of time can be the unsus- pected cause of long- term chronic pain in the face and jaws. Trigger points in masseter and temporalis muscles can cause trigger points to develop in the lateral pterygoids by making them work harder to open the mouth (Simons, Travell, and Simons 1999).

Travell and Simons link tinnitus (ringing in the ears) to trigger points in the sterno- cleidomastoid, masseter, and lateral pterygoid muscles. They quote studies showing that trigger point injection with procaine can completely relieve the condition. The key muscle may be the lateral pterygoid, which is very well hidden by the jawbone. Massage to the muscle is not difficult, though.

Massage the lateral pterygoid with the index finger of the same side hand inside the mouth (figure 4.46). The fingertip should seek the deep pocket above the gums, back beyond

Figure 4.44 Medial pterygoid massage with thumb (avoid pressing into the neck here)

Figure 4.45 Lateral pterygoid trigger points and referred pain pattern

If you need more help relieving mouth, jaw, or headache pain, look for

The Myofree Solution: The Missing Piece in the TMJ Puzzle in the

Chapter 4—Head, Face, and Neck Pain 85

your upper molars— the place you have to dig peanut butter out of. This “peanut butter pocket” is about the size of the tip of your index finger. Push back as far as you can, and then press both upward and forward toward your nose using tiny, short strokes. The pressure is aimed toward the crown of your head. If trigger points are present, this can be excruciat- ingly painful. Go easy. Rome wasn’t built in a day. It will take you a while to deactivate these little points. You won’t be able to do this massage unless your fin- gernail is very short.

After massaging the masse- ter and temporalis muscles, you

can use another approach to treat the lateral pterygoids. First, look in the mirror to find the opening of your ear. Place your finger on your face just in front of the ear canal. Open your jaw to feel the condyle of the jaw (the top round projection of the jawbone that interacts with the skull) move forward to create a hollow just in front of the ear. This is not the location of the trigger point; keep reading. Move one inch forward toward the nose to find a second very shallow hollow. Deep in here lies the lateral pterygoid. Once you find the spot, prop your mouth open about two to three fingers’ width wide with the bottom of a paper or Styrofoam cup or with an apple (figure 4.47). This will relax the masseter and allow deep massage of the lateral pterygoid. Use your index finger to press slightly up toward the top of the head and forward toward your nose. The stroke really resembles a half- circle and is very tiny. You might use a massage tool such as the Shemala Fingers or a pencil eraser for deep pressure. You will look ridiculous, but you will feel better. When the trigger points on both sides of the jaw are significantly less painful, stretch the lateral pterygoid by pushing the jaw (press below the lower front teeth) back toward the ears. The mouth should be relaxed and the teeth slightly apart.

Digastric and Mylohyoid