TMJ--simple/not so simple

 

Part of this one is simple.  That means that part of it isn’t.

I had an athlete with an odd injury last spring. A soccer player caught and elbow on the jaw which dislocated his temporomandibular joint (TMJ).  He came to the sidelines with his mouth open, telling me that he couldn’t close his mouth. He was in a lot of pain at both TMJ’s. 

I’ve done a lot of work with TMJ problems in my career.   For years, Drs. Witt, WIdloski, Gillespie, and I did a weekly TMJ clinic, where we saw the most difficult of the TMJ patients, mostly those with problems their dentist had been unable to resolve.

The TMJ is a very complex joint, unlike any other in the body. It might seem a simple hinge joint, but it does much more than that.  As the mouth opens, the jaw hinges but also slides forward down the slope of the maxilla—part of the skull.  Sitting on top of the mandible (jaw bone) is a disc that in a healthy joint, glides down that slope with the mandible.

Most of the time, it works smoothly and effectively.  When it doesn’t, you know it.

A lot of things can cause TMJ problems.  As a Physical Therapist, I see posture as a big contributor.  Dentists see a lot of contribution to problems from the way the teeth fit together.  Oral surgeons generally approach it from inside the joint itself. HEENT physicians are often in a position to see all the systems together

Foremost among other contributing factors is grinding your teeth, especially at night.  This is known as bruxism.  This can be a stress reaction, an occlusion (how your teeth fit together) problem, or other physical and emotional factors.

As for treatment—that is best done by a team approach, employing the efforts of the dentist, oral surgeon, physical therapist, and HEENT physician.  No one component seems more important than the others.  Often, it is a lot of little factors that together create big problems.

The solution then becomes removing as many of those little factors as possible.  Sometimes, the initial step is a simple football-type mouthpiece.  Other times, it means the construction of a custom splint that fits over the teeth.

At the very least, serious dental problems need to be solved.  The way the teeth fit together is huge.  As I said, posture can be a huge contributing factor.  Chronic allergies can contribute, as they often result in mouth breathing. Chewing on hard or chewy things are a problem.

Headaches are common.  There is a high correlation with neck problems.  Pain in the teeth may be the TMJ or may be organic problems there.

As for my soccer player, we were able to reduce that dislocation and then gradually return him to full competition without further problems. 

PT...more than a "few stretches"

 

“Can you just show me a few stretches to fix this problem?”  I’ve heard that a million times.

It’s usually preceded by a self-diagnosis, or, at least, a web-assisted diagnosis.  “My shoulder hurts, can you show me some stretches to take care of it?”  Or, “I hurt my back, what stretches can I do to take care of that?”

I’m not sure where anybody learned that a “few stretches” was the solution to their problems or (and even worse) that teaching stretches was all I do.

Don’t assume that I’m against giving free advice.  I do it all the time. Anybody that knows me knows that I am quite approachable with questions about health issues. 

My attitude has always been that if you have enough confidence in my abilities to trust me with health questions, then you are worthy of my time and full attention.  Even after doing this work for almost 48 years, I’m still honored when someone asks my opinion. 

My wife will tell you that it happens all the time.  It usually starts with someone saying “I know you don’t want to be bothered with stuff like this, but….” No, I really don’t mind being bothered. 

But don’t tell me what’s wrong and then tell me what to do about it. “My knee hurts, are there some stretches I can do to fix that?”  I just respectfully ask that you don’t reduce my professions to that.

Before you get out of sorts, let me offer you some specifics about what you can do. Free. Without asking. And not really just a few stretches.

If your shoulder hurts, it’s probably related to posture. You might say “but my posture is good—I always stand up straight.” That may be the case, but the problem is the world we live in.

Everything we do is in front of us. We sit at a computer for our work or we assemble equipment in a factory or we have hobbies or habits that are in front of us. The result is that we function throughout our day with our shoulders rolled forward.  Maybe not too much but enough.

That’s behind most of the shoulder problems I see in the clinic.  That and too much bench press. Overdevelopment of the front part of the shoulder yields the same result.

The solution is often quite simple—strengthen the upper back, particularly the muscles between your shoulder blades.  Focus strength training on pulling back.  Strengthen those muscles and you will go a long way toward solving the postural component of your problems.

Kneecap (patellar) problems are common, particularly among young teenage girls.  The treatment for that for too long has been attempts at strengthening the quadriceps muscles (those muscles on the front of the thigh). Trouble is, that wasn’t very effective.

What we know now is that the solution is more a matter of how the foot hits the ground and how strong the hips are.  Fix those problems and you will greatly influence the knee.

Neck problems?  Fix the way you sit.  Back problems?  Strengthen your core.  That’s not the whole solution, but it’s a start. For more, see your physical therapist for a thorough evaluation and a prescribed program of exercises and activities that fit the problem.  It’s never as simple as a few stretches.

Long life begins at childhood (duh...)

 

I’ve written often about chasing a long life, usually focusing on things that you need to do late in life in order to be healthy through your golden years. Unfortunately, it seems I’ve ignored the most important time—the developmental years.  Birth to 18.  That’s when you can impact health the most. 

Let’s look at what that means. And what you, as a parent, can do.

The single most important thing you can do is to be a good role model.  I remember an old saying “do as I say do, don’t do as I do.”  Huh-uh. Doesn’t really work.

Your children will model your behaviors.  If you eat right, they will too.  If you lead an active lifestyle, they will too.  Let’s face it—inactive kids become inactive adults.  And lifestyle choices, especially in the young, determine our health.  For the rest of our lives.

Your kids need regular exercise.  An hour a day or more.  That’s part of the reason youth sports can be so important. My rule was always that I don’t care what you play but you have to play something. 

That wasn’t a problem around my house.  My kids wanted to play everything. Sports were everything from softball to basketball to gymnastics and lots in between. They both finally settled on football and volleyball and had great careers. Family activities included hiking, swimming, skiing, paddling. You name it, we did it.

We once took a whitewater canoe course at the Nantahala Outdoor Center. I think the kids were 11 and 13, paddling solo whitewater canoes. We sometimes did crazy stuff like that. And backcountry backpacking trips.

The bottom line is that if you want your child to be more active, be more active yourself.  And, better than that, be active with them.  Go for a run. Play a sport. Shoot hoops together. Anything.

Getting adequate sleep is huge, but especially for the youngest among us.  Quality of sleep and regular sleeping hours are crucial to proper development.

Eating right is crucial.  Fruit.  Vegetables.  No sodas.  Avoid sugary drinks.  Sweet tea?  I think not.  Whole grain foods.  Lean meats.  Dress it up.  Don’t add sodium but there are lots of ways to make food tastier.  Never eat in front of the TV.  Ever. 

Again, you can’t put a burger and fries on your plate and tofu and broccoli on your kid’s plate. It just won’t work. Obese children become obese adults and then comes all the health problems that shorten your life and lessen the quality of your life—heart disease, diabetes, cancer.

But accept your child at any weight. Build their self-esteem while teaching them the value of the big three—proper nutrition, regular exercise, sufficient sleep. If the lessons are learned, they will be OK.

It wasn’t a problem when my kids were growing up, but screen time is definitely a problem these days.  I often see neck problems among teenagers from looking down at their phone all day.  The research is clear—too much screen time is bad for you and bad for your child. Period.

Smoking? That one’s easy. No one wants their child to smoke but 2^nd hand smoke is almost as dangerous.  And if you smoke, there’s a good chance your kid will too. Someday.

Health literacy is important.  Talk to your kids about why it is important to do all these things.  Talk about healthy living. Share meals together. Talk the talk but walk the walk. Your kids deserve that much.

Iron Sharpens Iron

 

I am part of a group called The ICCUS Society.  ICCUS is a group of sports physical therapists that come from around the world to meet every summer and argue for two days. Really.

It’s an iron sharpens iron thing. More on that in a bit.

All physical therapists graduate from physical therapy school with a doctoral degree, and all are considered generalists until they pursue advanced competencies. That can be in pediatrics, neurology, lymphedema, wound care, pelvic health, and others. Most of these are under the umbrella of the American Board of Physical Therapist Specialties.

There are a several avenues that a physical therapist can take to become a specialist.  For me, I became an Athletic Trainer and then a Sports Clinical Specialist (SCS). To become certified as a Sports Clinical Specialist, you must have post-graduate coursework in things like Emergency Care, years of experience working with athletes, and pass a rigorous examination.

For clarity, Athletic Trainers are a separate profession, today requiring a Masters Degree in Athletic Training.  Athletic Trainers are most often found on the sidelines of games and sporting events, but can be found in a variety of settings including clinics, schools, and industries.

There are other avenues to become a Sports Physical Therapist, most notably by completing a Sports Residency or Sports Fellowship, programs that require 1-2 years in a combined academic/athletic setting.

Back to ICCUS—there are 56 members, from around the globe.  Those members include international speakers, authors, and many that serve professional athletes and teams at the highest level. And when I say that we close the doors and argue for two days, it really is true. It can be daunting.

That’s where the iron sharpens iron comes in. Every three years, each member has to provide a presentation that is then critiqued by the whole group. To say that this group can be brutal is an understatement.  Either you know what you’re talking about or you get embarrassed in a hurry. Not everyone is up for it.

Iron sharpens iron.

That’s why you want to play the best competition. Sure, everyone likes to win, but champions want to get better.  So, you play the best.

That’s why you want coaches that will push you.  That’s how you find out how good you can be.

That’s why we keep the score in games. That’s why we crown champions. That’s why we keep won/loss records.

If you want to be the best version of yourself, regardless of the arena, you seek out the best of the best and challenge yourself to compete in that arena. 

That’s how you get to be the best.

Coaches Care

 

Most youth leagues could not function without parents that volunteer as coaches.  It’s almost rare to find a team of youngsters where the coach isn’t also a parent of one of the players.

I did it.  The first sport for my kids was T-Ball and that first year, I was determined to allow someone else to coach my kids.  It worked well—they both had really great coaches.  I still appreciate them for taking on six year old kids. 

But the need was so desperate over the next few years that I started coaching. And, before you could turn around, I was coaching everything that they did.

One year, I agreed to help coach a youth soccer team.  The head coach was “the only certified youth soccer coach” in the area.  I have no doubt that he knew a lot about the game of soccer but I have to tell you that he struggled in coaching 7 and 8 year old boys and girls.

So the next year, a friend and I decided we would take a Parks & Rec soccer team.  Go back a year and I will tell you that the first soccer game that I ever saw, I coached. If you could call it that. 

About all I knew about the game was that if we kicked it in their goal more than they kicked it in our goal, that we would win.  I also knew enough about sports to know that we didn’t need everybody to always run to the ball.  That second year, we did quite well with those basic principles.

Years ago, Charlie Finley and Tom Ware had started an AAU basketball program here called Blount Stars.  When my kids got old enough for that, I restarted their program then ran it and coached a couple of the teams for the next few years.

But that’s it.  After that, I put away my coaching hat. So, I’ve put in my time.  Been there.  Done that. And probably made every mistake in the book.

As an Athletic Trainer, I have had pleasure of being on the sidelines for literally hundreds of games that my kids and now my grandkids participate in. Keep in mind, though, that I was on the sidelines of Maryville High School football long before my son was on the team and was there for many years after he graduated.

With all that being said, I believe I can make this statement without prejudice and with a great deal of credibility--coaches will be better for an athletic career than parents.  Sound strange?

Here’s the thing—parents never want you to fail while coaches will push you to failure so you can discover what you’re capable of.  It’s really that simple.

In 45 years of doing this stuff, I can tell you that almost every coach I’ve ever encountered had the best interest of your child at heart. They my push and may coach hard, but they want the best for your kid.

And there’s something pretty special about somebody that will invest themselves in a kid that isn’t even theirs.

Be Safe

I was on my way to work recently. That’s not unusual—despite rumors to the contrary, I have not retired.  I still go in to work 5 days a week. Monday through Friday. Weekends too, from time to time.

It was quite early in the morning, which is also common for me.  I’m an early riser. I was on the road when I came around a corner, maybe a bit too fast and came upon a line of vehicles stopped at a red light.

No problem. I braked, maybe a bit too hard, but I had no trouble stopping in time.

But my mind got kicked into high gear at that point.  What if my brakes failed?  What if I had been texting at the same time?  What if I just wasn’t paying attention?

I would have plowed into that pickup truck at the back of the line. And that truck would likely have been pushed into the vehicle in front of it and so on and so on. 

Catastrophe averted because I was awake, paying attention, and not on my phone.

My daughter-in-law got T-boned a few years ago by a teenager who ran a red light, likely because she was texting with her friends.  Both drivers walked away but it could have been bad.

Statistics tell us that a huge portion of automobile accidents are due to distracted driving, and that the chief culprit there is texting while driving. (It is against the law, by the way.)  I think the statistics could be deceiving—I think the number could be higher than current estimates.

Anyway, the admonition to focus on driving when you’re behind the wheel is only part of the story today.

Oh sure, it’s the main point.  I’ve got three teenage drivers in the family, one more almost there, and a fifth not far behind.  I want them to be safe drivers. I want them to arrive alive.

It is a bit of a dark thought, but while attending a high school graduation recently, I thought about the fact that somewhere, some high school senior didn’t make it to their graduation.  They were killed in a car wreck. 

I still worry about my own children, now in their 40’s—still wanting to know when they arrive at their destination should they be making a long drive.  Always have. Always will.

The other part of the story is a simple bit of advice:  Focus on what you’re doing. Give the task at hand your full attention, whether it be your studies, your job, your sport…really anything you might be doing.

If you are true to yourself, you want to give the best of yourself at all times.  The world needs…the world deserves, your best effort.  In everything you do.

Be safe. 

Back to Basketball

 

I did a thing last week.  For the first time in 12 years, I played a game of basketball!

It seems crazy now, but I played regularly until I was 59.  I didn’t play in high school, choosing football instead.  But I kept playing whenever possible. Intramurals. Pick up games in the HPER building at UT.  Anywhere I could find a ball and a basket.

After college, I played pickup basketball wherever I could find a game.  Springbrook Park.  Sandy Springs Park. Everett Park. The Courts at the Candy Shop in Alcoa.

I played in Parks & Rec leagues back when the “over 28” league was considered the “old man’s” league. I played a few years in a church league, but that one got too rough. 

We had a standing game at noon on Tuesdays and Thursdays at Maryville College and one on Sunday evenings at Maryville High school. That one went on for decades.

In 2013, my right knee problems just got too bad. I couldn’t run, couldn’t cut. Never could jump much so that wasn’t impacted.  After going off ibuprofen for a week before a colonoscopy, I was achy for days.

So I quit playing basketball.  I could still ride my bicycle without pain so I had to be satisfied with that.

But oh, did I love playing basketball!  Loved it.  In my dreams, I never missed, made great passes, and rebounded like Dennis Rodman.  But only in my dreams.

After I quit, I missed playing dearly.  But it just wasn’t prudent.  Then, in 2019, I had my right knee replaced.  The result was life changing. It had been years since I could run—now I could run. 

During the 2019 football season, before I got my new knee, a white-hat referee made fun of how slowly I moved onto the field.  In 2020, with a new knee, I made a point to sprint past that same official on my way onto the field.

Yet, returning to basketball was never on my radar.  I often thought I might be able to play again, with the new knee and all, but never did. No real opportunities came up.  Then, a patient of mine suggested that I join this group of “older” players for a weekly game. She assured me I would be fine.

So, I showed up. And played. It wasn’t really an “older” group, but I didn’t care.  For an hour and a half I played, without coming off the court.  It was heavenly.  I couldn’t hit the broad side of a barn door but the basics of my game were still there.  And although I doubled my Aleve before bed, I didn’t really hurt that much. I do plan to go back but my work schedule often interferes. 

For years, patients with knee replacements were told that they could only do sedentary activities, like easy biking, golf, walking, maybe doubles tennis.

I’m not going to tell you that you can do anything on a replaced knee, but I know for certain that you can do more than you could before replacement.  Do the rehab and be smart about it and you can do most anything. Although I still don’t recommend jumping out of perfectly good airplanes.