For the blog for his Month, I am highlighting a good friend and fellow TMD colleague, Bill Esser, PT, MS, CCTT from Roseburg, Oregon. Bill thank you for your contribution to this month’s newsletter, and thank you for your continued willingness to share, educate and collaborate with me, your knowledge and expertise in treating patients with TMD and Facial Pain!

What can x-rays and palpation tell you about neck function and pain?

Therapists at Freedom Physical Therapy Services, S.C. might request a series of X-rays for patients with neck and facial pain. With radiographs, we can perform a cephalometric analysis of the cervical area. A transection of the line drawn from the posterior nasal sinus to the base of the occiput (horizontal line) and a line drawn from the tip of the odontoid process to the anterior inferior body of C2 (vertical/oblique line) establishes the craniovertebral angle. This angle should be 101 degrees+/-5 degrees.

As the craniovertebral angle decreases so does the space between the base of the skull and the C1 and C2 processes. Entrapment of the greater occipital nerve as it exits between the base of occiput and C1 and C2 processes is a common source of referral to the head and facial area. In patients who are in forward head posture this space is usually decreased as the cranium becomes posteriorly rotated. When viewing the head and neck in the sagittal plane, equal distance should be present between the base of occiput and C1, and between C1 and C2. A total of 20 mm of space should be present in this area, or the width of two fingers. If we do not have a radiograph, we use the two-finger rule to measure the space. Simply see if your index finger fits between the base of the occiput and C2 (the first spinous process palpable moving inferiorly from the cranium).

Palpation of the suboccipital triangle provides valuable clues as to whether compression of the upper cervical and greater occipital nerves is. If neck or facial pain, or headache are produced during palpation, physical therapy intervention designed to provide space for these nerves to pass is in order. Palpation of the suboccipital triangle is accomplished by starting at the midline at the base of the occiput and slowly bending the patient’s occiput over the palpating finger as you move to the transverse process(tp) of C1. Then from the top of C1 move directly inferior to the spinous process of C2, palpating back up to the midline.

Michael Karegeannes
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