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Neck and Back Problems, Numb Fingers and Toes

My shoulders have ached for years and years. I thought it was normal.
—a 45-year-old secretary

I'm numb one day and fine the next. There's no rhyme or reason.
—a 22-year-old student

After headaches, the most common symptoms of TMJ are pain and stiffness in the neck and shoulders. They often occur with headaches, and patients report that pain begins near the temples, spreads to the front and back of the head, and down into the neck and shoulders. The pattern of pain resembles a knight's helmet; the entire head, from the forehead back, and the neck and shoulders are in pain. The pain can begin anywhere and spread throughout the area. The place the pain begins may be the same every time or change from headache to headache.

Backaches, both in the upper and lower back, are also frequently reported by patients subsequently diagnosed as having TMJ. When connected with TMJ problems, numbness in the extremities is a result of muscle spasms, not neurological abnormalities.

Like headaches, all of these symptoms may be caused by TMJ, by conditions unrelated to TMJ, or by a combination of conditions. TMJ may be one part, either major or minor, of an entire complement of symptoms and conditions. It is also important to remember that an evaluation of shoulder, neck, and back pain and muscle spasms should investigate all the causes of spasms.

Conditions like arthritis can cause neck pain, and anyone suffering with regular and persistent neck or back pain should have this condition investigated. Spasms in the neck muscles may also result from something as simple to remedy as sleeping in a draft. Occasionally people have to correct their posture in order to get rid of neck pain. People who walk with their heads thrust forward can sometimes correct neck pain simply by consciously training themselves to hold themselves more erect.

ONE PATIENT WITH NECK PAIN

Michael Maloney didn't seek treatment for his neck pain. He was referred by another dentist to have extensive reconstructive work done. However, from the way Mr. Maloney moved his body and head, it was obvious that he was in considerable pain. "I have to be careful not to jar my neck," he said. "It's been sore for weeks, and my doctor says I have another pinched nerve."

The routine screening revealed that his neck muscles and his external pterygoid muscles were in spasm. In addition, he had a severe tooth-gearing problem, adding to the evidence that TMJ should be considered. However, Mr. Maloney said that he rarely had headaches and that when they did occur, they were quite mild. He also said he didn't have any of the other common symptoms of TMJ.

Mr. Maloney came seeking a particular dental treatment, but was told that he had TMJ and that perhaps his neck pain was related. As with similar patients, it was important that the TMJ be addressed before his reconstructive work was started. It was likely that either the work would trigger other symptoms or the work would need to be altered or destroyed if Mr. Maloney later sought treatment for the TMJ.

As often happens, Mr. Maloney was skeptical about these recommendations. He had never heard of TMJ, and he had been told and was accepting that his pain was caused by a pinched nerve. He decided to wait to have the dental work done, however, because he didn't want the additional discomfort while his neck still bothered him. He couldn't understand or believe that his pain could be connected with his teeth.

Mr. Maloney made his next appointment about a year later. He'd been through several more episodes of neck pain, and they were becoming more frequent and more severe. This time he was anxious to begin treatment for TMJ, partly because of his discomfort, but also because his physician had become more aware of TMJ and advised him to get help.

TREATING PAIN

This case demonstrates some important issues in the treatment of pain syndromes. Mr. Maloney's neck pain was diagnosed as a pinched nerve because, given the description of the symptoms, it was a logical explanation for the pain, and other reasons for the pain had been ruled out. This diagnosis was a descriptive diagnosis rather than an absolute one. Much pain experienced in the neck, shoulders, and back receives this kind of descriptive diagnosis rather than a definitive explanation.

A descriptive diagnosis has a number of ramifications for a patient. First, the patient is reassured that the condition isn't life-threatening. Second, it gives the patient a label for the pain—a name to put on a condition to explain it to friends, family, and co-workers. However, for a diagnosis based on a reasonable explanation of the pain, rather than the true cause, the only treatment is often pain-relief medication to help the patient cope through intense periods of discomfort.

When he first came to my office, Mr. Maloney managed to cope with the level of pain he was experiencing. But as the year went by, his threshold was lowered, he could no longer tolerate living with the periods of discomfort, and he eventually got fed up with the problem. He also had been given another possible reason for the symptom. He was then able to re-evaluate his treatment choices. Once aware of TMJ, he began to be aware of how he clenched his teeth, and he could even feel the tooth-gearing discrepancy. Furthermore, he now had another health practitioner tell him that he might find help elsewhere.

As TMJ becomes more widely known within the health care community, more patients are likely to be referred for TMJ evaluation; they will get more than a descriptive diagnosis. This was advantageous for Mr. Maloney, because he was pain-free within two weeks of beginning treatment.

SORE SHOULDERS

Another manifestation of TMJ that usually is combined with other symptoms is shoulder pain and stiffness. Generally this symptom accompanies headaches and neck pain. We don't know why certain muscles become significantly more susceptible to painful spasms than others. However, we could speculate that posture places more physical stress on those muscles, depending upon the type of work a person does or the activities he or she engages in.

Mr. Maloney was a carpenter and spent much of the day leaning over, looking up, kneeling, and lifting. The muscles in his neck were the most susceptible to stress from these activities. Other people doing similar work may complain of shoulder pain and never mention neck discomfort. Many, if not most, people occasionally have sore shoulders. They usually attribute it to things like sitting at a desk too long, playing tennis too hard, or sleeping in an awkward position.

Shoulder pain is often caused by simple, everyday activities. In women, one common cause of shoulder pain is carrying a heavy bag over one shoulder. For many women this is a daily activity. However, some people with TMJ notice that after treatment this stops being a significant problem.

Sore shoulders can result from injury to the shoulder joints, tendons, ligaments, or muscles. Muscle spasms themselves seldom damage the muscle. Arthritis and bursitis are also causes of shoulder and joint pain. Any person who has persistent pain of any kind should see a physician to have all these causes investigated.

Like headaches, shoulder pain can have more than one cause, resulting in confusion in diagnosis and treatment. This was the case with Margaret Adams. Ms. Adams had suffered with pain in one shoulder for many years. It was diagnosed as bursitis, and she had been under treatment for many years for that condition. She logically blamed all her shoulder pain on her diagnosed bursitis.

However, Ms. Adams also had frequent headaches and sought treatment for TMJ. She really didn't expect any resolution of her shoulder pain. During treatment, she noticed that her shoulder pain was less frequent and less severe. TMJ treatment eliminated one component of the shoulder problem, relieving much of her pain, and isolating her additional condition, thus making it easier to treat.

BACK PAIN

Back pain can have so many causes that entire books have been written about it. A person who complains of regular back pain should have all other possible causes investigated and eliminated before TMJ is considered. This is especially true if the person has no headaches or any other common symptoms of TMJ.

Back pain can be caused by structural problems in the spine and discs. Posture problems can produce back pain, with or without accompanying TMJ. An infection in the kidneys or in other internal organs can cause pain in the back, and even a peptic ulcer can cause this symptom.

Muscle spasms may also be caused by back strain from heavy lifting or sports injuries. Strain in the legs or shoulders may be felt as pain in the back because of an imbalance in the muscles in the whole chain. Even a slight injury may change the contraction patterns of the other muscles.

Any of these causes of back pain can exist independently or together with TMJ, and these causes should be investigated. When seeking a diagnosis, be mindful of the kind of diagnosis you are getting. Systemic diseases, herniated discs, and sports injuries that respond to treatment may not need further investigation. But when the cause of back pain is given as tension or stress, then TMJ should be investigated, bearing in mind that people with TMJ rarely experience back pain independently of other TMJ symptoms.

NUMB FINGERS AND TOES

Numbness in the fingers and toes is a symptom that alarms many patients. It is associated with neurological disorders, and patients often fear that they have suffered a stroke. Indeed, a physician should evaluate this symptom to rule out neurological disorders. A definitive diagnosis of TMJ shouldn't be made until all neurological causes have been ruled out. Remember, symptoms may have more than one cause.

When TMJ is the cause of extremity numbness, the symptom is related to muscle spasms. When a muscle is in spasm, it is contracting, and in the contraction it gets fatter. The increased "belly" of the muscle may press on the actual nerves as they exit from the spinal column and travel to the extremities.

Because muscle spasms come and go, numbness comes and goes. Variations in intensity appear to have less to do with the concept of dipping and rising of the threshold to pain. Numbness may occur with other painful symptoms or without it. It is one symptom that seems to have a time schedule and manifestation schedule that isn't predictably related to a patient's discomfort.

Occasionally a patient will report that his or her extremities become cold and may even change color, becoming very pale or even bluish. This is caused by the pinching of nerves of the tiny muscles around the blood vessels. Pinching or squeezing these nerves can change blood flow and affect the extremities. As with all the other symptoms of TMJ, coldness of the extremities and changes in skin color may be caused by other disorders. Raynaud's disease is a common cause of this symptom and should be investigated and ruled out before TMJ is considered.

As with headaches, while TMJ may cause the symptoms mentioned here, any manifestation of them should be considered a medical problem. If a physician rules out medical causes, the dental profession can be called in to investigate TMJ. Descriptive diagnoses—ones that only re-describe the symptoms without giving a logical reason for them—are not necessarily definitive and should be questioned.