DiagnosticTree/CheekJaw
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{
"tree_id": "cheek-and-jaw-pain", "region": "Cheek and Jaw Pain", "start": "agg-1",
"redflags": {
"emergency": [
{
"id": "rf-e1",
"label": "Cardiac referred pain",
"question": "Is there jaw or left-sided cheek pain with an exertional component — worse on exertion, better at rest — or associated chest tightness or arm pain?",
"rationale": "Cardiac ischaemia reliably refers pain to the jaw and cheek, particularly on the left side. This must be excluded before any musculoskeletal assessment.",
"action": "Call emergency services immediately."
},
{
"id": "rf-e2",
"label": "Mandibular fracture",
"question": "Is there a history of direct trauma to the jaw with malocclusion, inability to close the mouth, or bony crepitus on palpation of the mandible?",
"rationale": "Mandibular fracture must be excluded before intraoral examination or jaw manipulation.",
"action": "Emergency referral to oral/maxillofacial surgery or ED. Do not proceed with intraoral assessment."
},
{
"id": "rf-e3",
"label": "Parotid abscess or deep space infection",
"question": "Is there rapidly progressive swelling of the cheek or jaw with fever, trismus, and systemic illness?",
"rationale": "Deep space infection (Ludwig's angina, parapharyngeal abscess) is a life-threatening emergency. Rapid progressive swelling with fever requires immediate medical attention.",
"action": "Emergency medical referral immediately."
}
],
"urgent": [
{
"id": "rf-u1",
"label": "Temporal arteritis",
"question": "Is the patient aged 50+ with jaw claudication — pain that builds progressively during chewing then eases completely at rest — temporal headache, or scalp tenderness?",
"rationale": "Jaw claudication is pathognomonic for temporal arteritis. Can cause irreversible blindness if untreated. Same-day ESR required.",
"action": "Same-day GP referral + ESR and CRP. Do not delay for myofascial assessment."
},
{
"id": "rf-u2",
"label": "Parotid or neck malignancy",
"question": "Is there a hard fixed parotid or submandibular swelling, progressive facial nerve weakness, or unexplained trismus?",
"rationale": "Salivary gland malignancy and other neoplasms can present as cheek or jaw pain with or without a palpable mass.",
"action": "Urgent ENT or head and neck surgery referral."
},
{
"id": "rf-u3",
"label": "Eagle syndrome",
"question": "Is there throat, ear, and jaw pain provoked by turning the head or swallowing, with a sensation of foreign body in the throat?",
"rationale": "Elongated styloid process can mimic digastric and medial pterygoid TrP patterns. Intraoral palpation in the tonsillar fossa confirms.",
"action": "If recalcitrant to TrP treatment, panoramic radiograph and oral/maxillofacial surgery referral."
}
]
},
"nodes": {
"agg-1": {
"type": "choice",
"question": "What is the PRIMARY mechanism or distinctive quality of the cheek and jaw pain?",
"clinical_rationale": "Eleven muscles contribute to cheek and jaw pain. The first split separates them by mechanism and quality. Jaw activity (chewing, clenching, bruxism, biting) implicates the six masticatory and masticatory-chain muscles. Neck and shoulder loading without jaw aggravation implicates SCM sternal division and upper trapezius TrP₁. A distinctive sensory quality — prickling over the mandible, nasal arc from cheek to nose to forehead, nose-cheek-lip referral, or jumpy print — points to the satellite facial muscles (platysma, zygomaticus major, orbicularis oculi), which are nearly always driven by SCM sternal or masticatory TrPs.",
"options": [
{
"label": "Jaw activity aggravates — chewing, clenching, biting, or bruxism",
"sublabel": "Jaw use reproduces or worsens the cheek or jaw pain; may have tooth sensitivity or swallowing symptoms",
"next": "jaw-symptom-split-1"
},
{
"label": "Neck or shoulder loading aggravates — no clear jaw component",
"sublabel": "Rotation, shoulder elevation, sustained forward head position, or carrying load worsens the cheek or jaw angle pain",
"next": "autonomic-split-1"
},
{
"label": "Distinctive sensory quality or referral pattern — prickling, nasal arc, nose-lip referral, or jumpy print",
"sublabel": "Pain described as pinpricks over the jaw; OR curved arc from cheek up the nose to forehead; OR pain to side of nose and upper lip; OR letters jump when reading",
"next": "satellite-split-1"
}
]
},
"jaw-symptom-split-1": {
"type": "choice",
"question": "Within the jaw-aggravated group — which feature best characterises the cheek and jaw pain?",
"clinical_rationale": "Six muscles are active on jaw use. Their cheek and jaw pain patterns are separated by four distinguishing features. Tooth hypersensitivity in the upper molar zone (masseter superficial) vs lower incisor zone (digastric anterior) vs no tooth involvement is the first separator. Tinnitus (low roaring) points to the deep masseter. Ear stuffiness + dysphagia points to medial pterygoid. Closing/protrusion pain points to lateral pterygoid. Perceived swallowing difficulty with mid-cheek ache and dental appliance history points to buccinator. Pseudo-SCM throat and neck pain with swallowing points to digastric posterior.",
"options": [
{
"label": "Tooth hypersensitivity — heat, cold, percussion, or biting — WITHOUT dental pathology",
"sublabel": "Multiple teeth sensitive across a zone; dentist has found no cause",
"next": "tooth-zone-split-1"
},
{
"label": "Tinnitus — a low roaring or buzzing in the ear on the same side as the jaw pain",
"sublabel": "Ear noise possibly activated or interrupted by wide jaw opening; not associated with hearing loss",
"next": "exam-masseter-deep-1"
},
{
"label": "Ear stuffiness or muffled hearing AND difficulty swallowing — with restricted mouth opening",
"sublabel": "Barohypoacusis — cannot equalise ear pressure; swallowing compensation (extends neck, pushes tongue forward)",
"next": "exam-medial-pterygoid-1"
},
{
"label": "Pain specifically on CLOSING the jaw or biting down — and/or clicking in the jaw with jaw deviation",
"sublabel": "Worse on resisted jaw closure; TMJ click; premature tooth contact on the opposite side",
"next": "exam-lateral-pterygoid-1"
}
]
},
"tooth-zone-split-1": {
"type": "symptom",
"question": "Are the hypersensitive teeth in the UPPER jaw (molars, premolars, or incisors) — or in the LOWER jaw specifically at the incisor teeth?",
"symptom_name": "Tooth hypersensitivity zone — upper vs lower incisor",
"muscles_implicated": ["Masseter (Superficial)", "Digastric (Anterior Belly)"],
"clinical_rationale": "Upper tooth hypersensitivity across a zone is characteristic of masseter superficial and temporalis TrPs. Lower incisor tooth hypersensitivity specifically — without upper tooth involvement — is characteristic of the anterior belly of the digastric, which refers pain to the four lower incisor teeth. This distinction can prevent unnecessary dental treatment on the wrong arch.",
"yes": "exam-masseter-superficial-1",
"no": "exam-digastric-anterior-1"
},
"exam-masseter-superficial-1": {
"type": "examination",
"question": "Does flat or pincer palpation of the superficial masseter — from the zygomatic arch downward to the gonial angle — reproduce the cheek or jaw pain and confirm zone tooth hypersensitivity?",
"exam_type": "palpation",
"landmark": "Palpate the superficial masseter from the zygomatic arch downward to the gonial angle. The upper anterior TrP zone refers to the cheek, infraorbital area, upper and lower molar teeth, and eyebrow. Confirm zone tooth hypersensitivity — multiple teeth sensitive across a zone rather than a single tooth. Sinusitis-like maxillary pain with normal sinus radiographs confirms anterior-superior TrP referral. Note jaw deviation toward the affected side on slow mouth opening.",
"positive_finding": "Tenderness in the masseter belly reproducing cheek or jaw pain. Zone tooth hypersensitivity without dental pathology.",
"muscles_implicated": ["Masseter (Superficial)"],
"yes": "result-masseter-superficial",
"no": "buccinator-screen-1"
},
"exam-digastric-anterior-1": {
"type": "examination",
"question": "Does palpation of the anterior digastric belly — at the floor of the mouth along the inferior border of the mandible — reproduce the lower incisor tooth pain? Is mandibular deviation present on jaw opening?",
"exam_type": "palpation",
"landmark": "Anterior belly: palpate along the inferior border of the mandible from the midline symphysis posteriorly to the intermediate tendon zone near the hyoid. Ask the patient to relax the jaw completely. Mandibular Deviation Sign: ask the patient to open the jaw slowly and observe whether the mandible deviates toward the side of active TrPs. Anterior Digastric Test: place a finger on the lower incisors and ask the patient to open against resistance — pain reproduction confirms anterior belly involvement.",
"positive_finding": "Lower incisor tooth pain reproduced by anterior belly palpation. Mandibular deviation toward the TrP side on opening.",
"muscles_implicated": ["Digastric (Anterior Belly)"],
"yes": "result-digastric-anterior",
"no": "buccinator-screen-1"
},
"buccinator-screen-1": {
"type": "symptom",
"question": "Does the patient report a perceived difficulty swallowing — a sensation that swallowing is effortful or difficult — even though swallowing appears normal on observation? Is there a history of a dental appliance, orthodontic brace, or splint?",
"symptom_name": "Perceived dysphagia + dental appliance history",
"muscles_implicated": ["Buccinator"],
"clinical_rationale": "Perceived difficulty swallowing — reported by the patient but not observable on examination — is a referred autonomic effect of buccinator TrPs, not a structural swallowing disorder. Combined with a mid-cheek subzygomatic jaw ache and a history of dental appliance use, this symptom pattern is highly specific for buccinator TrP involvement. The swallowing movement appears completely normal on observation.",
"yes": "exam-buccinator-1",
"no": "digastric-posterior-screen-1"
},
"exam-buccinator-1": {
"type": "examination",
"question": "Does palpation of the buccinator — flat palpation of the mid-cheek from the outside, or pincer palpation with a gloved intraoral finger — reproduce local cheek pain or the deep subzygomatic jaw ache?",
"exam_type": "palpation",
"landmark": "Buccinator TrP: flat palpation of the mid-cheek with the index finger pad pressing inward toward the buccal mucosa — TrP tenderness will be focal and focal reproduction of the familiar cheek ache confirms it. Pincer palpation with a gloved intraoral finger pad against the cheek mucosa. The TrP is in the belly of the mid-cheek. Note: the buccinator is pierced by the parotid duct — avoid excessive pressure over Stensen's duct. Inspect for dental appliances, orthodontic hardware, or occlusal splints as the likely activating cause.",
"positive_finding": "Focal mid-cheek tenderness reproducing local cheek pain or deep subzygomatic jaw ache. Perceived swallowing difficulty confirmed as normal on observation.",
"muscles_implicated": ["Buccinator"],
"yes": "result-buccinator",
"no": "digastric-posterior-screen-1"
},
"digastric-posterior-screen-1": {
"type": "symptom",
"question": "Is there throat discomfort or pain anterior to the SCM and under the chin — a pattern resembling SCM pain — with the jaw pain following a period of masticatory muscle dysfunction?",
"symptom_name": "Pseudo-SCM throat and upper neck pain",
"muscles_implicated": ["Digastric (Posterior Belly)"],
"clinical_rationale": "The posterior belly of the digastric refers pain to the upper SCM region and throat — a pattern so similar to SCM TrP pain that it is called pseudo-sternocleidomastoid pain. An occasional component extends to the occiput. It nearly always develops secondary to masseter TrPs. The Swallowing Test (palpating the posterior belly while the patient swallows) and the Mandibular Deviation Sign are the key clinical tests.",
"yes": "exam-digastric-posterior-1",
"no": "result-overlap"
},
"exam-digastric-posterior-1": {
"type": "examination",
"question": "Does palpation of the posterior digastric belly — along the course from the mastoid notch downward and forward to the hyoid — reproduce the throat or upper neck pain? Does the Swallowing Test (palpation during swallowing) produce pain or tension?",
"exam_type": "palpation",
"landmark": "Posterior belly: palpate along its course from the mastoid notch, passing deep to the lower SCM and toward the hyoid. Jaw must be completely relaxed — tension will obscure the examination. Swallowing Test: palpate the posterior belly and ask the patient to swallow a small amount of saliva — pain or increased tension confirms involvement. Mandibular Deviation Sign: observe jaw opening for deviation toward the TrP side.",
"positive_finding": "Tenderness along the posterior belly from mastoid notch toward the hyoid. Swallowing Test positive.",
"muscles_implicated": ["Digastric (Posterior Belly)"],
"yes": "result-digastric-posterior",
"no": "result-overlap"
},
"exam-masseter-deep-1": {
"type": "examination",
"question": "Does firm flat palpation of the deep masseter — against the posterior ramus of the mandible and zygomatic buttress, and specifically at the upper posterior zone anterior to the tragus — reproduce the ear pain or activate the tinnitus?",
"exam_type": "palpation",
"landmark": "Deep masseter: palpate along the posterior ramus from the gonial angle upward to the zygomatic buttress with firm flat pressure. Tinnitus provocation test: sustained pressure at the upper posterior zone just anterior to the tragus — this TrP may activate or reproduce ipsilateral tinnitus. Note: infraorbital puffiness and palpebral fissure narrowing on the affected side (venous entrapment of maxillary vein). Tinnitus confirmed as low roaring quality without hearing loss or vertigo.",
"positive_finding": "Deep masseter palpation reproduces ear or jaw pain. Tinnitus provocation test activates or reproduces the familiar low roaring tinnitus.",
"muscles_implicated": ["Masseter (Deep)"],
"yes": "result-masseter-deep",
"no": "jaw-symptom-split-1"
},
"exam-medial-pterygoid-1": {
"type": "examination",
"question": "Does intraoral palpation of the medial pterygoid — gloved finger behind the last molar on the medial surface of the mandibular ramus — reproduce the ear stuffiness, throat pain, or jaw ache? Ask the patient to alternately clench and relax to identify the muscle.",
"exam_type": "palpation",
"landmark": "Intraoral central TrP: patient supine, jaw drops open as far as comfortable. Gloved index finger slides over the molar teeth to the bony anterior edge of the ramus — the medial pterygoid belly lies immediately posterior to this edge. Palpate for exquisite tenderness with referral to throat, palate, or ear. Gag reflex management: ask the patient to exhale fully or tap the ipsilateral temporalis as sensory distraction. Extraoral: press upward at the angle of the mandible along its inner medial surface.",
"positive_finding": "Intraoral palpation reproduces ear stuffiness, throat tightness, or jaw ache. Ear stuffiness (barohypoacusis) confirmed.",
"muscles_implicated": ["Medial Pterygoid"],
"yes": "result-medial-pterygoid",
"no": "exam-lateral-pterygoid-1"
},
"exam-lateral-pterygoid-1": {
"type": "examination",
"question": "Is pain reproduced or worsened by jaw PROTRUSION against resistance applied at the chin? Does placing a tongue blade between the molar teeth on the painful side eliminate pain on vigorous clenching?",
"exam_type": "provocation",
"landmark": "Resisted protrusion test: patient seated, examiner applies firm resistance at the chin while the patient protrudes the jaw — pain on resisted protrusion is specific to lateral pterygoid TrPs (0% of asymptomatic controls find this painful). Tongue blade test: insert a blade between the molar teeth on the painful side and ask the patient to clench vigorously — elimination of pain strongly implicates the inferior division on that side. Also assess: lateral excursion reduced toward the SAME side as the involved muscle; premature anterior tooth contact on the OPPOSITE side.",
"positive_finding": "Pain on resisted jaw protrusion. Tongue blade test eliminates pain on clenching. Lateral excursion reduced toward the painful side.",
"muscles_implicated": ["Lateral Pterygoid"],
"yes": "result-lateral-pterygoid",
"no": "buccinator-screen-1"
},
"autonomic-split-1": {
"type": "symptom",
"question": "Are there ipsilateral AUTONOMIC phenomena alongside the cheek or jaw pain — profuse tearing, rhinitis (watering or blocked nose on the same side), conjunctival redness, or apparent eyelid drooping WITHOUT pupil constriction?",
"symptom_name": "Autonomic phenomena — tearing, rhinitis, palpebral narrowing without miosis",
"muscles_implicated": ["SCM (Sternal Division)"],
"muscles_excluded": ["Upper Trapezius TrP₁"],
"clinical_rationale": "Autonomic phenomena are specific to the sternal division of the SCM. In the cheek and jaw region the sternal SCM refers to the cheek and jaw angle alongside its orbital and temporal patterns. Tearing is often more alarming than the pain itself. Palpebral fissure narrowing mimics Horner ptosis without miosis. Absence of autonomic phenomena routes to upper trapezius examination — trapezius TrP₁ refers to the jaw angle and temple at high intensity without autonomic features.",
"yes": "exam-scm-sternal-1",
"no": "exam-trapezius-1"
},
"exam-scm-sternal-1": {
"type": "examination",
"question": "Does pincer palpation of the SCM sternal head — grasping the full belly from mastoid to sternum — reproduce the cheek or jaw angle pain? Does the SCM Compression Test (firmly gripping the belly while swallowing) resolve a concurrent sore throat?",
"exam_type": "palpation",
"landmark": "Patient supine, head rotated slightly toward the TrP side. Pincer grip full sternal belly from mastoid to sternum. SCM Compression Test: firmly grip the belly and ask the patient to swallow — resolution of pharyngeal pain is pathognomonic of a sternal central TrP. Note palpebral fissure width — narrowing without miosis confirms sternal division. Head tilts toward the TrP side.",
"positive_finding": "Cheek or jaw angle pain reproduced. Tearing or rhinitis on the same side. SCM Compression Test may relieve sore throat.",
"muscles_implicated": ["SCM (Sternal Division)"],
"yes": "scm-satellite-screen-1",
"no": "exam-trapezius-1"
},
"scm-satellite-screen-1": {
"type": "choice",
"question": "SCM sternal is confirmed. Are any of these SATELLITE features also present alongside the cheek pain?",
"clinical_rationale": "SCM sternal TrPs commonly drive satellite TrPs in three facial muscles — zygomaticus major (nasal arc pattern), orbicularis oculi (jumpy print, nose-lip referral), and platysma (prickling over the mandible). Identifying active satellites at this stage changes the treatment plan — SCM must be treated first and the satellite often resolves without direct treatment. This is a clinical efficiency question rather than a diagnostic question.",
"options": [
{
"label": "Nasal arc pattern — cheek pain that curves up along the nose to the mid-forehead; jaw restriction 10–20mm",
"sublabel": "Curved path from cheek through nose to forehead; possibly reduced jaw opening",
"next": "result-scm-plus-zygomaticus"
},
{
"label": "Jumpy print when reading — OR pain to the side of the nose and upper lip",
"sublabel": "Letters jump when reading black on white; OR pain traces from the eye to the nose and upper lip",
"next": "result-scm-plus-orbicularis"
},
{
"label": "Prickling or pinprick sensation over the lateral jaw and mandible skin",
"sublabel": "Multiple simultaneous pinpricks over the jaw surface — not tingling, not electric",
"next": "result-scm-plus-platysma"
},
{
"label": "None of the above — cheek and jaw pain only",
"sublabel": "No nasal arc, no jumpy print, no nose-lip referral, no prickling",
"next": "result-scm-sternal"
}
]
},
"exam-trapezius-1": {
"type": "examination",
"question": "Does pincer palpation of upper trapezius TrP₁ — at the most vertical midportion of the anterior border — reproduce the jaw angle, temple, or cheek pain at high stimulus intensity?",
"exam_type": "palpation",
"landmark": "TrP₁ is at the midportion of the anterior border of the upper trapezius in the most vertical fibres. Grasp with a firm pincer grip. At high intensity TrP₁ refers up along the posterolateral neck to the mastoid, then into the temple and jaw angle. Note ipsilateral head tilt — ear toward the TrP shoulder. Confirm: does shoulder carrying on the same side reproduce or worsen the jaw or cheek pain?",
"positive_finding": "Jaw angle or cheek pain reproduced at high stimulus intensity by TrP₁. Ipsilateral head tilt present. Shoulder loading aggravates.",
"muscles_implicated": ["Upper Trapezius (TrP₁)"],
"yes": "result-trapezius",
"no": "result-overlap"
},
"satellite-split-1": {
"type": "choice",
"question": "Which distinctive feature or pattern best describes the cheek or jaw pain presentation?",
"clinical_rationale": "Three satellite facial muscles present with distinctive features that allow direct routing to examination without working through the full masticatory or SCM pathways. Prickling (multiple pinpricks) over the mandible is pathognomonic for platysma — always a satellite of SCM or scalene. The nasal arc (cheek to nose to forehead) is specific to zygomaticus major — a satellite of SCM sternal or masticatory dysfunction. Nose-cheek-lip referral with jumpy print is specific to orbicularis oculi — a satellite of SCM sternal. All three should route to their respective examination but also trigger SCM examination regardless.",
"options": [
{
"label": "Prickling over the lateral jaw — multiple simultaneous pinprick sensations over the mandible skin",
"sublabel": "Not tingling, not electric — like multiple simultaneous pinpricks on the jaw surface",
"next": "exam-platysma-1"
},
{
"label": "Pain curves from the cheek up the side of the nose to the mid-forehead — nasal arc",
"sublabel": "Curved path from cheek through nose to forehead; jaw opening may be mildly restricted",
"next": "exam-zygomaticus-1"
},
{
"label": "Pain to the side of the nose, cheek near the nose, and upper lip — OR jumpy print when reading",
"sublabel": "Letters jump or vibrate when reading black on white; OR pain from the eye to the nose and upper lip on the same side",
"next": "exam-orbicularis-1"
}
]
},
"exam-platysma-1": {
"type": "examination",
"question": "Does flat palpation of the platysma — pressing over the lateral jaw and anterior neck skin overlying the SCM — reproduce the prickling sensation? Are SCM and scalene TrPs also active on the same side?",
"exam_type": "palpation",
"landmark": "Platysma TrPs are most commonly found in the subcutaneous fascia overlying the SCM muscle belly. Palpate firmly over the lateral jaw and anterior neck skin. The prickling pain should be reproduced by sustained pressure over the TrP. ALWAYS examine the SCM, scalene, and masticatory muscles on the same side — platysma TrPs are virtually never present without at least one active TrP in those muscles.",
"positive_finding": "Focal tenderness over the platysma belly overlying the SCM, reproducing the prickling sensation over the lateral jaw.",
"muscles_implicated": ["Platysma"],
"yes": "result-platysma",
"no": "result-overlap"
},
"exam-zygomaticus-1": {
"type": "examination",
"question": "Does flat palpation of the zygomaticus major — along the diagonal from the zygomatic bone to the angle of the mouth — reproduce the nasal arc pattern? Is jaw opening mildly restricted (10–20mm reduction)?",
"exam_type": "palpation",
"landmark": "Palpate with the index finger pad along the diagonal from the malar prominence of the zygomatic bone to the angle of the mouth. The muscle is superficial and ribbon-like. Also measure interincisal opening — active TrPs reduce opening by 10–20mm; inactivating the TrPs should restore opening immediately as an intratreatment confirmation. Also examine SCM sternal division — zygomaticus major is almost always its satellite.",
"positive_finding": "Tenderness along the diagonal belly reproducing the nasal arc. Jaw opening possibly reduced 10–20mm.",
"muscles_implicated": ["Zygomaticus Major"],
"yes": "result-zygomaticus",
"no": "result-overlap"
},
"exam-orbicularis-1": {
"type": "examination",
"question": "Does flat palpation along the upper orbital rim from medial to lateral canthus reproduce a tender spot that refers pain to the side of the nose, cheek, or upper lip? Is jumpy print present when reading?",
"exam_type": "palpation",
"landmark": "Palpate firmly along the upper orbital rim from the medial canthus to the lateral angle. Referral is to the side of the nose, cheek near the nose, and upper lip — NOT to the eyebrow or forehead. Jumpy print: ask specifically whether letters appear to jump or vibrate when reading black text on a white background — this is pathognomonic for orbicularis oculi TrP involvement. Confirm pupils equal and reactive — palpebral fissure narrowing without miosis.",
"positive_finding": "Orbital rim tenderness reproducing nose-cheek-lip referral. Jumpy print confirmed. Palpebral narrowing without miosis.",
"muscles_implicated": ["Orbicularis Oculi"],
"yes": "result-orbicularis",
"no": "result-overlap"
},
"result-masseter-superficial": {
"type": "result",
"diagnosis": "Masseter — Superficial Head Trigger Point",
"confidence": "high",
"wiki_page": "Muscle:Masseter",
"chapter_ref": "Travell & Simons Vol.1 — Ch.8 Masseter",
"notes": "Superficial masseter TrPs refer to the cheek, lower jaw, upper and lower molar teeth, maxilla (commonly described as sinusitis without fever or discharge), eyebrow, and temple. Zone tooth hypersensitivity — percussion, heat, cold, biting pressure — distributed across multiple teeth in the molar-premolar zone without dental pathology is cardinal. Sinusitis-like maxillary pain with normal sinus radiographs confirms the anterior-superior TrP pattern. Jaw deviation toward the affected side on slow opening is a useful clinical sign. Gonial angle tenderness on flat palpation is enthesopathy from bruxism, not a primary TrP. Treatment is not complete until SCM and upper trapezius key TrPs are inactivated.",
"treatment_hint": "Pincer palpation with one digit inside the mouth and one outside. Spray and stretch, intraoral massage. Address parafunctional habits. Treat SCM and upper trapezius as key TrPs first.",
"also_consider": ["Upper Trapezius (key TrP)", "SCM Sternal (key TrP)", "Temporalis ATrP₁", "Masseter Deep"],
"less_likely": [
{ "muscle": "Masseter Deep", "reason": "Zone tooth hypersensitivity and cheek-centred pattern argue for superficial head; deep head produces tinnitus and ear pain without tooth referral" },
{ "muscle": "Buccinator", "reason": "Zone tooth hypersensitivity is not a buccinator feature — buccinator produces mid-cheek local pain and subzygomatic ache with perceived dysphagia" },
{ "muscle": "Medial Pterygoid", "reason": "No ear stuffiness or dysphagia; tooth hypersensitivity in the molar zone is specific to masseter superficial" }
],
"confirmatory": [
"Zone tooth hypersensitivity (upper and lower molars) across multiple teeth without dental pathology",
"Sinusitis-like maxillary pain with normal sinus radiographs",
"Jaw deviation toward the affected side on slow opening",
"Gonial angle enthesopathy — bruxism indicator, not TrP"
],
"satellite_trps": ["Temporalis", "Medial Pterygoid", "Deep Masseter", "SCM (key TrP)", "Upper Trapezius (key TrP)"],
"landing_page_topics": [
"Superficial vs deep masseter — cheek/teeth vs tinnitus/ear distinction",
"Zone tooth hypersensitivity — preventing unnecessary dental treatment",
"Sinusitis misdiagnosis",
"Gonial angle enthesopathy vs TrP distinction"
],
"related_pages": [
{ "label": "Masseter Deep →", "page": "Muscle:Masseter" },
{ "label": "Temporalis TrP →", "page": "Muscle:Temporalis" },
{ "label": "TMJ Screening →", "page": "Pain:TMJ_Screening_Examination" }
]
},
"result-masseter-deep": {
"type": "result",
"diagnosis": "Masseter — Deep Layer Trigger Point",
"confidence": "high",
"wiki_page": "Muscle:Masseter",
"chapter_ref": "Travell & Simons Vol.1 — Ch.8 Masseter",
"notes": "Deep masseter TrPs refer pain deep into the ear, to the TMJ area, and to the diffuse mid-cheek. The upper posterior TrP is the tinnitus TrP — it produces a low roaring unilateral tinnitus that may be activated or interrupted by wide jaw opening, without hearing loss or vertigo. Infraorbital puffiness and palpebral fissure narrowing on the affected side may result from venous entrapment of the maxillary vein. Active TrPs in the deep layer closely mimic TMJ rheumatic disease — the joint itself is non-tender on palpation. Bilateral tinnitus suggests a systemic cause rather than myofascial.",
"treatment_hint": "External flat palpation against the posterior ramus and zygomatic buttress. Spray and stretch over TMJ. Tinnitus provocation test confirms involvement. Treat SCM and upper trapezius as key TrPs first.",
"also_consider": ["Masseter Superficial", "Lateral Pterygoid", "SCM Sternal (key TrP)", "Upper Trapezius (key TrP)"],
"less_likely": [
{ "muscle": "Masseter Superficial", "reason": "No tooth hypersensitivity; tinnitus and ear referral are specific to the deep layer" },
{ "muscle": "Medial Pterygoid", "reason": "No ear stuffiness or dysphagia; tinnitus (low roaring) is specific to deep masseter" },
{ "muscle": "Lateral Pterygoid", "reason": "No resisted protrusion pain; tinnitus and ear referral argue for deep masseter" }
],
"confirmatory": [
"Tinnitus provocation test positive — sustained pressure at upper posterior zone activates tinnitus",
"Tinnitus: low roaring quality, no hearing loss, no vertigo — distinguishes from vestibular cause",
"Tinnitus activated or interrupted by wide jaw opening",
"Joint palpation negative — no TMJ capsule tenderness",
"Infraorbital puffiness and palpebral narrowing on affected side (venous entrapment)"
],
"satellite_trps": ["Temporalis", "Medial Pterygoid", "SCM (key TrP)", "Upper Trapezius (key TrP)"],
"landing_page_topics": [
"Tinnitus mechanism and provocation test",
"Venous entrapment — infraorbital puffiness mechanism",
"Bilateral tinnitus — systemic vs myofascial",
"Deep vs superficial layer palpation technique"
],
"related_pages": [
{ "label": "Masseter Superficial →", "page": "Muscle:Masseter" },
{ "label": "Lateral Pterygoid TrP →", "page": "Muscle:Lateral_Pterygoid" },
{ "label": "TMJ Screening →", "page": "Pain:TMJ_Screening_Examination" }
]
},
"result-medial-pterygoid": {
"type": "result",
"diagnosis": "Medial Pterygoid Trigger Point",
"confidence": "high",
"wiki_page": "Muscle:Medial_Pterygoid",
"chapter_ref": "Travell & Simons Vol.1 — Ch.9 Medial Pterygoid",
"notes": "Medial pterygoid TrPs refer diffusely to the tongue, pharynx, hard palate, below and behind the TMJ, and deep into the ear. Pain is NOT referred to the teeth — distinguishes from masseter and temporalis. Barohypoacusis (ear stuffiness, inability to equalise ear pressure) is characteristic — tense TrP bands block the tensor veli palatini from opening the eustachian tube. The compensatory swallowing pattern is pathognomonic: patient extends neck and pushes tongue forward when swallowing. Bitter metallic taste indicates chorda tympani entrapment between the medial pterygoid and the mandible.",
"treatment_hint": "Intraoral ischemic compression and spray and stretch. Resisted jaw opening for reciprocal inhibition. Address lateral pterygoid and masseter concurrently — medial pterygoid rarely has TrPs in isolation.",
"also_consider": ["Lateral Pterygoid", "Masseter", "SCM"],
"less_likely": [
{ "muscle": "Lateral Pterygoid", "reason": "Ear stuffiness and dysphagia are specific to medial pterygoid; lateral pterygoid produces closing/protrusion pain" },
{ "muscle": "Masseter Deep", "reason": "Ear stuffiness and throat referral argue for medial pterygoid; tinnitus is specific to deep masseter" },
{ "muscle": "Buccinator", "reason": "True difficulty swallowing with ear stuffiness is medial pterygoid; buccinator produces perceived difficulty only, without ear involvement" }
],
"confirmatory": [
"Ear stuffiness (barohypoacusis) — inability to equalise ear pressure; specific to medial pterygoid",
"Compensatory swallowing — extends neck and pushes tongue forward; pathognomonic",
"Pain NOT referred to teeth — distinguishes from masseter and temporalis",
"Chorda tympani entrapment: bitter metallic taste",
"Mandibular deviation most marked to the contralateral side at maximum opening"
],
"satellite_trps": ["Lateral Pterygoid", "Masseter", "Temporalis", "Digastric"],
"landing_page_topics": [
"Intraoral palpation technique and gag reflex management",
"Barohypoacusis — eustachian tube mechanism",
"Chorda tympani entrapment — metallic taste",
"Compensatory swallowing pattern",
"Resisted jaw opening for reciprocal inhibition"
],
"related_pages": [
{ "label": "Lateral Pterygoid TrP →", "page": "Muscle:Lateral_Pterygoid" },
{ "label": "Masseter TrP →", "page": "Muscle:Masseter" },
{ "label": "TMJ Screening →", "page": "Pain:TMJ_Screening_Examination" }
]
},
"result-lateral-pterygoid": {
"type": "result",
"diagnosis": "Lateral Pterygoid Trigger Point",
"confidence": "high",
"wiki_page": "Muscle:Lateral_Pterygoid",
"chapter_ref": "Travell & Simons Vol.1 — Ch.11 Lateral Pterygoid",
"notes": "The lateral pterygoid is the chief myofascial source of TMJ area pain. Inferior division TrPs displace the condyle anteriorly, producing premature anterior tooth contact on the opposite side and altered occlusion. Clicking results from lateral pterygoid dysfunction. Pain is NOT referred to the teeth. Severe pain to the maxillary sinus region may be described as sinusitis. Buccal nerve entrapment produces weird tingling or numbness of the cheek with buccinator weakness.",
"treatment_hint": "Tongue-tip-to-palate test confirms as chief cause of muscular imbalance. Tongue blade test confirms inferior division. Spray and stretch, intraoral ischemic compression. Treat masseter and temporalis first to allow adequate mouth opening. Address forward head posture and parafunctional habits.",
"also_consider": ["Medial Pterygoid", "Masseter Deep", "SCM"],
"less_likely": [
{ "muscle": "Medial Pterygoid", "reason": "Resisted protrusion pain and tongue blade test are specific to lateral pterygoid; medial pterygoid produces throat and palate referral" },
{ "muscle": "Masseter Deep", "reason": "Closing pain and condylar displacement argue against masseter; no tinnitus" },
{ "muscle": "Buccinator", "reason": "Resisted protrusion and condylar displacement are specific to lateral pterygoid" }
],
"confirmatory": [
"Resisted jaw protrusion pain — 0% of asymptomatic controls; highly specific",
"Tongue blade test eliminates pain on clenching — confirms inferior division",
"Tongue-tip-to-palate test straightens incisal path on opening",
"Lateral excursion reduced toward the SAME side as involved muscle",
"Pain NOT referred to teeth",
"Buccal nerve entrapment: cheek tingling with buccinator weakness"
],
"satellite_trps": ["Medial Pterygoid", "Masseter Deep", "Temporalis (posterior fibres)"],
"landing_page_topics": [
"Tongue-tip-to-palate and tongue blade tests",
"Condylar displacement and occlusal changes",
"Buccal nerve entrapment",
"Intraoral palpation false positive rate (27.6%)",
"Resisted protrusion as confirmatory test"
],
"related_pages": [
{ "label": "Medial Pterygoid TrP →", "page": "Muscle:Medial_Pterygoid" },
{ "label": "Masseter TrP →", "page": "Muscle:Masseter" },
{ "label": "TMJ Screening →", "page": "Pain:TMJ_Screening_Examination" }
]
},
"result-digastric-anterior": {
"type": "result",
"diagnosis": "Digastric — Anterior Belly Trigger Point",
"confidence": "high",
"wiki_page": "Muscle:Digastric",
"chapter_ref": "Travell & Simons Vol.1 — Ch.12 Digastric",
"notes": "The anterior belly refers pain to the four lower incisor teeth — a pattern that leads to unnecessary dental treatment when the muscle is not examined. The distinction between upper tooth hypersensitivity (masseter, temporalis) and lower incisor hypersensitivity (anterior digastric) is one of the most clinically useful separators in the cheek and jaw pain group. The anterior belly TrPs develop secondary to masseter TrPs and are part of the masticatory-chain complex — treat masseter first.",
"treatment_hint": "Treat masseter TrPs first — anterior digastric is their satellite. Spray and stretch. Anterior Digastric Test: resist jaw opening to confirm. Assess hyoid mobility — restricted lateral shift indicates suprahyoid muscle tension.",
"also_consider": ["Masseter (key TrP)", "Medial Pterygoid", "Mylohyoid"],
"less_likely": [
{ "muscle": "Masseter Superficial", "reason": "Lower incisor specificity distinguishes anterior digastric from masseter molar-zone hypersensitivity" },
{ "muscle": "Temporalis ATrP₁", "reason": "Temporalis refers to the upper incisors from the anterior spoke; lower incisors are specific to anterior digastric" }
],
"confirmatory": [
"Lower incisor tooth hypersensitivity specifically — four lower incisors, without upper tooth involvement",
"Anterior belly palpation at the floor of the mouth reproduces lower incisor pain",
"Anterior Digastric Test: resist jaw opening — pain reproduction confirms",
"Mandibular deviation toward the TrP side on slow jaw opening",
"Masseter TrPs also active — anterior digastric is their satellite"
],
"satellite_trps": ["Masseter (key TrP)", "Medial Pterygoid", "Mylohyoid"],
"landing_page_topics": [
"Lower incisor referral — preventing unnecessary dental treatment",
"Anterior vs posterior belly — different referral patterns",
"Hyoid mobility assessment",
"Anterior Digastric Test technique"
],
"related_pages": [
{ "label": "Masseter TrP →", "page": "Muscle:Masseter" },
{ "label": "SCM TrP →", "page": "Muscle:Sternocleidomastoid" }
]
},
"result-digastric-posterior": {
"type": "result",
"diagnosis": "Digastric — Posterior Belly Trigger Point",
"confidence": "moderate",
"wiki_page": "Muscle:Digastric",
"chapter_ref": "Travell & Simons Vol.1 — Ch.12 Digastric",
"notes": "The posterior belly refers pain to the upper SCM region and throat — a pattern so similar to SCM TrP pain that it is called pseudo-sternocleidomastoid pain. An occasional component extends to the occiput. The digastric nearly always develops TrPs secondary to masseter TrPs rather than in isolation. The mutual satellite relationship with the SCM (either can drive the other) requires systematic examination of both. Eagle syndrome must be excluded if posterior belly TrPs are recalcitrant.",
"treatment_hint": "Treat masseter TrPs first. Spray and stretch the posterior belly. Swallowing Test confirms. Assess hyoid mobility. Eagle syndrome exclusion: intraoral palpation in the tonsillar fossa if recalcitrant.",
"also_consider": ["Masseter (key TrP)", "SCM Sternal Division", "Medial Pterygoid", "Stylohyoid"],
"less_likely": [
{ "muscle": "SCM Sternal Division", "reason": "No autonomic phenomena; pseudo-SCM pattern with swallowing involvement argues for posterior digastric" },
{ "muscle": "Medial Pterygoid", "reason": "No ear stuffiness or barohypoacusis; throat pain with pseudo-SCM pattern is specific to posterior digastric" }
],
"confirmatory": [
"Pseudo-SCM pain pattern — upper SCM region and throat, not the full facial and autonomic SCM pattern",
"Swallowing Test positive — pain or tension in posterior belly during swallowing",
"Mandibular Deviation Sign — deviation toward TrP side on slow jaw opening",
"Masseter TrPs identified — digastric is almost always secondary",
"Eagle syndrome excluded — no intraoral tonsillar fossa tenderness"
],
"satellite_trps": ["Masseter (key TrP)", "SCM Sternal Division", "Medial Pterygoid", "Mylohyoid"],
"landing_page_topics": [
"Pseudo-SCM pain — posterior belly vs SCM sternal",
"Anterior belly and lower incisor tooth pain",
"Swallowing Test and hyoid mobility",
"Eagle syndrome exclusion",
"Mandibular Deviation Sign"
],
"related_pages": [
{ "label": "SCM TrP →", "page": "Muscle:Sternocleidomastoid" },
{ "label": "Masseter TrP →", "page": "Muscle:Masseter" }
]
},
"result-buccinator": {
"type": "result",
"diagnosis": "Buccinator Trigger Point",
"confidence": "high",
"wiki_page": "Muscle:Buccinator",
"chapter_ref": "Travell & Simons Vol.1 — Ch.13 Buccinator",
"notes": "Buccinator TrPs produce local cheek pain and a deep subzygomatic jaw ache that is one of the most reliably misdiagnosed presentations in the cheek and jaw group — the combination of jaw pain and perceived swallowing difficulty leads directly to a working diagnosis of TMJ syndrome in the majority of cases. The perceived dysphagia is a referred autonomic effect of the TrP — swallowing movement is completely normal on observation. Ill-fitting dental appliances and prolonged orthodontic treatment are the primary activating mechanisms. Buccal nerve entrapment by lateral pterygoid is in the differential when cheek tingling accompanies the pain.",
"treatment_hint": "Address dental appliances as the primary activating cause. Intraoral ischemic compression. Electrotherapy has been documented as effective in the source text. Treat masticatory TrPs concurrently.",
"also_consider": ["Masseter Superficial", "Lateral Pterygoid", "TMJ screening"],
"less_likely": [
{ "muscle": "Masseter Superficial", "reason": "No tooth hypersensitivity in zone; mid-cheek local pain with perceived dysphagia is specific to buccinator" },
{ "muscle": "Medial Pterygoid", "reason": "Perceived (not actual) dysphagia — swallowing is normal on observation; medial pterygoid produces actual swallowing compensation" },
{ "muscle": "Lateral Pterygoid", "reason": "No resisted protrusion pain; mid-cheek ache with perceived dysphagia and dental appliance history is specific to buccinator" }
],
"confirmatory": [
"Perceived dysphagia — reported difficulty swallowing, with normal swallowing movement on observation; specific autonomic effect",
"Mid-cheek TrP tenderness reproducing local cheek pain and subzygomatic jaw ache",
"Dental appliance, orthodontic brace, or occlusal splint history — primary activating mechanism",
"TMJ syndrome misdiagnosis confirmed by negative joint palpation and normal jaw opening after TrP treatment"
],
"satellite_trps": ["Masseter", "Lateral Pterygoid", "Orbicularis Oris"],
"landing_page_topics": [
"Perceived vs actual dysphagia — buccinator referral mechanism",
"Dental appliance as primary activating cause",
"TMJ syndrome misdiagnosis pattern",
"Buccal nerve entrapment exclusion",
"Electrotherapy as treatment option"
],
"related_pages": [
{ "label": "Masseter TrP →", "page": "Muscle:Masseter" },
{ "label": "Lateral Pterygoid TrP →", "page": "Muscle:Lateral_Pterygoid" }
]
},
"result-scm-sternal": {
"type": "result",
"diagnosis": "SCM Trigger Point — Sternal Division",
"confidence": "high",
"wiki_page": "Muscle:Sternocleidomastoid",
"chapter_ref": "Travell & Simons Vol.1 — Ch.7 Sternocleidomastoid",
"notes": "The sternal division of the SCM refers to the cheek and jaw angle alongside its orbital, temporal, vertex, and occipital patterns. The cardinal distinguishing features are the ipsilateral autonomic phenomena: profuse tearing (often more alarming than the pain itself), rhinitis, and palpebral fissure narrowing without miosis. Head tilts toward the TrP side. Treating sternal SCM frequently resolves satellite TrPs — zygomaticus major, orbicularis oculi, and platysma — without direct treatment of those muscles.",
"treatment_hint": "Pincer palpation and spray and stretch, superior to inferior. SCM Compression Test confirms sternal central TrP. Correct forward head posture. Treat SCM before facial satellites.",
"also_consider": ["Zygomaticus Major (satellite)", "Orbicularis Oculi (satellite)", "Platysma (satellite)", "Upper Trapezius"],
"less_likely": [
{ "muscle": "Masseter Superficial", "reason": "No jaw aggravation identified as primary mechanism; autonomic phenomena argue for SCM sternal" },
{ "muscle": "Trapezius TrP₁", "reason": "Autonomic phenomena are specific to SCM sternal; no shoulder loading as primary aggravator" }
],
"confirmatory": [
"SCM Compression Test positive — pharyngeal pain resolves on gripping the sternal belly during swallowing",
"Profuse ipsilateral tearing — specific to sternal division",
"Rhinitis on TrP side — nasal congestion without infection",
"Palpebral narrowing without miosis — exclude true Horner syndrome",
"Head tilts toward TrP side"
],
"satellite_trps": ["Zygomaticus Major", "Orbicularis Oculi", "Platysma", "Temporalis", "Masseter"],
"landing_page_topics": [
"Sternal vs clavicular division — full symptom profiles",
"Horner syndrome exclusion",
"Satellite TrP treatment sequence",
"CN XI entrapment monitoring"
],
"related_pages": [
{ "label": "Zygomaticus Major →", "page": "Muscle:Zygomaticus_Major" },
{ "label": "Orbicularis Oculi →", "page": "Muscle:Orbicularis_Oculi" },
{ "label": "Upper Trapezius TrPs →", "page": "Muscle:Trapezius/Upper" }
]
},
"result-scm-plus-zygomaticus": {
"type": "result",
"diagnosis": "SCM Sternal Division + Zygomaticus Major Satellite",
"confidence": "high",
"wiki_page": "Muscle:Sternocleidomastoid",
"chapter_ref": "Travell & Simons Vol.1 — Ch.7 SCM; Ch.13 Zygomaticus Major",
"notes": "Both SCM sternal and zygomaticus major are active. Zygomaticus major TrPs refer in a nasal arc (cheek to lateral nose to mid-forehead) and may restrict jaw opening by 10–20mm. They develop as satellites of SCM sternal (which refers to the cheek — the zygomaticus major lies in this reference zone) or masticatory dysfunction. Treat SCM first — zygomaticus major often resolves without direct treatment. If direct treatment is needed, immediate restoration of jaw opening after TrP inactivation confirms the TrP as the cause.",
"treatment_hint": "Treat SCM sternal first. Reassess jaw opening and nasal arc pain. If zygomaticus persists: spray and stretch along diagonal course; ischemic compression from zygomatic bone to angle of mouth.",
"also_consider": ["Masseter (masticatory chain TrP)", "Buccinator"],
"less_likely": [
{ "muscle": "Masseter Superficial", "reason": "SCM sternal confirmed; zygomaticus nasal arc is a satellite pattern, not masseter superficial" }
],
"confirmatory": [
"SCM Compression Test positive — sternal division confirmed",
"Nasal arc referral: cheek to lateral nose to mid-forehead",
"Jaw opening restricted 10–20mm — should improve immediately on TrP inactivation",
"Treat SCM first — zygomaticus often resolves without direct treatment"
],
"satellite_trps": ["Zygomaticus Minor", "Orbicularis Oris", "Buccinator"],
"landing_page_topics": [
"Satellite treatment sequence — SCM before zygomaticus",
"Jaw opening restriction as confirmation",
"Nasal arc vs masseter referral distinction"
],
"related_pages": [
{ "label": "Zygomaticus Major page →", "page": "Muscle:Zygomaticus_Major" },
{ "label": "SCM TrP →", "page": "Muscle:Sternocleidomastoid" }
]
},
"result-scm-plus-orbicularis": {
"type": "result",
"diagnosis": "SCM Sternal Division + Orbicularis Oculi Satellite",
"confidence": "high",
"wiki_page": "Muscle:Sternocleidomastoid",
"chapter_ref": "Travell & Simons Vol.1 — Ch.7 SCM; Ch.13 Orbicularis Oculi",
"notes": "Both SCM sternal and orbicularis oculi are active. Jumpy print (letters jumping when reading black text) is pathognomonic for orbicularis oculi TrP involvement. The relationship is typically satellite — SCM sternal refers to the orbit, activating orbicularis oculi. Treat SCM first — orbicularis oculi often resolves without direct treatment.",
"treatment_hint": "Treat SCM sternal division first. Reassess jumpy print and nose-lip referral. If orbicularis persists: flat palpation along upper orbital rim; address habitual squinting; check refractive error.",
"also_consider": ["Frontalis", "Upper Trapezius"],
"less_likely": [],
"confirmatory": [
"SCM Compression Test positive — sternal division confirmed",
"Jumpy print pathognomonic for orbicularis oculi TrP",
"Palpebral narrowing without miosis — both muscles contribute",
"Treat SCM first — orbicularis satellite often resolves"
],
"satellite_trps": ["Orbicularis Oculi", "Frontalis"],
"landing_page_topics": [
"Jumpy print mechanism and resolution",
"Bidirectional satellite relationship",
"Treatment sequence"
],
"related_pages": [
{ "label": "Orbicularis Oculi page →", "page": "Muscle:Orbicularis_Oculi" },
{ "label": "SCM TrP →", "page": "Muscle:Sternocleidomastoid" }
]
},
"result-scm-plus-platysma": {
"type": "result",
"diagnosis": "SCM Sternal Division + Platysma Satellite",
"confidence": "high",
"wiki_page": "Muscle:Sternocleidomastoid",
"chapter_ref": "Travell & Simons Vol.1 — Ch.7 SCM; Ch.13 Platysma",
"notes": "Both SCM sternal and platysma are active. The prickling quality of platysma pain — multiple simultaneous pinpricks over the lateral mandible — combined with SCM headache can be alarming and suggest neurological pathology to patients and clinicians. Platysma TrPs are virtually never present without active TrPs in the SCM, scalene, or masticatory muscles. Treat SCM first — platysma nearly always resolves without direct treatment.",
"treatment_hint": "Treat SCM sternal first. Reassess prickling. If platysma persists: spray and stretch the anterior neck; ischemic compression over identified TrPs.",
"also_consider": ["Scalene muscles", "SCM Clavicular Division"],
"less_likely": [],
"confirmatory": [
"SCM Compression Test positive — sternal division confirmed",
"Prickling over lateral mandible — multiple pinpricks, not tingling or electric",
"Platysma TrP tenderness overlying SCM belly",
"Treat SCM first — platysma satellite nearly always resolves"
],
"satellite_trps": ["Platysma", "Scalene muscles"],
"landing_page_topics": [
"Prickling quality — neurological misattribution prevention",
"Satellite relationship with SCM and scalene",
"Treatment sequence"
],
"related_pages": [
{ "label": "Platysma page →", "page": "Muscle:Platysma" },
{ "label": "SCM TrP →", "page": "Muscle:Sternocleidomastoid" }
]
},
"result-trapezius": {
"type": "result",
"diagnosis": "Upper Trapezius TrP₁ — Jaw Angle and Temple Referral",
"confidence": "moderate",
"wiki_page": "Muscle:Trapezius",
"chapter_ref": "Travell & Simons Vol.1 — Ch.6 Trapezius",
"notes": "Upper trapezius TrP₁ at the anterior border is the most common TrP in the body. At high intensity its referral extends to the jaw angle, temple, and back of the orbit. The jaw angle cheek pain from trapezius is a high-intensity spillover — the primary referral is posterolateral neck to mastoid. Ipsilateral head tilt is the consistent postural sign. Shoulder loading is the primary daily perpetuating factor. Upper trapezius is a key TrP driving temporalis, SCM, and semispinalis capitis as satellites.",
"treatment_hint": "Pincer palpation and spray and stretch with side-bending away and contralateral rotation. Correct shoulder elevation — ipsilateral bag or purse is the dominant perpetuating factor.",
"also_consider": ["SCM Sternal Division", "Temporalis (satellite)", "Levator Scapulae"],
"less_likely": [
{ "muscle": "SCM Sternal Division", "reason": "No autonomic phenomena; shoulder loading is the primary aggravator, not neck posture alone" },
{ "muscle": "Masseter Superficial", "reason": "Shoulder loading — not jaw activity — is the primary aggravator; no tooth hypersensitivity" }
],
"confirmatory": [
"TrP₁ at anterior border of upper trapezius reproduces jaw angle or cheek pain",
"Primary referral is posterolateral neck to mastoid — jaw angle is high-intensity spillover",
"Ipsilateral head tilt — ear toward TrP shoulder",
"Shoulder carrying on same side reproduces the pain"
],
"satellite_trps": ["Temporalis", "SCM", "Semispinalis Capitis", "Levator Scapulae"],
"landing_page_topics": [
"TrP₁ referral at different intensities",
"Shoulder carry and workstation correction",
"Satellite relationship with temporalis and SCM"
],
"related_pages": [
{ "label": "Temporalis TrP →", "page": "Muscle:Temporalis" },
{ "label": "SCM TrP →", "page": "Muscle:Sternocleidomastoid" }
]
},
"result-platysma": {
"type": "result",
"diagnosis": "Platysma Trigger Point",
"confidence": "moderate",
"wiki_page": "Muscle:Platysma",
"chapter_ref": "Travell & Simons Vol.1 — Ch.13 Platysma",
"notes": "Platysma TrPs produce a distinctive prickling pain — multiple simultaneous pinpricks over the lateral mandible and lower face — that is deeply alarming to patients and clinicians because it can suggest neurological pathology. The prickling quality is not like the tingling of an electric current; it is a superficial cutaneous pricking sensation. Platysma TrPs are virtually never present without active TrPs in the SCM, scalene, or masticatory muscles — these are the key TrPs to identify and treat. A supraclavicular TrP may refer hot prickling pain across the front of the chest.",
"treatment_hint": "Treat SCM, scalene, and masticatory TrPs first — platysma is their satellite and nearly always resolves without direct treatment. If direct treatment needed: spray and stretch the anterior neck; ischemic compression over identified TrPs.",
"also_consider": ["SCM (key TrP)", "Scalene muscles (key TrP)", "Masseter"],
"less_likely": [
{ "muscle": "SCM Sternal Division", "reason": "No autonomic phenomena at this stage — but always examine SCM; platysma is its satellite" },
{ "muscle": "Lateral Pterygoid", "reason": "Prickling over the mandible skin is specific to platysma; lateral pterygoid produces cheek tingling from buccal nerve entrapment" }
],
"confirmatory": [
"Prickling — multiple simultaneous pinpricks over lateral mandible skin; not tingling, not electric",
"Platysma TrP tenderness in subcutaneous fascia overlying the SCM",
"SCM and/or scalene TrPs also active on same side — always confirmed",
"Reassurance: prickling is myofascial, not neurological"
],
"satellite_trps": ["SCM (key TrP)", "Scalene muscles (key TrP)"],
"landing_page_topics": [
"Prickling quality — distinction from neurological tingling",
"Satellite relationship with SCM and scalene",
"Supraclavicular TrP — chest prickling variant",
"Patient reassurance — not neurological"
],
"related_pages": [
{ "label": "SCM TrP →", "page": "Muscle:Sternocleidomastoid" },
{ "label": "Scalene TrPs →", "page": "Muscle:Scalene" }
]
},
"result-zygomaticus": {
"type": "result",
"diagnosis": "Zygomaticus Major Trigger Point",
"confidence": "moderate",
"wiki_page": "Muscle:Zygomaticus_Major",
"chapter_ref": "Travell & Simons Vol.1 — Ch.13 Zygomaticus Major",
"notes": "Zygomaticus major TrPs refer in a nasal arc from the cheek, along the lateral nose, across the nasal bridge, to the mid-forehead. TrP tightness restricts jaw opening by 10–20mm — inactivating TrPs restores opening immediately. They develop as satellites of SCM sternal (which refers to the cheek) or severe masticatory dysfunction.",
"treatment_hint": "Treat SCM sternal or masticatory TrPs first. If direct treatment needed: spray and stretch along diagonal; ischemic compression. Immediate jaw opening improvement confirms TrP inactivation.",
"also_consider": ["SCM Sternal (key TrP)", "Masseter", "Buccinator"],
"less_likely": [
{ "muscle": "Orbicularis Oculi", "reason": "Nasal arc is specific to zygomaticus; orbicularis oculi refers to the nose and upper lip, not the forehead" },
{ "muscle": "Platysma", "reason": "Nasal arc pattern is not platysma — platysma produces prickling over the mandible" }
],
"confirmatory": [
"Nasal arc referral: cheek to lateral nose to nasal bridge to mid-forehead",
"Jaw opening restricted 10–20mm — immediate improvement on TrP inactivation confirms",
"Palpation along diagonal from zygomatic bone to angle of mouth reproduces the pattern",
"Confirm SCM sternal TrPs — zygomaticus is almost invariably satellite"
],
"satellite_trps": ["Zygomaticus Minor", "Orbicularis Oris", "SCM Sternal (key TrP)"],
"landing_page_topics": [
"Nasal arc — clinical misdiagnosis as sinusitis",
"Jaw opening restriction as confirmation test",
"Satellite relationship with SCM sternal"
],
"related_pages": [
{ "label": "SCM TrP →", "page": "Muscle:Sternocleidomastoid" },
{ "label": "Buccinator TrP →", "page": "Muscle:Buccinator" }
]
},
"result-orbicularis": {
"type": "result",
"diagnosis": "Orbicularis Oculi Trigger Point",
"confidence": "moderate",
"wiki_page": "Muscle:Orbicularis_Oculi",
"chapter_ref": "Travell & Simons Vol.1 — Ch.13 Orbicularis Oculi",
"notes": "Orbicularis oculi TrPs refer pain to the side of the nose, cheek near the nose, and upper lip — one of the very few muscles that refers to the nose. Jumpy print (letters jumping when reading black text on white) is pathognomonic and resolves with TrP inactivation. Palpebral fissure narrowing without miosis resembles Horner ptosis. Nearly always a satellite of SCM sternal — examine and treat SCM regardless.",
"treatment_hint": "Examine and treat SCM sternal — orbicularis is almost always its satellite and often resolves without direct treatment. If direct: flat palpation along upper orbital rim; eliminate habitual squinting; address refractive error.",
"also_consider": ["SCM Sternal Division (key TrP)", "Frontalis"],
"less_likely": [
{ "muscle": "Zygomaticus Major", "reason": "Nose-cheek-lip referral without nasal arc to forehead is specific to orbicularis oculi; zygomaticus arcs to the forehead" }
],
"confirmatory": [
"Jumpy print — pathognomonic, resolves with TrP inactivation",
"Nose-cheek-lip referral pattern — unique in this region",
"Palpebral fissure narrowing without miosis",
"Examine SCM regardless — orbicularis is almost invariably its satellite"
],
"satellite_trps": ["SCM Sternal (key TrP)", "Frontalis"],
"landing_page_topics": [
"Jumpy print mechanism",
"Horner syndrome exclusion",
"Nose/lip referral uniqueness",
"Satellite relationship with SCM"
],
"related_pages": [
{ "label": "SCM TrP →", "page": "Muscle:Sternocleidomastoid" },
{ "label": "Orbicularis Oculi page →", "page": "Muscle:Orbicularis_Oculi" }
]
},
"result-overlap": {
"type": "overlap",
"text": "Findings are inconclusive. Multi-muscle involvement is common in cheek and jaw pain — upper trapezius and SCM are frequently key TrPs activating masticatory satellites. Perform a systematic screen in order of clinical priority.",
"screen_these": [
"Upper Trapezius TrP₁ — anterior border pincer palpation; shoulder loading; head tilt",
"SCM sternal head — full pincer palpation; SCM Compression Test; autonomic phenomena",
"Masseter superficial — palpation from zygomatic arch to gonial angle; zone tooth hypersensitivity",
"Masseter deep — posterior ramus palpation; tinnitus provocation test",
"Lateral pterygoid — resisted protrusion test; tongue blade test",
"Medial pterygoid — intraoral palpation; ear stuffiness; swallowing compensation",
"Digastric both bellies — posterior: Swallowing Test; anterior: lower incisor test",
"Buccinator — mid-cheek flat and intraoral palpation; perceived dysphagia; dental appliance history",
"Platysma — subcutaneous palpation overlying SCM; prickling quality",
"Zygomaticus major — diagonal palpation; nasal arc; jaw opening",
"Orbicularis oculi — upper orbital rim; jumpy print; nose-lip referral"
],
"wiki_page": "Differential:Cheek_And_Jaw_Pain"
}
},
"broad_differential": [
{
"id": "bd-1",
"condition": "Temporomandibular Joint Disorder",
"confidence": "common",
"mimics": "Cheek and jaw pain with jaw movement — overlaps with masseter, lateral pterygoid, and medial pterygoid TrP patterns",
"distinguishing_feature": "True TMJ capsulitis: periarticular aching pain tender on joint palpation (lateral pole anterior to tragus), periarticular not muscle-belly tenderness. Myofascial TrP pain was the primary diagnosis in 55% of patients in the Minnesota TMJ study vs 21% with primary joint disorder. Joint and TrP pain commonly coexist.",
"action": "Palpate TMJ lateral pole and retrodiscal tissues. If acute joint inflammation, refer before masticatory stretching. Treat masticatory TrPs concurrently with palliative joint care."
},
{
"id": "bd-2",
"condition": "Dental Pathology — Pulpitis, Abscess, or Cracked Tooth",
"confidence": "common",
"mimics": "Tooth pain — masseter superficial, temporalis ATrP₁–₃, and anterior digastric all refer to teeth without dental pathology",
"distinguishing_feature": "True dental pathology: periapical radiographic changes, pain from a single tooth (not a zone), cold test positive for one tooth, reproduction from the tooth itself not from muscle palpation. Myofascial referral: zone hypersensitivity across multiple teeth, normal radiographs, reproduced by palpating the TrP.",
"action": "Request periapical radiograph. Palpate relevant TrPs before any irreversible dental treatment. Inactivating the TrP should resolve tooth hypersensitivity."
},
{
"id": "bd-3",
"condition": "Temporal Arteritis",
"confidence": "uncommon — critical in over-50s",
"mimics": "Jaw pain — jaw claudication overlaps with masseter and temporalis TrP patterns superficially",
"distinguishing_feature": "Jaw claudication is pathognomonic — pain builds progressively during chewing and eases completely at rest. This is fundamentally different from TrP pain which is worsened by chewing in general. Age over 50. Elevated ESR.",
"action": "This is a red flag covered in the checklist."
},
{
"id": "bd-4",
"condition": "Parotid Sialolithiasis (Duct Stone)",
"confidence": "uncommon",
"mimics": "Pre-auricular and cheek pain — overlaps with masseter deep head and buccinator TrP patterns",
"distinguishing_feature": "Pain peaks predictably during or immediately before meals. Visible or palpable parotid swelling that partially resolves after eating. Stensen's duct palpable.",
"action": "Palpate parotid duct. Ultrasound first-line. Refer to oral surgery."
},
{
"id": "bd-5",
"condition": "Eagle Syndrome",
"confidence": "rare",
"mimics": "Throat, jaw, and cheek pain — overlaps with posterior digastric and medial pterygoid TrP patterns",
"distinguishing_feature": "Pain provoked by turning the head or swallowing. Elongated styloid process palpable in the tonsillar fossa on intraoral examination. Recalcitrant to TrP treatment.",
"action": "This is a red flag covered in the checklist. Panoramic radiograph; oral/maxillofacial surgery referral."
},
{
"id": "bd-6",
"condition": "Trigeminal Neuralgia",
"confidence": "rare",
"mimics": "Cheek and jaw pain — overlaps with masseter and SCM sternal patterns",
"distinguishing_feature": "Lancinating electric shock quality with characteristic facial grimace. Trigger zones on face. Ceases completely between attacks. Consciousness unimpaired.",
"action": "Refer to neurology. MRI to exclude vascular compression. Carbamazepine first-line."
},
{
"id": "bd-7",
"condition": "Atypical Facial Pain / Persistent Idiopathic Facial Pain",
"confidence": "uncommon",
"mimics": "Chronic cheek and jaw pain — overlaps with multiple TrP referral patterns",
"distinguishing_feature": "Persistent, diffuse, poorly localised, changing quality over time. Does not conform to any neural or muscular distribution. Significant psychological overlay common. Exclude all organic causes first — systematic TrP examination is essential before this diagnosis is assigned.",
"action": "Systematic TrP examination of all muscles in this algorithm before assigning a diagnosis of atypical facial pain. Psychosocial assessment alongside."
},
{
"id": "bd-8",
"condition": "Sinusitis",
"confidence": "uncommon",
"mimics": "Cheek pressure and pain — masseter superficial and buccinator TrPs produce pain described as sinus pain",
"distinguishing_feature": "True sinusitis: fever, purulent nasal discharge, radiographic mucosal thickening. Myofascial sinus pain: normal radiographs, no fever, no discharge, reproduced by TrP palpation.",
"action": "Palpate relevant TrPs first. Request sinus imaging only if clinical features make sinusitis plausible."
}
]
}