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BY TIL LUCHAU & BETHANY WARD









Image 1: The medial pterygoids (purple) along with the masseters (orange) form left and right "slings" that
support, close, and help align the mandible. Also shown are the lower head of the lateral pterygoids (green)
and the articular surfaces of the TMJ (yellow). Source images courtesy of Primal Pictures, used with permission.
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WORKING WITH THE MEDIAL AND
LATERAL PTERYGOIDS

Where would we be without jaws? In the evolutionary version of our creation story, there was a long period
when no animals had them. Ancient animals such as amphioxus had a mouth, but not a mandiblei. Once
jaws appeared, however, they proved extremely popular, as now all vertebrates (except for lampreys and
hagfish) have mandibles.
As useful as jaws aie, they uo come with complications. In mouein humans, piimaiy among these aie
Tempoiomanuibulai }oint anu Nuscle Bisoiueis (TN}NB oi TNB), oi Tempoiomanuibulai }oint
synuiome. These umbiella teims uesciibe conuitions chaiacteiizeu by biting uiscomfoit, jaw
clicking, facial anu jaw pain, eaiaches, heauaches, gastiic uistuibance, anu iestiicteu jaw motion,
among othei symptoms. Although estimates of TNB pievalence iange fiom 4.6%
ii
to 17.9%
iii
of the
populations stuuieu, the numbei of people who expeiience TNB-like symptoms at some point is
piobably even highei. Foitunately, theie aie effective ways that hanus-on woik can help ielieve anu
pievent the symptoms associateu with TNB.
In this article, well discuss myofascial techniques for two of the most valuable players in TMD: the
medial and lateral pterygoids. Although often overlooked, in our clinical experience, direct, sensitive work
with these important structures is often the key to alleviating TMJ symptoms, and a part of shifting the
usage patterns that contribute to continued misalignment and joint irritation.
Since the pterygoids are deep muscles, they will not usually be the first structures you choose to address.
Necessary preparation would include work with larger head/neck/shoulder patterns, and with outer layers
such as the masters, temporalis, and digastrics. In our next article, well describe ways to work with these
supporting players. In the meantime, we will assume that readers are familiar with other methods for
preparing the surrounding structures before working the pterygoids. For inspiration, you may want to check
out Advanced-Trainings.coms Anterior Neck/Shoulder Differentiation Technique on YouTube, which
addresses the superficial cervical fascia and its effect on jaw alignment and mobility.
Speaking, swallowing, and mastication all require three-dimensional movement of the mandible. But with
this high degree of mobility comes greater susceptibility to jaw misalignment. Restricted soft tissues,
imbalanced movement patterns, and fascial strain from elsewhere in the body can disrupt the delicate
balance of the TMJs. The effects of jaw misalignment are compounded by the powerful forces of bite
compression, which can squeeze or bind the articular disks and surrounding tissues. The result is tissue
irritation, pain, and if uncorrected, possible joint degeneration and damage over time.
Although paits of the pteiygoius can be accesseu extia-oially, in oui expeiience, woiking insiue the
mouth (when agieeable to the client) is the most effective way to auuiess these stiuctuies. Befoie
woiking intiaoially, be suie to explain the puipose anu intention of the woik, anu obtain explicit
peimission fiom youi client to woik within his oi hei mouth. Nost clients aie veiy ieceptive to
intiaoial woik when they unueistanu what it entails anu why it's being consiueieu.
MEDIAL PTERYGOIDS
Fiom a myo-stiuctuial point of view, many (if not most) TN} symptoms aie ielateu to joint
compiession anu misalignment. Because the meuial pteiygoius play a key iole in both factois,
woiking these stiuctuies is inuicateu whenevei you see symptoms of TN}.
It is useful to think of the meuial pteiygoius as the "insiue masseteis" of the mouth. Like the
masseteis, meuial pteiygoius aie stiong jaw-closeis. Togethei, the meuial pteiygoius anu masseteis
cieate two v-shapeu slings (Image 1) that suppoit anu elevate the jaw. Babitual tension oi imbalance
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heie will exeit inappiopiiate foice on the TN},
contiibuting to iiiitation anu uysfunction. The
meuial uppeimost attachments on the
sphenoiu bone aie high anu ueep in the soft
palate, anu aie piobably impossible to palpate
uiiectly. Bowevei, the belly of the muscle is
easily accessible wheie it lines the insiue of the
jaw, in a miiioi image of the massetei on the
outsiue. The lowei inseitions aie accessible
just meuial to the angle of the manuible.
To woik the meuial pteiygoius, gently palpate
them on the meuial aspect of the jaw,
simultaneously fiom both insiue anu outsiue
the mouth (Images S anu 4). Feel foi aieas of
highei tonus in the muscle belly, while using
caie not to mistake the glanus anu othei
uelicate stiuctuies heie foi aieas of tension
(Image 2). Some clients can have a milu gag
ieflex in this aiea, so woik slowly anu
cautiously. Ask youi client to make small, slow
jaw movements to help you uistinguish the
infeiioi attachments just insiue the manuible's
angle, as this is wheie uolgi tenuon oigans aie
most concentiateu; steauy piessuie heie
influences the postuial ieflexes that govein the
iesting tone of the entiie muscle gioup
iv
. 0ui intention is ielease; so encouiage youi client to ielax
his oi hei jaw anu to bieathe, while you keep youi piessuie steauy, slow, anu ieceptive.
The mouth, inciuentally, has even moie of the biain's sensoiy coitex ueuicateu to it, than oui hanus
uo. Thus, the mouth may be the only place we woik wheie youi client feels youi touch moie acutely
than you feel theii tissue. Be extiemely sensitive anu patient when woiking intiaoially. Tiy it on
youiself fiist to get a sense of the kinu of touch neeueu, anu the feeling of ielease afteiwaius.

Images 3 and 4: To work the medial pterygoids, gently press into their lower attachments on the medial aspect
of the jaw from both inside and outside the mouth simultaneously. Ask your client to make small, slow jaw
movements to help you locate the attachments and encourage release
Image 2: When working the medial pterygoid (purple),
keep in mind that they lie close the salivary and
parotid glands, nerves, and delicate mucous
membranes under the tongue. Image courtesy of Primal
Pictures, used with permission.
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LATERAL PTERYGOIDS
The lateial pteiygoiu muscles affect TN} health in at least two impoitant ways. Fiist, they initiate jaw
opening. Since theii lowei heaus inseit on the manuibulai conuyle (Image S), they pull the jaw
anteiioily in oiuei to begin the movement of jaw uepiession. If one siue's lateial pteiygoiu is tightei
than the othei's, this will misalign the jaw's movement.
The lateral pterygoid affects the TMJ in a second way. As you open and close your mouth, the TMJ's
articular disk is positioned by its suspensory membrane, which is attached directly to the upper head of the
lateral pterygoid (Image 6). In a healthy joint, this helps keep disk in position to cushion the contact point
between the mandibular condyle and the temporal bone during opening and closing. However, excessive
tension in the lateral pterygoids can contribute to anterior displacement of the articular disk. When this
happens, or when there is excessive compression on the disk, the condyle can slide on and off the disk
during jaw movement, producing the pop or click often associated with TMD. In more severe cases, the
disk remains anterior to the condyle; the telltale popping sound is absent, but jaw opening is painful and
limited.


Image 6: As the jaw depresses,
membranes contiguous with the TMJ
capsule and the upper head of the lateral
pterygoid ("LP") suspend the articular disk
within the joint (in green). When there is
tension, misalignment, or excessive
compression, the disk can be displaced
(most often anteriorly). Note also that the
anterior tissue of the external acoustic
meatus (marked e) forms the posterior
side of the TMJ joint capsule. Source
image courtesy of Primal Pictures, used
with permission.
Image 5: The lateral pterygoid is in a
unique position to both pull the jaw
forward, and to influence the position
of the TMJ's articular disk, as the
superior head attaches to the TMJ
capsule (yellow) and to the articular
disk within. The zygomatic arch and
the coronoid process of the mandible
have been removed in this view to
better show the lateral pterygoid.
Image courtesy of Primal Pictures, used
with permission.
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LATERAL PTERYGOID ASSESSMENT
Since the anterior wall of the ear canal is contiguous with the posterior side of the TMJ capsule (Image 7),
we can easily assess the amount of anterior mandibular condyle movement here. Position the tip of your
little finger just inside each ear passage (Images 8 and 9). With your finger pads, feel for the mandibular
condyles, which are palpable on the anterior wall of the canal. Ask your client to slowly begin to open his
or her jaw, and you'll feel the condyles glide anteriorly. As the jaw begins to open, which condyle glides
anteriorly (away from your finger pad) first? The lateral pterygoid on that side is likely tighter, so work that
side as described below and recheck.




Image 7 (right): The anterior wall of the external
acoustic meatus (purple) is the posterior side of
the TMJ capsule (yellow). Palpating the
movement of the condyle just inside the ear
canal is an effective way to assess lateral
pterygoid tension and balanced function. Source
image courtesy of Primal Pictures, used with
permission.

Images 8 (left) and 9 (right): To assess left-right balance of the lateral pterygoids, use your finger pads to
palpate the anterior wall of the external acoustic meatus. Feel for any left/right differences in the anterior
movement of the mandibular condyles as the jaw begins to open. The tighter lateral pterygoid will
usually be on the side that moves earlier or more.
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LATERAL PTERYGOID RELEASE TECHNIQUE
Because the lateial pteiygoius can be uifficult to locate
v
, exploie this aiea in youi own mouth befoie
woiking with a client. 0sing youi little fingei, sliue along the outsiue of youi uppei teeth until you
come to the back euge of the last molai. Lateially, feel the insiue of youi cheek foi a veitical bony fin
this is the coianoiu piocess of the manuible, anu the stiong tempoialis tenuon. You can confiim
you'ie on the coianoiu piocess by opening anu closing youi jaw slightly; the piocess will cleaily
move. Now shift youi jaw to the same-siue (Image 1u) to open up moie space between the coianoiu
piocess anu the teeth. Notice that a pocket opens up behinu the last molai (Image 11). You may have
to open youi mouth a bit moie to feel this, but only uo so enough to accommouate youi fingei as you
move it fuithei posteiioily anu slightly meuially. The tip of youi fingei will now be on the lateial
pteiygoiu; confiim anu iefine youi location by opening youi jaw slightly anu feeling the muscle
contiact.
0se the same appioach with youi clients, being veiy gentle, patient, anu specific. Auuiess the tightei
siue fiist, baseu on youi assessment of conuyle movement as uesciibeu above. Apply steauy, slow,
ieceptive piessuie to the lateial pteiygoiu while asking foi small opening anu closing movements to
facilitate its ielease. Reassess to see if the left anu iight manuibulai conuyles' anteiioi gliue is moie
cooiuinateu, anu check in with youi client about any changes in pain level oi theii own peiception of
movement. You may neeu to woik back anu foith between the lateial pteiygoius to achieve moie
balanceu movement anu gieatei comfoit.

TEAM PLAYERS
Although the meuial anu lateial pteiygoius aie often the "most valuable playeis" when woiking with
TNB, they aie by no means the entiie team. Like stai playeis, theii key iole can oveishauow the
impoitance of othei stiuctuies anu ielationships. If you ignoie the iest of the team, youi ability to
help clients with TN} uisoiueis will be limiteu. As mentioneu, in the seconu pait of this aiticle, we'll
piesent techniques foi auuiessing some of these othei impoitant team membeis.
To maximize youi effectiveness, iemembei to attenu to both local factois (such as jaw tension anu
alignment, bite occlusion, anu heau position), as well as global, whole-bouy patteins, since issues
such as pelvis muscle tension
vi
, pelvic angle
vii
, anu spinal cuives
viii
have all been shown to coiielate
with jaw function.
As myofascial theiapists, oui intent is to ielease any soft tissue iestiictions anu movement patteins
which inteifeie with alignment anu pain-fiee function. This appioach can be a veiy effective
compliment to othei methous, such as stabilisation exeicises, postuial woik, etc. Since theie aie
many appioaches to TN} anu no single methou woiks with all clients, uon't hesitate to use a vaiiety
of appioaches oi to iefei clients to otheis as you tiack the iesults of youi woik.
Images 10 and 11: To access
the lateral pterygoid, ask your
client to shift their jaw towards
the side you're working, and
slide your finger posteriorly and
slightly medially. Because the
lateral pterygoid inserts on the
TMJ capsule and the suspensory
membrane of the articular disk,
work here can reduce tensions
that cause the anterior disk
displacement characteristic of
TMD.
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Til Luchau is a lead instructor at Advanced-Trainings.com Inc., which offers continuing education DVDs
and seminars throughout the United States and abroad. Til is a Certified Advanced Rolfer and on the
faculty of the Rolf Institute of Structural Integration.
Bethany Ward is certified in Advanced Myofascial Techniques. She is also a Certified Advanced Rolfer
and Rolf Movement Practitioner, and a Rolf Institute faculty member. She and lead instructor, Larry
Koliha, will be teaching Advanced-Trainings.com workshops in Australia throughout October 2012.
Contact them at info@advanced-trainings.com or on Advanced-Trainings.com's Facebook page.



i
Though still existent, amphioxus are thought to be an evolutionary predecessor to the modern vertebrates
they resemble.
ii
Isong U, Gansky SA, Plesh O. Temporomandibular joint and muscle disorder-type pain in U.S. adults: the
National Health Interview Survey. J Orofac Pain. 2008 Fall;22(4):317-22.
iii
Deng YM, Fu MK, Hgg U. Prevalence of temporomandibular joint dysfunction (TMJD) in Chinese
children and adolescents. A cross-sectional epidemiological study. Eur J Orthod. 1995 Aug;17(4):305-9.
Review. PubMed PMID: 8521924.
iv
Schleip, R. Fascial plasticity a new neurobiological explanation: Part I. Journal of Bodywork and
Movement Therapies (2003) 7(1), 11-19
v
Due to their location, there has been some debate about whether or not the lateral pterygoids can be
palpated intraorally. (See: Tuerp JC, Minagi S. Palpation of the lateral pterygoid region in TMD--where is
the evidence?, J Dent. 2001 Sep; 29(7):475-83, and Stratmann U, Mokrys K, Meyer U, et. al. Clinical
anatomy and palpability of the inferior lateral pterygoid muscle, J Prosthet Dent. 2000 May;83(5):548-54).
A more recent study (Stelzenmller W, Weber N-I, zkan V et al. Is the lateral pterygoid muscle palpable?
A pilot study for determining the possibilities of palpating the lateral pterygoid muscle. International
Poster, Journal of Dentistry and Oral Medicine 2006; 8(1):Poster 301), employing MRI and
electromyogram verification, concluded that the lateral pterygoid's "muscle structure and pain sensation can
be determined by digital palpation and subsequently treated by functional massage...". This outcome is
consistant with our clinical experience that addressing this area is an effective approach to alleviating TMD
symptoms. (Thanks to Dr. Leon Chaitow.)
vi
Lippold C, Danesh G, Schilgen M, Derup B Hackenberg L. Relationship between thoracic, lordotic, and
pelvic inclination and craniofacial morphology in adults. Angle Orthod. 2006;76:779-85.
vii
Rocabado Seaton, Mariano & Iglarsh, Z. Annette. The Musculoskeletal Approach to Maxillofacial Pain.
NY: Lippincott Williams & Wilkins, 1990
viii
Cuccia A, Caradonna C. The relationship between the stomatognathic system and body posture. Clinics
2009;64(1):61-6.