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Correlation between pain and dysfunction and intra-articular adhesions in patients with internal derangement of the temporomandibular joint
J Oral
Maxillofac Surg
50:705-708.
1992
Correlation Between Pain and Dysfunction and Intra-articular Adhesions in Patients With Internal Derangement of the Temporomandibular Joint KEN-ICHIRO YOSHIYUKI
MURAKAMI, DDS, PHD,* NATSUKI SEGAMI, DDS, PiiD,t MORIYA, DDS,t AND TADAHIKO IIZUKA, DMD, DMSc$
The correlation between pain and dysfunction scores obtained by questionnaire and an adhesions index obtained via arthroscopic inspection was investigated in 28 patients with internal derangements (closed lock) of the temporomandibular joint (TMJ). A weak correlation was found between pain scores and the adhesions index. However, joint noise had a negative correlation with both severity and distribution of adhesions in the TMJ. A weak, but statistically significant, negative correlation also was found between the degree of interincisal opening and the adhesions index. This study indicates that intra-articular adhesions are one of the factors contributing to limited mouth opening in patients with closed lock, but that they do not cause TMJ pain.
It has been suggested that adhesions contribute to the pathophysiology of painful hypomobility of the temporomandibular joint (TMJ).lM3 However, there have been no objective data provided with regard to this matter. This study was designed to compare the clinical symptoms of pain, limited range of jaw motion, and jaw locking with the severity of adhesions in patients with closed lock. Material
and Method
Twenty-eight patients, two males and 26 females, with a diagnosis of TMJ internal derangement with closed lock made on the basis of both clinical exami-
From the Department of Oral and Maxillofacial Surgery, Faculty of Medicine, Kyoto University, Kyoto, Japan. * Assistant Professor and Associate Head. t Assistant Professor. $ Professor and Chairman. Supported by a grant from Scientific Research of Japan Ministry of Education and Culture (No. 0377 I5 19). Address correspondence and reprint requests to Dr Murakami: Department of Oral and Maxillofacial Surgery, Kyoto University Hospital, Sakyoku Kyoto 606, Japan. 0 1992 American
Association
0278-2391/92/5007-0008$3.00/O
of Oral and Maxillofacial
Surgeons
nation and magnetic resonance imaging, were studied. The average age of the patients was 3 1.9 + 17.5 years. The average interincisal opening was 27.9 + 5.2 mm, and the average duration of locking was 9.4 + 13.1 months. A pain and dysfunction questionnaire was filled out by each patient prior to arthroscopy. The pain questionnaire consisted of a visual analog scale (VAS) and eight items regarding pain4 (Fig 1). The dysfunction questionnaire consisted of five items (Fig 2). Each item was scored from zero to four points. Both the severity and distribution of adhesions in the upper joint compartment were assessed by consensus of two surgeons during arthroscopic examination. The severity was graded by inspection and palpation with a probe and recorded on a scale from 0 to 10 (Table 1). All data, including age, duration of locking, degree of interincisal opening, pain and dysfunction scores, and arthroscopic indices, were statistically tested by the Spearman correlation. Results
Table 2 shows the Spearman correlation coefficients between the pain and dysfunction scores and the ar-
706
CORRELATION
1.
Rate the INTENSITY
of your USUAL
BETWEEN TMJ PAIN-DYSFUNCTION
AND ADHESIONS
PAIN during the LAST WEEK by placing a slash (/)
somewhere on the line below.
I No pain 2.
: Please
INSTRUCTIONS
I Most intense pain imaginable
check the appropriate answer to the following questions. Hurts A Little
Doesn’t Hurt At All
A. Jaw Pain Questions
Hurts A Lot
u~~e~~~~le
Unbearable Pain Without Relief
1.
Does it hurt when you open wide or yawn ?
2.
Does it hurt when you chew, or use the jaws ?
3.
Does it hurt when you are not chewing or using the jaws?
4.
Is your pain worse on waking ?
c__
___
~
5.
Do you have pain in front of the ears or ear aches ?
~
~
~
FIGURE 1. Pain questionnaire. Visual analog scale and jaw pain questions.
Do you have jaw muscle (cheek) pain ?
6.
~
7.
Do you have pain in the temples?
6.
Do you have pain or soreness in the teeth ?
___
throscopic index of adhesions. Pain at rest and the severity of adhesions showed a weak but statistically significant correlation. Table 3 shows the Spearman correlation coefficients between jaw dysfunction and the adhesion index. The indices of both severity and distribution of adhesions were negatively correlated with the dysfunction question regarding joint noise. A weak, but statistically significant, negative correlation was found between the decreased interincisal opening and the distribution of adhesions. A statistically significant correlation (P 5 .05) was found between the duration of closed lock and both the severity and distribution of adhesions (correlation coefficients were .56 1 and .638, respectively). The age of the patient and the distribution index of adhesions were also correlated (correlation coefficient, .428). 3.
INSTRUCTIONS
: Please
check
the
No B.
Jaw
Function
Questions
Do your jaw joints make noise so that it bothers you or others? Do you find it difficult to open your mouth wide?
Does your jaw ever get stuck (lock) as you open it? Does your jaw ever lock open so you cannot close it? Is Your table ?
bite
uncomfor-
appropriate Maybe A Little
answer
Discussion The etiology and pathogenesis of intra-articular adhesions has not been fully elucidated. Kaminishi and Davis’ described two hypotheses based on the orthopedic literature. One theory is that synovitis causes fibrin deposition, which decreases joint lubrication. The resultant suction-cup effect and immobilized joint causes the fibrin deposition to continue and form fibrous adhesions. Another theory is that hematomas in the synovial membrane attract fibroblasts and fibrocytes, which form scar tissue and secondary fibrous bands and walls. Both hypotheses are based on primary intra-articular inflammation that progresses secondarily to adhesions. The high incidence of synovitis in internally deranged TMJs has been documented,2 and to the
Quite A Lot
following Almost All The Time
questions. All The Time Without Stopping
FIGURE 2. Jaw dysfunction questionnaire. The five-item questionnaire used to assess jaw function.
MURAKAMI
707
ET AL
Table 3. Correlation Coefficients Between Jaw Dysfunction and Adhesions
Table 1. Severity of Adhesions Grade
Findings Adhesions No adhesion, no fibrous change Filmy adhesion (mild) (moderate to severe) Fibrosynovial band (mild to moderate) (severe) Fibrous band (mild to moderate) (severe) Pseudo-capsular wall (mild to moderate) (severe) Capsular fibrosis (mild to moderate) (severe)
Dysfunction
Distributmn
I. Jaw joints make 2. 3. 4. 5. 6.
noise Difficult opening Jaw get stuck (locked) Jaw locks open Uncomfortable bite Total score Opening degree
-0.458* -0.183 0.132 0.233 0.164 -0.105 -0.334
-0.4s4* -0.276 -0.075 0.212 0.332 PO.147 -0.393*
* P < .05
trauma has been considered as one of the causes of disc displacement. The present study disclosed a correlation between the seventy of adhesions and the duration of locking. This suggests that adhesions should be considered as secondary pathology in TMJ hypomobility, and that this condition makes the dysfunction more severe. Correlation between the degree of adhesion and pain level, in general, was low. There have been no investigations regarding the distribution of pain receptors or nerve endings in the adherent tissue in the TMJ. A full explanation of the relationship between TMJ pain at rest and the severity of adhesions is not possible at this time. From this study, however, one can state that the extent of the adhesions has a poor relationship with the pain level in patients with closed lock. We have previously described the positive correlation between synovitis indices and pain scores in the closed lock.4 A negative correlation between joint noise (clicking and crepitus) and adhesions was found in this study. This indicated that the joint noise level in internally deranged TMJs decreased with progression of the Table 2. Correlation Coefficients Between Pain and Adhesions
adhesions. The relationship between the degree of adhesion and interincisal opening was, in general, low. This suggests that adhesions are one cause of limited mouth opening, but that they are concomitant pathology in the internally deranged TMJ with closed lock. The results suggests that the distribution of the intra-articular adhesions may have a more important role in limiting TMJ mobility than the severity of each adhesion. Recent studies following both the outcome of open and arthroscopic surgery have shown that the disc does not significantly alter its position. At the same time, high success rates have been reported.5l6 The pain relief can be explained by the reduction of synovitis, but the improvement of jaw hypomobility cannot be fully explained. We have believed that lysis of adhesions was the reason for release of the closed lock. Based on the current study, the arthroscopic lavage of the joint space, alleviation of the suction-cup effect,7 and lateral eminential release of impinged capsule’ may be more reasonable explanations for eliminating the pathophysiology of the closed lock internal ‘derangement. Acknowledgment The authors wish to thank Dr Carol Bibb for her review and help in preparation of the manuscript.
Ahesions Pain
I. 2. 3. 4. 5. 6. 7. 8.
Pain on opening Pain on chewing Pain at rest Pain when walking Preauricular pain Cheek pain Temple pain Toothache * P < .05.
*Verity
Distribution
-0.208 -0.235 -0.087 0.383*
~0.138 ~0.239 -0.045 0.223
-0.29 I 0.080 -0.079 0.033 -0.126
-0.286 0.209 0.069 0.109 0.075
References I. Kaminishi RM, Davis CL: Temporomandibular joint arthrostopic observations of superior space adhesions. Oral MaxilJofac Surg Clin North Am 1:103, 1989 2. Segami N, Murakami K, Fujimura K, et al: Arthroscopic findings of internal derangement with closed lock of the temporomandibular joint [in Japanese]. J Jpn Stomatol Sot 38:857, 1989 3. Kurita K, Bronstein SL, Westesson P-L, et al: Arthroscopic diagnosis of perforation and adhesions of the temporomandibular joint: Correlation with postmortem morphology. Oral Surg 68: 130, 1989 4. Murakami K, Segami N, Fujimura K, et al: Correlation between pain and synovitis in patients with internal derangement of
708
DISCUSSION
the temporomandibular joint. J Oral Maxillofac Surg 49: 1159, 1991 5. Westesson P-L, Cohen JM, Tallents RH: Magnetic resonance imaging of temporomandibular joint after surgical treatment of internal derangement. Oral Surg 7 1:407,199 1 6. Moses JJ, Sartoris D, Glass R, et al: The effect of arthroscopic surgical lysis and lavage of the superior joint space on TMJ
J Oral
Maxillofac
50:708.
1992
disc position and mobility. J Oral Maxillofac Surg 47:674, 1989 7. Sanders B: Arthroscopic surgery of the temporomandibular joint: Treatment of internal derangement with persistent closed lock. Oral Surg 62:361, 1986 8. Moses JJ: Lateral impingement syndrome and eudaural surgical technique. Oral Maxillofac Surg Clin North Am 1:165, 1989
Surg
Discussion Correlation Between Pain and Dysfunction and Intra-articular Adhesions in Patients With Internal Derangement of the Temporomandibular Joint Leslie Hefez,
DMD, MS
University of Illinois at Chicago The authors have studied the correlation between pain and dysfunction associated with internal derangements of the temporomandibular joint (TMJ) and the presence of intraarticular adhesions. Their conclusion is that the presence of adhesions contributes to limitation of opening but not to pain. The phenomenon of closed lock has recently undergone significant reevaluation. Initially, many clinicians attributed the locking of the jaw to the disc position. It has now been recognized that a number of factors may be responsible, all of which may be present concurrently, but with varying significance. Masticatory muscle tension, intra-articular vacuum effect, synovial fluid lubrication, and disc position are some of the more plausible factors that have been suggested. Lysis of adhesions and lavage of the superior joint space are an effective means of improving mouth opening in the cases of closed lock in which there is an intra-articular cause and effect. The mere presence of intra-articular findings, however, does not cement this cause-and-effect relationship. Condensing the index of severity of adhesions may have facilitated recording of the data. However, the authors do not differentiate in absolute numbers between those patients complaining of muscular and joint pain. The localization of the discomfort is more important than the timing when predicting outcomes. In my experience, pain in closed lock situations caused by stretching of the mouth can be resolved with the arthroscopic procedure. This pain is typically muscular in origin, and not preauricular. When there is pain directly over the joint in patients with chronic closed lock, it is also frequently present in the contralateral joint secondary to hypermobility. The
restoration of homolateral joint mobility can reduce the pain associated with the hypermobility pattern. When there is pain on preauricular palpation, the clinical inference is that there is intra-articular inflammation. Preauricular pain may also be a finding in patients with a normal range of motion and absence of internal derangement. In my experience, lysis of adhesions is of limited benefit in these patients. What does surgery accomplish, aside from lysing the adhesions? The results of surgery may explain the increased mobility and range of motion. Postoperatively, however, because the degree of joint degeneration has not been reversed, one can presume that adhesions could reform. Postoperative physical therapy is therefore important in preserving some of the measured gain in opening. The distribution of the reformed adhesions may make it easier to maintain an improved opening, but I do not concur with the authors that the results of their study indicate that distribution is an important factor. The results indicate a lack of correlation, but do not suggest another cause for the limitation of movement. The finding of a low relationship between the presence of adhesions and interincisal opening would suggest that the adhesions are consequential to the pathology. The authors suggest that reduction of pain may be caused by reduction of synovitis. The criteria for diagnosis of synovitis were not enumerated. This condition probably has a tendency to be overdiagnosed. The mere presence of superficial vascularity on the posterior attachment does not prove that inflammation is present. The diagnostic arthroscopic procedure itself creates immediate intra-articular inflammation and the improvement of closed lock is typically often immediate. The simple “wheel and flare” histamine test performed on the forearm demonstrates the rapidity of the inflammatory response with the mildest insult. The authors acknowledge that they have examined a group of patients with a potpourri of pain complaints, all of which are probably not related to intra-articular pathology. The study is relevant because it alerts the clinician to the importance of proper selection of patients based on history, present illness, and clinical examination. The presence of adhesions, however, does not infer the presence of significant symptoms.
Maxillofac Surg
50:705-708.
1992
Correlation Between Pain and Dysfunction and Intra-articular Adhesions in Patients With Internal Derangement of the Temporomandibular Joint KEN-ICHIRO YOSHIYUKI
MURAKAMI, DDS, PHD,* NATSUKI SEGAMI, DDS, PiiD,t MORIYA, DDS,t AND TADAHIKO IIZUKA, DMD, DMSc$
The correlation between pain and dysfunction scores obtained by questionnaire and an adhesions index obtained via arthroscopic inspection was investigated in 28 patients with internal derangements (closed lock) of the temporomandibular joint (TMJ). A weak correlation was found between pain scores and the adhesions index. However, joint noise had a negative correlation with both severity and distribution of adhesions in the TMJ. A weak, but statistically significant, negative correlation also was found between the degree of interincisal opening and the adhesions index. This study indicates that intra-articular adhesions are one of the factors contributing to limited mouth opening in patients with closed lock, but that they do not cause TMJ pain.
It has been suggested that adhesions contribute to the pathophysiology of painful hypomobility of the temporomandibular joint (TMJ).lM3 However, there have been no objective data provided with regard to this matter. This study was designed to compare the clinical symptoms of pain, limited range of jaw motion, and jaw locking with the severity of adhesions in patients with closed lock. Material
and Method
Twenty-eight patients, two males and 26 females, with a diagnosis of TMJ internal derangement with closed lock made on the basis of both clinical exami-
From the Department of Oral and Maxillofacial Surgery, Faculty of Medicine, Kyoto University, Kyoto, Japan. * Assistant Professor and Associate Head. t Assistant Professor. $ Professor and Chairman. Supported by a grant from Scientific Research of Japan Ministry of Education and Culture (No. 0377 I5 19). Address correspondence and reprint requests to Dr Murakami: Department of Oral and Maxillofacial Surgery, Kyoto University Hospital, Sakyoku Kyoto 606, Japan. 0 1992 American
Association
0278-2391/92/5007-0008$3.00/O
of Oral and Maxillofacial
Surgeons
nation and magnetic resonance imaging, were studied. The average age of the patients was 3 1.9 + 17.5 years. The average interincisal opening was 27.9 + 5.2 mm, and the average duration of locking was 9.4 + 13.1 months. A pain and dysfunction questionnaire was filled out by each patient prior to arthroscopy. The pain questionnaire consisted of a visual analog scale (VAS) and eight items regarding pain4 (Fig 1). The dysfunction questionnaire consisted of five items (Fig 2). Each item was scored from zero to four points. Both the severity and distribution of adhesions in the upper joint compartment were assessed by consensus of two surgeons during arthroscopic examination. The severity was graded by inspection and palpation with a probe and recorded on a scale from 0 to 10 (Table 1). All data, including age, duration of locking, degree of interincisal opening, pain and dysfunction scores, and arthroscopic indices, were statistically tested by the Spearman correlation. Results
Table 2 shows the Spearman correlation coefficients between the pain and dysfunction scores and the ar-
706
CORRELATION
1.
Rate the INTENSITY
of your USUAL
BETWEEN TMJ PAIN-DYSFUNCTION
AND ADHESIONS
PAIN during the LAST WEEK by placing a slash (/)
somewhere on the line below.
I No pain 2.
: Please
INSTRUCTIONS
I Most intense pain imaginable
check the appropriate answer to the following questions. Hurts A Little
Doesn’t Hurt At All
A. Jaw Pain Questions
Hurts A Lot
u~~e~~~~le
Unbearable Pain Without Relief
1.
Does it hurt when you open wide or yawn ?
2.
Does it hurt when you chew, or use the jaws ?
3.
Does it hurt when you are not chewing or using the jaws?
4.
Is your pain worse on waking ?
c__
___
~
5.
Do you have pain in front of the ears or ear aches ?
~
~
~
FIGURE 1. Pain questionnaire. Visual analog scale and jaw pain questions.
Do you have jaw muscle (cheek) pain ?
6.
~
7.
Do you have pain in the temples?
6.
Do you have pain or soreness in the teeth ?
___
throscopic index of adhesions. Pain at rest and the severity of adhesions showed a weak but statistically significant correlation. Table 3 shows the Spearman correlation coefficients between jaw dysfunction and the adhesion index. The indices of both severity and distribution of adhesions were negatively correlated with the dysfunction question regarding joint noise. A weak, but statistically significant, negative correlation was found between the decreased interincisal opening and the distribution of adhesions. A statistically significant correlation (P 5 .05) was found between the duration of closed lock and both the severity and distribution of adhesions (correlation coefficients were .56 1 and .638, respectively). The age of the patient and the distribution index of adhesions were also correlated (correlation coefficient, .428). 3.
INSTRUCTIONS
: Please
check
the
No B.
Jaw
Function
Questions
Do your jaw joints make noise so that it bothers you or others? Do you find it difficult to open your mouth wide?
Does your jaw ever get stuck (lock) as you open it? Does your jaw ever lock open so you cannot close it? Is Your table ?
bite
uncomfor-
appropriate Maybe A Little
answer
Discussion The etiology and pathogenesis of intra-articular adhesions has not been fully elucidated. Kaminishi and Davis’ described two hypotheses based on the orthopedic literature. One theory is that synovitis causes fibrin deposition, which decreases joint lubrication. The resultant suction-cup effect and immobilized joint causes the fibrin deposition to continue and form fibrous adhesions. Another theory is that hematomas in the synovial membrane attract fibroblasts and fibrocytes, which form scar tissue and secondary fibrous bands and walls. Both hypotheses are based on primary intra-articular inflammation that progresses secondarily to adhesions. The high incidence of synovitis in internally deranged TMJs has been documented,2 and to the
Quite A Lot
following Almost All The Time
questions. All The Time Without Stopping
FIGURE 2. Jaw dysfunction questionnaire. The five-item questionnaire used to assess jaw function.
MURAKAMI
707
ET AL
Table 3. Correlation Coefficients Between Jaw Dysfunction and Adhesions
Table 1. Severity of Adhesions Grade
Findings Adhesions No adhesion, no fibrous change Filmy adhesion (mild) (moderate to severe) Fibrosynovial band (mild to moderate) (severe) Fibrous band (mild to moderate) (severe) Pseudo-capsular wall (mild to moderate) (severe) Capsular fibrosis (mild to moderate) (severe)
Dysfunction
Distributmn
I. Jaw joints make 2. 3. 4. 5. 6.
noise Difficult opening Jaw get stuck (locked) Jaw locks open Uncomfortable bite Total score Opening degree
-0.458* -0.183 0.132 0.233 0.164 -0.105 -0.334
-0.4s4* -0.276 -0.075 0.212 0.332 PO.147 -0.393*
* P < .05
trauma has been considered as one of the causes of disc displacement. The present study disclosed a correlation between the seventy of adhesions and the duration of locking. This suggests that adhesions should be considered as secondary pathology in TMJ hypomobility, and that this condition makes the dysfunction more severe. Correlation between the degree of adhesion and pain level, in general, was low. There have been no investigations regarding the distribution of pain receptors or nerve endings in the adherent tissue in the TMJ. A full explanation of the relationship between TMJ pain at rest and the severity of adhesions is not possible at this time. From this study, however, one can state that the extent of the adhesions has a poor relationship with the pain level in patients with closed lock. We have previously described the positive correlation between synovitis indices and pain scores in the closed lock.4 A negative correlation between joint noise (clicking and crepitus) and adhesions was found in this study. This indicated that the joint noise level in internally deranged TMJs decreased with progression of the Table 2. Correlation Coefficients Between Pain and Adhesions
adhesions. The relationship between the degree of adhesion and interincisal opening was, in general, low. This suggests that adhesions are one cause of limited mouth opening, but that they are concomitant pathology in the internally deranged TMJ with closed lock. The results suggests that the distribution of the intra-articular adhesions may have a more important role in limiting TMJ mobility than the severity of each adhesion. Recent studies following both the outcome of open and arthroscopic surgery have shown that the disc does not significantly alter its position. At the same time, high success rates have been reported.5l6 The pain relief can be explained by the reduction of synovitis, but the improvement of jaw hypomobility cannot be fully explained. We have believed that lysis of adhesions was the reason for release of the closed lock. Based on the current study, the arthroscopic lavage of the joint space, alleviation of the suction-cup effect,7 and lateral eminential release of impinged capsule’ may be more reasonable explanations for eliminating the pathophysiology of the closed lock internal ‘derangement. Acknowledgment The authors wish to thank Dr Carol Bibb for her review and help in preparation of the manuscript.
Ahesions Pain
I. 2. 3. 4. 5. 6. 7. 8.
Pain on opening Pain on chewing Pain at rest Pain when walking Preauricular pain Cheek pain Temple pain Toothache * P < .05.
*Verity
Distribution
-0.208 -0.235 -0.087 0.383*
~0.138 ~0.239 -0.045 0.223
-0.29 I 0.080 -0.079 0.033 -0.126
-0.286 0.209 0.069 0.109 0.075
References I. Kaminishi RM, Davis CL: Temporomandibular joint arthrostopic observations of superior space adhesions. Oral MaxilJofac Surg Clin North Am 1:103, 1989 2. Segami N, Murakami K, Fujimura K, et al: Arthroscopic findings of internal derangement with closed lock of the temporomandibular joint [in Japanese]. J Jpn Stomatol Sot 38:857, 1989 3. Kurita K, Bronstein SL, Westesson P-L, et al: Arthroscopic diagnosis of perforation and adhesions of the temporomandibular joint: Correlation with postmortem morphology. Oral Surg 68: 130, 1989 4. Murakami K, Segami N, Fujimura K, et al: Correlation between pain and synovitis in patients with internal derangement of
708
DISCUSSION
the temporomandibular joint. J Oral Maxillofac Surg 49: 1159, 1991 5. Westesson P-L, Cohen JM, Tallents RH: Magnetic resonance imaging of temporomandibular joint after surgical treatment of internal derangement. Oral Surg 7 1:407,199 1 6. Moses JJ, Sartoris D, Glass R, et al: The effect of arthroscopic surgical lysis and lavage of the superior joint space on TMJ
J Oral
Maxillofac
50:708.
1992
disc position and mobility. J Oral Maxillofac Surg 47:674, 1989 7. Sanders B: Arthroscopic surgery of the temporomandibular joint: Treatment of internal derangement with persistent closed lock. Oral Surg 62:361, 1986 8. Moses JJ: Lateral impingement syndrome and eudaural surgical technique. Oral Maxillofac Surg Clin North Am 1:165, 1989
Surg
Discussion Correlation Between Pain and Dysfunction and Intra-articular Adhesions in Patients With Internal Derangement of the Temporomandibular Joint Leslie Hefez,
DMD, MS
University of Illinois at Chicago The authors have studied the correlation between pain and dysfunction associated with internal derangements of the temporomandibular joint (TMJ) and the presence of intraarticular adhesions. Their conclusion is that the presence of adhesions contributes to limitation of opening but not to pain. The phenomenon of closed lock has recently undergone significant reevaluation. Initially, many clinicians attributed the locking of the jaw to the disc position. It has now been recognized that a number of factors may be responsible, all of which may be present concurrently, but with varying significance. Masticatory muscle tension, intra-articular vacuum effect, synovial fluid lubrication, and disc position are some of the more plausible factors that have been suggested. Lysis of adhesions and lavage of the superior joint space are an effective means of improving mouth opening in the cases of closed lock in which there is an intra-articular cause and effect. The mere presence of intra-articular findings, however, does not cement this cause-and-effect relationship. Condensing the index of severity of adhesions may have facilitated recording of the data. However, the authors do not differentiate in absolute numbers between those patients complaining of muscular and joint pain. The localization of the discomfort is more important than the timing when predicting outcomes. In my experience, pain in closed lock situations caused by stretching of the mouth can be resolved with the arthroscopic procedure. This pain is typically muscular in origin, and not preauricular. When there is pain directly over the joint in patients with chronic closed lock, it is also frequently present in the contralateral joint secondary to hypermobility. The
restoration of homolateral joint mobility can reduce the pain associated with the hypermobility pattern. When there is pain on preauricular palpation, the clinical inference is that there is intra-articular inflammation. Preauricular pain may also be a finding in patients with a normal range of motion and absence of internal derangement. In my experience, lysis of adhesions is of limited benefit in these patients. What does surgery accomplish, aside from lysing the adhesions? The results of surgery may explain the increased mobility and range of motion. Postoperatively, however, because the degree of joint degeneration has not been reversed, one can presume that adhesions could reform. Postoperative physical therapy is therefore important in preserving some of the measured gain in opening. The distribution of the reformed adhesions may make it easier to maintain an improved opening, but I do not concur with the authors that the results of their study indicate that distribution is an important factor. The results indicate a lack of correlation, but do not suggest another cause for the limitation of movement. The finding of a low relationship between the presence of adhesions and interincisal opening would suggest that the adhesions are consequential to the pathology. The authors suggest that reduction of pain may be caused by reduction of synovitis. The criteria for diagnosis of synovitis were not enumerated. This condition probably has a tendency to be overdiagnosed. The mere presence of superficial vascularity on the posterior attachment does not prove that inflammation is present. The diagnostic arthroscopic procedure itself creates immediate intra-articular inflammation and the improvement of closed lock is typically often immediate. The simple “wheel and flare” histamine test performed on the forearm demonstrates the rapidity of the inflammatory response with the mildest insult. The authors acknowledge that they have examined a group of patients with a potpourri of pain complaints, all of which are probably not related to intra-articular pathology. The study is relevant because it alerts the clinician to the importance of proper selection of patients based on history, present illness, and clinical examination. The presence of adhesions, however, does not infer the presence of significant symptoms.