Therapy for the TMJ and Nuchal Ligament.

BrownEyed Cowgirl requested some more information on what I work on to help Willy's TMJ and pole ligament issues. It sounded like a great idea for a post that might do some good, so here it is. I fully intended to take some pictures while I was at the barn yesterday but it was SO stinking hot that after attempting to ride (25 min, mostly walk) I gave up, hosed off the horse, grazed, and rushed to the a/c in the car. I did manage to pull some "stock" photos from my computer and some off the net, so hopefully that will help the explanations.

I want to start with a little disclaimer. I am not a vet, or a chiropractor, or an expert in any other area that pertains to horses. What I am describing in this post is what I'm doing for my horse, based on a thorough assessment, recommendations, and instruction from my chiropractor. Your horse might have very different underlying issues. That said, I think it's very unlikely that any of this could harm any horse but again, I'm not an expert. I know you're all smart and I don't need to say this but I wouldn't feel right if I didn't.

The Temporomandibular Joint (TMJ)

The TMJ is the joint of the jaw between the temporal bone and the mandible, hence it's name. There is actually a fair bit of information on this joint, and various disorders of it, online. Therefore, I am not going to go into the biomechanics of it and all the possible issues. Suffice it to say that many things can lead to problems in the TMJ such as how they are ridden, dental work (or lack thereof), and even the simple fact that they eat all day can lead to tightness. This can lead to a whole host of behaviours (like Willy’s headshaking) and soreness in seemingly unrelated parts of the body, such as the sore back (closer to pelvis) Willy has on-and-off. The good news is Dr. J assures me that these secondary areas of soreness begin to resolve as the TMJ begins to function better. She also works on the area to provide some immediate therapeutic benefit and relief.

Interestingly, TMJ tightness is known for causing issues at the pelvis. Although Willy’s pelvis showed plenty of “spring” and was very supple, he was a bit body sore. Furthermore, the TMJ and atlantoaxial joint have very intimate relations. The atlantoaxial joint is where the atlas (aka the first cervical vertebra, C1), articulates with the second cervical vertebra (C2). So, TMJ issues will often present with atlas/pole issues as well. Wish I knew all this 3 months ago! It still amazes me how all the pieces fit together so completely.

In my search for pictures, I found this site and found the article very good article that is (mostly) in line with what my chiropractor has told me. For more information, check out Equine CranioSacral Workshops.

This shows the articulation and some structures of the TMJ.

Ok, so what do we do about it? Body work! It’s so simple and produces such amazing results that I intend to always do some TMJ massage from now on, just with lessened intensity for preventative maintenance.

First, we need to locate the TMJ. Look for the big bone that sticks out at the top of your horse’s cheek. It’s shaped somewhat like a flat-ish chevron ^ or boomerang.

Here you can see the area quite clearly as Mr. Will has a drink.

In normal head position, you would see vertical striations from his

TMJ down through his cheek. Here, he is drinking so they are parellel to the bone.

Run your fingers side-to-side under that bone. You will probably feel some ligaments that run vertically into the cheek. You might be able to see them, especially if it’s very tight. Yes? These are what you want to be working on. Apply pressure/massage across the ligaments, so your movements are perpendicular to the way the ligament runs (you can work in the same direction too, but it should mostly be across the grain).

How much pressure? Back in March I had encountered some information on the TMJ and discovered some Cranio-Sacral people (like the link above but not that exact one) that emphasized using only the lightest touch. I tried it and it did nothing as far as I could tell. I remember not being able to keep my hand in the right spot with such a light touch because he was headshaking so badly. Because of what I had read online I was afraid to use more pressure and abandoned the idea. I was told by Dr. J to use as much pressure as I can muster for this and I have strong hands from years and years of rock climbing. I use a lot of pressure when I'm working deep and have nothing but good results. In fact, I think the more muscle I put in, the more he gets out of it. You’ll have to test this out for yourself, I guess.

I generally start with a med-light general massage of the TMJ and full cheek. Then I work up to medium with more focus on the specific ligaments, and finally full pressure on the ligaments. Once I think he’s had enough, I basically do the same thing in reverse and end with firm but gentle total cheek massage. I do most of the work one side at a time but end facing him and massage both cheeks at once. This is the droopy eye and lip stage!
You are looking for him to yawn or open his mouth, move his jaw side to side, lick and chew, and drop his head, as low as he wants, no cross-ties! Now that I’ve been doing it awhile, I don’t always get strong reactions, sometimes just a head-tilt and a slight opening of mouth.

Some other points:
- I work the atlas area first because it’s actually more aggravating to Willy. I like to finish on the relaxed note that the TMJ massage provides.
- You can use a curry to do this if you want. I personally prefer to use my hands so I can feel everything but I imagine this might be hard for someone with arthritis, for example. I blew a tendon in my hand two winters ago and I have to be really careful how I use my fingers when I’m massaging, so I can relate.
- Listen to your horse. You’ll start to figure out how much is best to do before/after the ride. I generally take a more “relaxation massage” approach before a ride and really work deep after the ride. However, lately I’m finding it better to do a bit deeper pole work before the ride as it’s helping him relax more under saddle. It changes day by day and I just try my best to interpret the cues he’s giving me.

The Nuchal Ligament

This is the ligament that attaches at the atlas and runs down the entire length of the neck.

In yellow.

Tightness here can cause many of the same issues as disorders of the TMJ and problems in one are associated with problems in the other. In my case, I have the added bonus of some scar tissue in the atlas area. Willy has never been worked over-bent or forced into a frame, so our best guess is that he suffered some trauma to the area. It isn’t much and Dr. J thinks it will completely break up as I continue to work the area.

It’s a little harder to describe how to locate this ligament. Start at your horse’s head, right where the skull attaches to the neck, right about where the crown piece on your bridle rests. Just behind the bony protrusion that is the skull, run your fingers up and down the top couple inches of the crest. Again, you are working each side separately, so you’re probing to each side of the vertebrae, not on them.

You should feel something similar to a fat guitar string somewhere in there. Similar in feel to the ligaments in the TMJ. Some days I have a harder time finding it, which is a good sign.  It can also depend on their head position, so see if you can get your horse to raise or lower its head. I find it best if it’s level or a bit above level, but that’s not easy!  It can be easier to work from the off-side, so standing on the right when working the left side, and vice versa. I do a combination and still try out new ways of positioning myself.For the first 4 to 6 inches, you will be able to follow it along on either side of the cranial vertebrae. Right about where the muscle groups really differentiate, you probably won’t be able to find it any more.

Work it the same way as I described for the TMJ, mostly massaging crosswise to the ligament, going back and forth over it. Pay special attention anywhere where you feel “crunchies” as it’s a trouble spot. It can be scar tissue, previous sites of sprain, inflammation, muscle knots, etc. Either way, it needs to be worked. You won’t get rid of it all at once, just give any spot like that some extra time.

You can expect the same type of reactions from the horse; yawning, dropping the head, etc. During this work it’s especially important to let him stretch down.

I finish up with some carrot stretches to stretch out that ligament.

Any questions?

Chiro Follow up

We had a follow-up appointment with the chiropractor today. I’ve been trying to write an interim post but never quite managed to finish it, so this is a bit of everything. For simplicity I’ll add a few updates in [square brackets]. Then I need to do a garden post!!

Dr. J saw a lot of improvement today, both in his demeanor and how everything felt. She could tell that I was diligent in doing the prescribed work and seemed pleasantly surprised by just how much he’s improved. It must be an awesome thing, to help horses and people like she does.

My usual approach is to do all the soft-tissue work before I ride but not as deep or strong as I need to for full benefit. My idea with this is I want to relax the TMJ and atlas areas before I ride but I don’t want to do the deep work in case it’s still making him a bit sore. With that in mind, I work deeper after the ride and do carrot and leg stretches, followed by some hand grazing and then he’s in his stall for the night or back out until bedtime (depending on time of day). I don’t know if this approach is necessary but it makes sense to me and is working very well for us. [I described this to Dr. J and she thought it was a great approach].

Willy is one happy horse these days. He’s still playful and mischievous but he is a much more content version of himself. It’s hard to articulate. The obvious difference is he no longer constantly tosses his head while on cross-ties. Picture the sounds that head tossing would make in the ties. Now imagine that for 30+ minutes at a time. The barn is a much quieter, peaceful place! I honestly think I forgot what things were like “before” and now it seems so novel to have him standing quietly, often so relaxed he has droopy eyelids and lips.

Happy horse.
We've been working pretty well considering our set backs.

One ride, I didn’t do the muscle work before I rode. I wanted to ride with someone who was already mostly ready and it was mid-morning and I had done a full work-up the night before, so I figured it wouldn’t make much difference if I did the work after the ride. I noticed the difference right away. Although he was overall still much better than he has been for months, he did some headshaking on the crossties and a bit under saddle while walking. Considering I hadn’t seen ANY of it since our chiro appointment, except while actively working the atlas and TMJ areas, it was telling.

Last week, I didn’t go out 2 days in a row. I am there at least 5 days a week and never skip 2 days in a row except for the few times I’ve been out of town for work. This time it was because Alex was going out of town for 13 days and I decided to spend the nights with him. The difference was clear the next morning. He was still better than he was pre-chiro, on average, but he was tossin’ that noggin around a fair bit and not very relaxed. Probably akin to his “good” days during this whole ordeal. Since we were seeing the vet for vaccinations that morning, I took my time doing his muscle work and really got some good reactions from him (dropping his head, yawning)

Dr. J asked, during an email exchange last week, if she could use parts of my update email on her testimonial page. Um, hell ya! I am happy to help her spread the word about the work she does. She offers a more complete service than the status quo chiropractor around here, so I’m all for promoting her. I offered to write something specific for a testimonial, too. Laura and I laughed about what a sob story it would sound like, “I was on the verge of putting my gelding down and Jen saved his life” or some other dramatic summary. Although we laughed and I’m not the drama type, it has to be said that it’s not far off the mark. 

I had been preparing myself for weeks that it was something BAD. The worst of the bad was the lack of diagnosis despite trying. We were quickly realising that reality. Chiropractic work was my last gasp. I’m SO glad I had done a ton of research on practitioners in my area prior to this AND so glad I didn’t go with the status quo chiro for our area. I suspect that particular practitioner, good as she is, would not have identified Willy’s problems. They are pretty simple but could be easily missed by someone who doesn’t look beyond the vertebrae. 

My vet is one of the most respected in our area and still he missed the TMJ/atlas issues. He might have even been a causal or contributing factor.  I didn’t see anything during the float that would indicate it was poorly or harshly done, not that I’ve seen all that many.  So, I don’t really know what to think on that front. Personally, I think the vet exacerbated some pre-existing issues in both areas but he didn’t cause the scar tissue or tightness in the ligaments at Willy’s atlas/pole. Regardless, the float was obviously the tipping point.

I’m having the time of my life again, with a renewed appreciation for how awesome it is to ride through the fields or do some schooling on a happy horse. I have also gained a healthy respect for how fast things can go wrong and how deeply it affects me.

Tricksy things, those ligaments.

Ok, it's early days, but I need to get something out of my system.

SQUUUUUUUUUEEEEEeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeeee!!!!

Whew! So, uh, it appears I have a new horse.

You might recognize him :-)

The chiropractor came out on Monday and did a full workup on Willy, including extremities and soft tissues. I was very impressed with how thorough she was with us (over an hour) and she was great about explaining things and answering questions. Willy has never had chiro work before but he took to it suprisingly well, though he certainly wasn't the model patient.

The culprits? The ligaments at his pole are very tight and he has a touch of scar tissue in there as well but the biggest culprit seems to be his temporomandibular joint (TMJ).  [I could go on here about how I suspected this but didn't really know enough or where to turn and how it's disappointing my vet never even mentioned it...but I shall refrain]. In fact, he didn't display any headshaking until she started working those two areas.  Then, his head went bonkers for quite awhile while Dr. J worked  but he also did a lot of yawning, dropping his head, and other signs that we hit the spot. It seemed like he could only enjoy it for so long before it became too much and he would move away and look for distractions.

Overall, it seemed to already make him feel better and she was sure the headshaking would resolve within a few weeks. I was shown how to work on those areas and I will definitely be doing so. I'm nothing if not dedicated when I have something to accomplish!  It was very strange to have such confidence of a resolution after months of uncertainty. I can't quite trust it but my ride yesterday (day 3 of soft tissue work) went a long way to making me a believer.

He was not just better, he felt better than ever. We had some of our best trot work. I didn't want to ask him to work in a frame for too long, just enough to test out how he felt. I had to force myself to stop because he felt so good. We had gentle communication through the reins again!  He was also much happier to work long and low. We spent a good bit of time just walking outside to loosen up at the end and I was giddy.

When I got home, I didn't say anything at first as I was unpacking my bag etc. Finally, Alex said "Oh go on and tell me, you're practically levitating!" Hee hee. So ya, I know it's early days but...

Squeeeeeeeeeeeeeeeeee!

The Plan.

I've been trying to update all week but I've been super tired and have been battling sinus headaches on and off all week. I suspect it's partly due to the lovely flowers Alex gave me for our anniversary a couple weeks ago but I'm keeping them around as long as possible anyway - 5 years married, 13 together! The flowers stay.

So, the good news is Willy's back has not been reactive since last Sunday (Apr 29th) and he is completely undisturbed when I poke around. I suspect he'd been playing extra hard since he hadn't been getting the normal amount of exercise and likely torqued something back there that took a couple days to resolve.

In the meantime, we walked. A lot.
Willy is still a little rough with some winter coat in these pics.

Why does the camera add 10lbs to me and not the horse?!?

Also tried to get some conformation shots. It's a lot harder than it looks! 

I should have straightened the image as it's obvious the horizon in angled. 

Plus we are on a slight slope ourselves. So yeah, harder than it looks.

We had two good rides Monday and Tuesday. They were what I consider conditioning rides where my goal was just to make him move a lot over varied terrain and also have some fun riding outside. Willy hasn't lost any of his enthusiasm for exploring and asks to go into the trails/fields every time we pass a path leading out. It felt like "old" times for the first time in awhile.  Yes, he still did some headshaking but I've decided to basically ignore it for now since it's no worse and he doesn't seem especially bothered by it.

Thursday and Friday I asked for more - lots of transitions (within and between gait), figures, paying attention to me even with yellow school bus of doom screeching past, etc. He's been really good. 

We are putting more pressure on my vet and St. Hy to get back to us with the radiologists report. It's been 26 days, which has to be considered ridiculous by anyone's standard. I just don't get it. I know my vet has been calling himself this week but I've still had no word.

I had a long talk with Willy's owners last Friday (Apr 27) night as I thought it was time to touch base on the way forward and to check in that we are on the same page. Of course, this was in the middle of his back issue and without my rides this week, so things were looking extra dire.  I am very, very fortunate to have such a good relationship with them. I can't imagine it working this well in any other situation. I've given them a heads up that I might not continue the lease past May, if the situation isn't showing any signs of improvement. They agree that makes sense and is in my best interest. We discussed many details but the basic idea is that we are putting a limit on further diagnostics because we are at the point of diminishing returns.

There are still plenty of "ifs" so I'm trying to live each day as it comes and to clear my mind of it all when I'm with Will. I've sometimes wondered if my worried/occupied thoughts about his physical state are actually making them worse. At the very least, we know they sense our tension and respond to it. So I'm trying to remember to live simply in the moment with him. Fortunately I have lots of practice at this, with all the puppy training I've done!

I've scheduled a chiropractor appointment for Monday (tomorrow), so we'll see if that leads to any new information. It's pretty much the last reasonable option I have at the moment. It's certainly not an exceptional measure and something that has a reasonable chance of helping. I'm prepared either way, at least as much as I can be.

I'm also trying another new bit. It's similar to a Happy Mouth but not quite. I was never able to find a double-jointed rubber or copper bit. Will doesn't seem to like a full copper bit anyway and I wondered if the difference I felt with the rubber (negative) was due to the rubber or to the style. I know the rubber is super gentle but I suspect that my feel and his response were better with a double jointed bit. I suspect he has a fairly small mouth internally and therefore the rubber bit takes up a lot of space. I also think (again, based on nothing better than my thoughts/feelings/observations) that this is why he was happy in the double-jointed bit for so long (it conforms better) and perhaps the single joints have been extra irritating. I don't think this is going to lead to the answer to his headshaking, but it's still worth making him comfortable otherwise. I also have a Happy Mouth on special order, just in case.

So it's chiro Monday and then the month of May to see where things stand. I'm also relieved, if not happy, to report that we discussed what would happen to Willy if I stop leasing him because his issues do not resolve and/or get worse. We agree that no matter what he will not come to poor treatment or harm and, if it came to it, we would euthanise him.

But we aren't there yet! He might just remember he's a riding pony after all ;-)  It just feels good having all our cards on the table.

More photo attempts. 

Not too happy to be in a hay field without eating!