Current Pain and Headache Reports (2020) 24:18

https://doi.org/10.1007/s11916-020-00851-1

OTHER PAIN (AD KAYE AND N VADIVELU, SECTION EDITORS)

Temporal tendinosis: A cause of chronic orofacial pain

Hart B. Bressler 1 & Masad Markus 2 & Rachel P. Bressler 3 & Saul N. Friedman 4 & Lawrence Friedman 5

# Springer Science+Business Media, LLC, part of Springer Nature 2020

Abstract
Purpose of Review Diverse musculoskeletal disorders and neuropathic symptoms of the face pose significant diagnostic chal-
lenges. In particular, temporal tendinosis is generally overlooked in the medical and dental literature and is therefore a poorly
understood topic and often problematic cause of chronic orofacial pain. In this article, we explore temporal tendinosis as a cause
of unresolved orofacial pain by reviewing the complex anatomy of the temporalis muscle, common presentations of temporal
tendinosis, possible etiologies for injury and place a strong emphasis on required diagnostic evaluation and clinical management.
Recent Findings Temporal tendinosis remains under diagnosed due to a combination of anatomical complexity and incomplete
description in the majority of general anatomy medical textbooks. The two main presentations are unilateral facial pain with or
without temporal headache and pain radiating from the distal temporalis tendon to the temporalis muscle. Diagnosis should be
made with a combination of focused history, physical examination and specialised imaging, preferably with ultrasound but with
MRI an alternate option. While many management options are available, optimal treatment remains unclear.
Summary Temporal tendinosis is an under-recognised and under-treated condition. Despite the fact that orofacial pain is one of
the single most common complaints of patients presenting to physicians or dentists, it is widely acknowledged that training for
diagnosis and manage of temporal tendinopathy among primary care physicians in both medical and dental professions is
inadequate. This may result in extensive workups, leading to suboptimal management and chronic pain syndromes.

Keywords Temporalis . Tendinitis . Tendonitis . Tendinopathy . Temporomandibular disorder (TMD) . Chronic pain

Introduction Temporal tendinosis or tendinopathy is generally

Musculoskeletal disorders and neuropathic pain contribute to
the various potential causes of orofacial pain and headaches.
However, these conditions often pose a significant diagnostic
challenge as the wide range of diagnoses with similar clinical
presentations can lead to uncertainty, misdiagnosis and subse-
quent mismanagement [1–3].
overlooked as a differential diagnosis for facial pain.
Traditionally, the terminology of tendinitis has been used to
classify chronic tendon pathologies. However, tendinitis is a
condition in which the substance of the tendon exhibits in-
flammation referring to a clinical syndrome but not to a spe-
cific histopathologic entity. Recent literature suggests that
chronic tendon pathologies do not contain significant inflam-

This article is part of the Topical Collection on Other Pain

* Hart B. Bressler 2
Second Year, Schulich School of Medicine, University of Western
h.bressler@utoronto.ca Ontario, 1151 Richmond St, London, Ontario N6A 5C1, Canada
3
Family Dental Centre, 110 N Front Street, Belleville, Ontario K8P
Lawrence Friedman 5J8, Canada
lawrence.friedman@nygh.on.ca 4
Division of Nuclear Medicine, Mallinckrodt Institute of Radiology,
Washington University School of Medicine, Saint Louis, MO 63110,
1 USA
Department of Family and Community Medicine, Mount Sinai
5
Hospital, University of Toronto, 600 University Ave, Department of Medical Imaging, North York General Hospital, 4001
Toronto, Ontario M5G 1X5, Canada Leslie Street, Toronto, Ontario M2K 1E1, Canada
 18 Page 2 of 9 Curr Pain Headache Rep (2020) 24:18

matory components, and acute tendinous inflammatory reac- Proper diagnosis and treatment of orofacial pain and head-
tions generally reduce within 10 days following initial trauma aches therefore requires one to have foreknowledge of tempo-
[4]. Tendinosis is chronic tendon degeneration without classi- ral tendinosis as a differential diagnosis and an accurate in-
cal clinical or histological signs of inflammation, which can depth knowledge of the anatomy in this small region. In this
lead to structural pathological changes over time, evolving article, we review anatomy, proposed mechanisms, signs and
into localised facial pain inferior to the region of the mid- symptoms, as well as recommend diagnostic criteria to aid in
zygomatic arch. Tendinosis can develop secondary to either the diagnosis of temporal tendinosis.
biological causes or mechanical stressors such as inflammato-
ry or degenerative processes, trauma or abnormal repetitive
strains.
Inappropriate marginalisation of this specific tendon has
Anatomy
caused it to be virtually ignored in the medical and dental
The temporalis muscle acts to elevate and retract the mandible
literature. A generalised PubMed literature search performed
and plays an important function in mastication [12]. The mus-
on 11th October 2019 yielded a substantial difference in re-
cle originates from the temporal fossa and deep surface of the
sults for the more common tendinopathies versus temporal
temporal fascia and can be divided into superficial, deep and
tendinosis. For example, a search for ‘Achilles tendinopathy’
posterior divisions that join into the distal tendon. The average
yielded 2125 articles, versus only 18 articles from a search for
size of the tendon is 20 mm, which traverses deep to the
‘temporalis tendinopathy’, of which only 7 relate to the actual
zygomatic arch [13]. The insertion of the temporal tendon
temporalis tendon. Other well known tendinopathies such as
attaches to the coronoid process [14, 15], the anterior border
lateral epicondylitis, supraspinatus, patellar and plantar fasci-
of the ramus of the mandible, as well as the medial and lateral
itis also yielded comparatively high numbers.
borders of the retromolar fossa (which is located posteriorly to
Orofacial pain in the anatomic region of the temporalis tendon
the last molar of the mandible) (Fig. 1).
is often thought to be caused by the temporomandibular joint
The temporalis muscle, tendon and neighbouring anatom-
(TMJ) and not the tendon itself. The International Headache
ical structures, including somatic and autonomic nerves, are
Society has classified temporomandibular disorders (TMD) as
one subtype of secondary headache disorders [5]. Likewise, the
dental community has focused primarily on the TMJ. The
American Academy of Orofacial Pain further categorised TMD
into two subheadings: articular and masticatory muscle disorders
[6, 7]. Temporal tendinitis is included under masticatory muscle
disorders, while tendinosis was omitted.
A set of evidence-based diagnostic criteria for TMD was
recently established by the Research Diagnostic Criteria for
Temporomandibular Disorders (RDC/TMD) Consortium
Network of the International Association for Dental
Research and the Orofacial Pain Special Interest Group of
the International Association for the Study of Pain. An ex-
panded new set of diagnostic criteria for tendonitis was added
[8, 9]. However, the criteria fail to differentiate between ten-
donitis and tendinosis.
Temporal tendinosis remains an underdiagnosed category of
orofacial pain primary due to two reasons. The first is due to the
deep location and the complexity of the anatomy. The second is a
result of the incomplete descriptions of the anatomy in the vast
majority of medical textbooks [10••, 11••]. A review of 24 stan-
dard medical and dental anatomical textbooks reveals only two
books that accurately depicted the anterior distal temporalis ten-
don insertion on the retromolar triangle area. Further, despite the
correct illustrations, the insertion points were not labelled [9].
Most of the textbooks that were reviewed in this study were
general anatomy textbooks and not written with a specialty- Fig. 1 The temporal muscle originates from the temporal fossa and the
based focus, demonstrating that the specific details of the distal temporal tendon inserts at the coronoid process of the lower
temporalis tendon is often disregarded [11••]. mandible
Curr Pain Headache Rep (2020) 24:18 Page 3 of 9 18

enclosed in a small space, making the tendon both hard to

palpate and to visualise [16]. This is confirmed in a study in
which palpation of the temporomandibular joint and muscles
of mastication was noted to be commonly performed but with
generally unreliable results [17].

Mechanisms of Injury

Temporalis tendon injuries commonly involve a history of

direct trauma to the side of the face, such as in a fall on a hard
surface, or a sudden movement, such as lateral whiplash from
a motor vehicle accident. The process initially starts with an
inflammatory response manifesting as an acute temporal
tendinitis which resolves in the short term [4] and temporal
tendinosis develops over the long term. Other cases of tempo-
ral tendinosis can stem from long standing abnormal exces-
sive mastication, such as chewing hard toffee, or repetitive
strain over many years, such as prolonged playing of embou-
chure instruments (e.g. the clarinet or flute). Pathology is typ-
ically associated with the temporalis tendon of the coronoid
process and/or less commonly with the surrounding soft tis-
sues. However, these injuries are hypothesised to develop sec-
ondary to mechanical stress forces through the opening and
closing of the jaw. The combination of these forces, along
with inadequate opening and closing of the jaw or lack of
flexibility of the temporalis muscle, can result in chronic
changes to the temporalis tendon insertion, leading to
tendinosis or tendinopathy.
Clinical Presentation
Temporalis tendinosis can manifest itself in varying clinical
presentations but generally presents in one of two ways sim-
ilar to clinical disorders of other tendons within the body. The
first way is a unilateral facial pain with or without temporal
headache. The clinical presentation can be localised adjacent
and above the insertion at the coronoid process of the lower
mandible without any referred pain, as in patellar or Achilles
tendinopathy. Patients often point inferior to the zygomatic
arch as the site of pain, away from the temporomandibular
joint, as demonstrated in Fig. 2. The second presentation
may be pain radiating from the distal temporalis tendon to
the temporalis muscle, similar to referred forearm pain in lat-
eral epicondylitis [18, 19]. It should be recognised that the
close proximity of the anatomical structures of the face can
confound clinical diagnosis, and little is known with regard to
the pattern of pain presentation of temporalis tendinosis.
Therefore, it is important to look case by case, as pain patterns
vary.
Patients typically present with chronic facial pain and
temporalis stiffness that is gradual in onset, progressive in
Fig. 2 Patient self identifies site of localised pain inferior to the
zygomatic arch, away from the temporomandibular joint
nature and aggravated with jaw activity. The pain may appear
with sudden bursts of activity, such as chewing and/or yawn-
ing. The patient may note that they are compensating with
excessive chewing on the opposite side to avoid aggravation
of the symptomatic tendon. Examination in the open-mouth
position will often demonstrate a localised area of maximal
tenderness over the medial or lateral aspects of the coronoid
process. However, this is usually non-specific. In some cases,
there can be a restriction of mandibular opening.
One study examining 353 cases of temporal tendinitis not-
ed the most common pain syndromes in decreasing order to
be: facial pain in 68% of cases, temporal headaches in 54%,
zygoma pain in 49%, eye pain in 26%, TMJ pain in 26%, ear
pain in 26%, odontalgia in 18%, neck pain in 9% and man-
dibular pain in 7% of cases [20]. However, this research relied
on a retrospective analysis of charts of patients with TMDs,
and accurate confirmation of the presence of temporal tendi-
nitis or tendinosis could not be obtained, as palpation is non-
specific and diagnostic imaging was not performed.
There is also research on the temporal tendon describing
the pain pattern as intermittent aching behind the orbit that can
radiate to the supra-orbital area, ear and to the temporoman-
dibular joint [21, 22•, 23, 24]. A headache may occur once a
month for up to 6 months, and then may slowly increase to
daily occurrences with photophobia, nausea and vomiting
[21]. However, these studies confirm the presence of temporal
‘tendinitis’ solely by palpation of the insertion of the tendon at
the coronoid process of the mandible, looking for an
 18 Page 4 of 9
exacerbation of pain [24]. As explained below, accurate con-
firmation of temporal tendinosis is problematic in these stud-
ies due to the unknown but likely low sensitivity and speci-
ficity of temporalis tendon palpation, and the fact that many of
the described symptoms can be confounding due to other un-
derlying causes.
Temporal tendinosis pain is generally localised and should
not be confused with various confounding facial or headache
symptoms. The symptoms of unilateral pain include orbital
pain, retrobulbar pain, referred pain to the maxillary sinus
and dentoalveolar pain. This pain can be secondary to entrap-
ment of the maxillary nerve as well as the zygomatic branches,
which travels anteriorly across the medial side of the
temporalis muscle by the pterygopalatine fossa. The entrap-
ment may occur due to spastic or edematous changes of the
medial aspect of the temporalis muscle, which leads to these
confounding facial pain symptoms [25] (Fig. 3).
Fig. 3 Entrapment of the maxillary nerve as well as the zygomatic
branches, which travels anteriorly across the medial side of the
temporalis muscle by the pterygopalatine fossa may lead to various
unilateral facial pain symptoms secondary to spasm or edematous
changes of the medial aspect of the temporalis muscle
Curr Pain Headache Rep (2020) 24:18
The complex and dense anatomy of the palpated region
[16], including many nerves, necessarily undermines the spec-
ificity of using such a physical exam in isolation to confirm
temporal tendinosis. Therefore, it is questionable whether
many of the listed symptoms are truly caused by temporal
tendinosis or merely confounding conditions, again
emphasising the need for imaging studies in conjunction with
physical examination.
It is also important to distinguish between acute muscle
strain and chronic pathology at the temporalis tendon inser-
tion. Treatment for these conditions differs and therefore ne-
cessitates an aggressive early diagnosis to prevent undesired
complications of chronic facial pain. In general, temporalis
muscle strain or musculotendinous strain responds to conser-
vative rehabilitation therapy [26, 27], whereas the insertion
tendinopathy often progresses to prolonged facial pain.
Diagnosis
Precise intraoral palpation is a difficult technique, as one
needs the ability to differentiate the anatomy of the general
oral mucosa, buccinator muscle, as well as the lateral and
medial pterygoid muscles [8, 28–30]. In addition, the location
of the distal temporalis tendon at the coronoid process con-
tributes to the complexity of intraoral palpation. Extraoral pal-
pation of the coronoid process is not possible with the mouth
closed, due to its position deep to the zygomatic arch [31]. No
studies on inter- and intra-examiner reliability for palpation of
the temporalis tendon were found in literature searches per-
formed at the time of this article. Therefore, sensitivity and
specificity of direct palpation of the distal temporalis tendon is
not yet established [9].
Some textbooks advocate palpation for the diagnosis of
tendinitis [32, 33], despite the fact that no clinical distinction
between tendinitis and tendinosis can be made, as the major
factor in differentiating the two is chronological and based on
the patient’s history. However, palpation can be a useful guide
towards further investigation, as it can still give information
regarding non-specific tendon tenderness and other anatomic
subtleties. There are multiple techniques that can be used to
palpate the temporalis tendon. Localisation of the painful area
is best achieved with intraoral single digit palpation at the
medial aspect of the coronoid process, as illustrated in Fig. 4
[32, 33]. The lateral aspect of the coronoid process can also be
palpated intraorally [32]. To dynamically stress the tendon in
medial and lateral directions, it is preferable to utilise the bi-
digital pincer grasp palpation technique using the thumb and
index finger, as illustrated in Fig. 5. The pincer grasp palpation
technique allows one to palpate the medial side of the
temporalis tendon and the masseter muscle, which overlay
the lateral aspect of the coronoid process simultaneously.
This allows one to note a subtle difference between normal
Curr Pain Headache Rep (2020) 24:18
Fig. 4 Single-digit intraoral palpation of the right temporalis tendon as
demonstrated a on a patient during palpation of the medial aspect of the
coronoid process, with b the overlying corresponding anatomy
and abnormal sides. However, masseter myalgia can be a con-
founding factor in isolating temporal tendon pain with this
technique. It is recommended that this test be used in conjunc-
tion with single digit intraoral palpation to avoid confusion.
This is relatively simple for a primary care physician to utilise
as a first step to evaluate the tenderness or thickness of the
distal temporalis tendon and determine if an ultrasound
a b
Fig. 5 Bi-digital pincer grasp palpation technique of the right temporalis
tendon as demonstrated on a a patient with correct positioning and b
illustration of the finger technique
Page 5 of 9 18
referral is warranted. If the tendon is not tender, other sources
of facial pain need to be considered.
Diagnostic imaging in conjunction with clinical examina-
tion allows for a more precise diagnosis. It is important to note
that diagnostic imaging is unable to differentiate between ten-
dinitis and tendinosis; it simply indicates tendon pathology,
which can be used in conjunction with palpation and the clin-
ical history to make a diagnosis. Although both ultrasound
(US) and magnetic resonance imaging (MRI) may be used
for radiological evidence, US is preferable. US is time effi-
cient, less expensive and more readily available compared
with MRI. Furthermore, ultrasound allows for the examina-
tion of both the TMJ and temporalis tendon at the same time or
setting, unlike MRI, which only permits evaluation of one at a
time. However, it is operator dependent and has a steep learn-
ing curve [34]. It is also essential that the ultrasound probe be
positioned directly adjacent to the superficial anatomical
structures to allow for more accurate and clear visualisation
of the temporalis tendon and its pathology.
During ultrasound evaluation, the mouth is required to be
open in order to visualise the coronoid process out from under
the zygomatic arch [11••]. Typically, temporalis tendinopathy
is a retrospective diagnosis that is confirmed through diagnos-
tic imaging. On ultrasound, temporal tendinopathy presents
with thickening of the tendon, as illustrated in Fig. 6 [4].
The tendon may appear hyperechoic, isoechoic or
hypoechoic, depending on the duration of tendinopathy and
the presence of calcifications and scarring.
It is important to note that evaluation for temporal
tendinosis with MRI can only be done with a dedicated
temporal-tendon protocol. Although the temporalis tendon is
in close proximity anatomically to the TMJ, a standard MRI of
the TMJ does not include the temporalis tendon anatomy.
Dedicated high-resolution imaging with different sequences,
accurate angulation to the orientation of the temporalis tendon,
and intravenous contrast is required. As both anatomical struc-
tures cannot be viewed on the same image, this may contribute
to the underdiagnosis of temporal tendinosis. On MRI, the
abnormal temporalis tendon presents with bright signal on
water sensitive sequences, and abnormal enhancement follow-
ing intravenous gadolinium contrast administration. An exam-
ple with three different views of the abnormal temporalis ten-
don; axial, coronal and sagittal is presented in Fig. 7.
However, it is imperative that imaging be used in combination
with physical examination to diagnose chronic temporalis
tendinosis and to rule out any other possible anatomic structures
or pathology that could be implicated in facial pain.
Pathology
Medical specialties such as orthopaedic surgery, physiatry and
rheumatology treat or are at least aware of tendinopathies at
 18 Page 6 of 9
Fig. 6 a Abnormal thickened right temporalis tendon with increased echogenicity on ultrasound and b normal appearance of the tendon. The coronoid
processes are outlined in yellow, and the temporalis tendons are outlined in blue
major joints in the human body, including Achilles, patellar,
common extensor tendon at the lateral epicondyle,
supraspinatus and bicipital tendons of the shoulder.
However, these specific clinical disciplines generally do not
address facial pain, resulting in temporal tendinopathy typi-
cally being neglected. Similarly, clinical specialties that deal
with facial pain, such as otolaryngologists, neurologists, den-
tists or anaesthesiologists, do not normally deal with tendon
disorders. Therefore, temporal tendinopathy tends to be
missed by them as well. Another factor is the inadequate train-
ing among medical and dental practitioners in the area of pain
management [35, 36].
The nomenclature of tendinitis is used almost exclusively
in the dental literature [37–39], with little recognition of
tendinosis or tendinopathy, indicating a confusion of the un-
derlying processes. Tendinosis, unlike tendinitis, involves dis-
ruption of collagenous structure and mucoid degeneration,
leading to a macroscopic degenerative process. Some cases
may develop angiofibrolastic proliferation [40]. Research re-
garding the Achilles tendon discovered that tendinopathy did
not show signs of inflammatory processes, and therefore sug-
gested a shift in terminology from tendinitis to tendinosis [41].
These findings have been confirmed by other investigators,
who also support the use of tendinosis while examining dif-
ferent tendons [42–45]. Despite the growing body of proof
and movement towards correctly identifying tendinopathy
Curr Pain Headache Rep (2020) 24:18
processes, many contemporary investigators still rely on the
terminology of tendinitis [20, 46–49], and overlook
tendinosis, which may result in ineffective management.
Temporal tendinitis is typically associated with direct or
indirect trauma to the head or face resulting from motor vehi-
cle crashes (MVCs) [20, 21]; however, many idiopathic cases
have also been reported [43].
Management
Historically, non-invasive treatment for temporalis
tendinopathy included cessation of physical activity, oral den-
tal appliance, passive deep physical therapy, anti-
inflammatory drug medications and gradual strengthening ex-
ercises of the temporalis muscle. Physical cessation of activity
is particularly difficult given that one needs use of their jaw on
a daily basis. In contrast, treatments for muscle strains gener-
ally include rest, ice and compression.
Invasive intratendinous approaches have been used to de-
crease pain and promote healing in numerous tendinopathies
in other regions of the body. However, the authors have not
found published work describing evaluation of this treatment
for temporalis tendinosis. Invasive intratendinous approaches
include ultrasound-guided local anaesthetic/corticosteroid in-
jection at the temporalis tendon, as illustrated in Fig. 8 [11••],
Curr Pain Headache Rep (2020) 24:18
a ƒFig. 7
b ticosteroids can be effective in the short term, evidence within
R L
Page 7 of 9 18
a Axial plane MR image demonstrating abnormal enhancing right
temporalis tendon at the level of the coronoid process compared with
normal non-enhancing left temporalis tendon (used with permission from
John Wiley and Sons). b Coronal plane MR image demonstrating abnor-
mal right temporalis tendon. c Sagittal plane MR image demonstrating
abnormal right temporalis tendon. The coronoid processes are outlined in
yellow, the medial temporalis tendons are outlined in blue and the laterals
are outlined in red. Other conditions such as infectious myositis, fatty
infiltration and previous corticosteroid injections have been ruled out
tendon needle fenestration [4], prolotherapy [50], platelet in-
jections (PRP) [51] and botulinum toxin injections [52].
Corticosteroid injection is a common intervention for low-
grade inflammation, which recent studies have demonstrated
to be present in chronic tendinopathy [53]. Corticosteroids act
directly at the site of injection to reduce local pain, swelling
and inflammation, while improving function. Two cases of
treated temporalis tendinosis have been documented in the
literature with long-term success [11••]. However, while cor-
medical literature is lacking on the long-term effectiveness of
such injections. Repeated injections can lead to long-term ten-
dinous structural changes, including atrophy [52].
Needle fenestration of the tendon via ultrasound guidance
leads to bleeding, inflammation and microtears. This acts to
increase local growth factors and collagen precursor levels,
disturbing the chronic degenerative changes to the tendon
and ultimately promoting healing [4].
Prolotherapy treatment for tendinopathies involves the in-
jection of a solution (proliferant), which causes local cell death
and triggers the body’s wound-healing cascade [50]. Despite
the many different options of injectables, there is little litera-
ture for the temporalis tendon.
Autologous blood injection (using whole blood or platelet-
rich plasma) is theorised to promote healing through the action
of growth factors on the affected tendon. PRP has been used
Fig. 8 Demonstration of an ultrasound-guided injection technique using
an extraoral approach with the needle parallel to the ultrasound transducer
for optimal visualisation of the needle tip
 18 Page 8 of 9
for chronic tendinopathies of the Achilles, patellar, quadriceps
and rotator cuff tendons [51].
Botulinum toxin A inhibits acetylcholine release at the neu-
romuscular junction leading to weakness of the muscle, there-
by decreasing the tensile strength of the tendon. While it is
more often a treatment for neurological conditions, the phar-
macokinetics and pharmacodynamics of botulinum toxin for
tendinopathy remain unknown [52].
Injection of local anaesthetic has been described for treat-
ment and diagnosis of temporal tendinitis, as well as older
surgical options including incision, reflection and reduction
of the coronoid process [11••, 21]. Surgery generally should
be reserved as a last resort due to morbidity and inconsistent
outcomes in tendinopathy. Due to the lack of knowledge and
underreporting regarding temporalis tendinopathy, it is not
advised as an option.
Regardless of the substance used for injection of the
temporalis tendon, blind injection of the distal temporalis ten-
don is generally discouraged. Therefore, it is of utmost impor-
tance to use ultrasound guidance [11••].
Various interventions for treatment may be explored; how-
ever, further research is necessary for a clearer understanding
on which would be optimal for temporalis tendinopathy. In a
systematic review of the literature to determine the best treat-
ment options for tendinopathy, NSAIDs and corticosteroids
were found to provide short-term relief, but long-term effec-
tiveness was not demonstrated [52, 54]. Ultimately, the paper
concedes that ideal treatment for tendinopathy remains
unclear.
Conclusion
Temporal tendinosis is an under-recognised and under-treated
condition. Despite the fact that orofacial pain is one of the
single most common complaints of patients presenting to phy-
sicians or dentists, it is widely acknowledged that training for
diagnosis and management of temporal tendinopathy among
primary care physicians in both medical and dental profes-
sions is inadequate. This may result in extensive workups,
leading to suboptimal management and chronic pain
syndromes.
Many conditions of facial pain act as confounding vari-
ables to temporalis tendinosis due to the complex musculo-
skeletal and neuropathic anatomy in that region. A focused
history and physical exam are required for those presenting
with suspected temporal tendinosis. However, palpation alone
does not have the sensitivity or specificity for a conclusive
diagnosis. Medical imaging, preferably an ultrasound exami-
nation, is required to confirm the presence of temporal
tendinosis or other potential pathologies. While many man-
agement options are available, optimal treatment remains un-
clear. Further studies and education is required to expand the
Curr Pain Headache Rep (2020) 24:18
awareness of the clinical symptoms, diagnosis and manage-
ment of temporalis tendinopathy in order to obtain a more
accurate understanding of the epidemiology.
Acknowledgements The authors thank Judy Rubin for her work and
artistic contribution for the illustrations of Figs. 1 and 3.
Compliance with Ethical Standards
Conflict of Interest The authors declare that they have no conflict of
interest.
Human and Animal Rights and Informed Consent This article does not
contain any studies with human or animal subjects performed by any of
the authors. Patients shown in figures have consented to have their image
used.
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