Caring Medical - Where the world comes for ProlotherapyErnest Syndrome – the missing diagnosis of unresolved TMJ pain

Ross Hauser, MD  | Caring Medical Regenerative Medicine Clinics, Fort Myers, Florida
David N. Woznica, MD | Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
Danielle R. Steilen-Matias, MMS, PA-C | Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois

Ernest Syndrome – the missing diagnosis of unresolved TMJ pain

In the more than 25 years of helping patients with chronic pain, we often find that what people have been diagnosed with is not really the problem causing them their continued and chronic pain. Such is the case of people who were diagnosed with problems of TMJ and still have jaw pain and related issues.

In this article, we will focus on Ernest syndrome as the missing diagnosis in TMJ pain.

The problems of Ernest syndrome surrounds the damage and weakening of the stylomandibular ligament, a small but powerful ligament that connects the skull to the jaw by way of the styloid process of the temporal bone to the mandible. The missing diagnosis of Ernest Syndrome as the cause of TMJ related pain is found in that both TMJ and Ernest Syndrome have similar if not identical symptoms.

From our published research: Dextrose Prolotherapy and Pain of Chronic TMJ Dysfunction. Hauser R, Hauser M, Blakemore K. Dextrose prolotherapy and pain of chronic TMJ dysfunction. Practical Pain Management. 2007; November/December:49-55.

In our clinics, we are very aware of what damaged ligaments can do, so it is reassuring to us that medical research is documenting some of the same things that we have seen over the years. In regard to Ernest Syndrome, this problem may be much more prevalent than doctors think, so maybe we should not call this a “rare,” disorders. Further, patients with unresolved TMJ and jaw pain should be examined for stylomandibular ligament damage.

Recently doctors at the University of Valencia in Spain wrote in the medical journal Neurología (1) that Ernest syndrome is characterized by pain in:

  • the preauricular area (external ear)
  • mandibular angle (jaw),
  • pain radiating to the neck, shoulder, and eye on the same side.
  • palpation of the stylomandibular ligament, gently pressing on it, will cause pain.

These symptoms, which are common to the myriad of disorders that TMJ and cervical neck instability can  produce, including the tenderness on pressing into “the behind the ear area,” while implicating a problem of Ernest Syndrome, will still and often confuse clinicians that Ernest Syndrome is being caused by other types of orofacial pain including TMJ.

Ernest Syndrome  the researchers conclude: “may, therefore, be more prevalent than the literature would indicate.”

In 1987, Dr. WE Shankland II described a detailed clinical analysis of 68 patients diagnosed as suffering from Ernest syndrome. (2) This is an often-cited paper by researchers exploring the problems of treatment of Ernest Syndrome.

  • “Injury to the stylomandibular ligament is a real and frequent disorder causing craniomandibular pain.”
  • Symptoms of Ernest’s syndrome, in decreasing order of occurrence, are:
    • TMJ and temporal pain,
    • ear and mandibular pain,
    • posterior tooth sensitivity,
    • eye pain
    • throat pain.
    • shoulder pain may be involved.

Of the patients in this study, 77.94% were treated successfully via nonsurgical management of their complaints. Resolution of this disorder is usually accomplished by a combination of a diagnostic injection of local anesthetic at the insertion of the ligament, localized injection of cortisone substitute, and placing the patient on a soft diet.

While we will agree that injection therapy will help the patients, we would prefer the injection of simple dextrose as opposed to cortisone. Cortisone acts and an anti-inflammatory and is not curative in nature. Dextrose injections or Prolotherapy is an injection that seeks to strengthen weakened ligaments by causing inflammatory repair. This is explained below.

Unnecessary TMJ Surgery for Ernest Syndrome

Ernest Syndrome is named for Edwin A. Ernest, III D.M.D., a dentist who has published pioneering research on facial pain conditions. Dr. Ernest reported that pain of the stylomandibular ligament would refer pain to the jaw and mimic TMJ in the 1982 medical book Temporomandibular Joint & Craniofacial Pain—An Orthopedic & Neurological Approach to Diagnosis and Management.

In the October 2006 issue of Practical Pain Management, (3) Dr. Ernest described two patients who were inappropriately operated on for TMJ. When TMJ issues did not resolve, the two patients were ultimately diagnosed with Ernest Syndrome resulting from motor vehicular trauma.

Dr. Ernest summarized these cases studies with this warning to doctors and dentists: “This paper serves to emphasize for physicians and dentists that inclusion of Ernest Syndrome in the differential diagnosis of ear symptoms, TMJ pain, and other craniofacial pains will help to prevent unwarranted surgery of the TM Joint.”

Ernest Syndrome Dextrose Injections – Prolotherapy

As we mentioned above, Ernest syndrome is caused by damage to the stylomandibular ligament and the pain this damaged ligament causes throughout the jaw, neck and into the shoulders and upper spine. While we believe Ernest Syndrome to be a missing diagnosis in patients suffering from unresolved TMJ related pain, it is usually not a problem that sits in isolation. Ernest syndrome can be occurring concurrently with other problems. Ernest’s Syndrome can also be confused with Eagle Syndrome which is an elongation of the styloid process and stylohyoid ligament calcification.

Dr. Hauser discusses the various conditions that Ernest Syndrome can occur with or be mistaken for including Barre-Lieou syndrome.

Prolotherapy involves the injection of a small amount of various proliferant solutions (such as hypertonic dextrose, or platelet-rich plasma) at the painful entheses of ligaments.

The basic mechanism of Prolotherapy is simple.

  • Prolotherapy solutions are injected into your painful areas to begin a reparative action.
  • The injections create a localized inflammation triggering the immune system to create the building blocks of ligament repair.

Prolotherapy patient information in brief

Prolotherapy involves using a safe and simple base solution containing dextrose as the primary proliferant, along with an anesthetic (procaine), that is given into and around the entire painful/injured area (many injections vs only a few injections.) This basic Prolotherapy solution used for over 70 years includes the above mentioned hypertonic dextrose (1­2.5% concentration) along with an anesthetic.

If you have a question about Ernest Syndrome, get help and information from our Caring Medical staff



1 Peñarrocha-Oltra D, Ata-Ali J, Ata-Ali F, Peñarrocha-Diago MA, Peñarrocha M. Treatment of orofacial pain in patients with stylomandibular ligament syndrome (Ernest Syndrome). Neurologia. 2013 Jun;28(5):294-8. doi: 10.1016/j.nrl.2012.06.009. Epub 2012 Aug 14. [Google Scholar]
2 Shankland WE. Ernest syndrome as a consequence of stylomandibular ligament injury: a report of 68 patients. Journal of Prosthetic Dentistry. 1987 Apr 1;57(4):501-6. [Google Scholar]
3 Ernest EE. Ernest Syndrome and Insertion of the SML at the Mandible. PPM 2006 Volume 6, Issue #7


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