Torticollis, sometimes known as twisted neck or wryneck, is a condition that causes the head to tilt or twist to one side, often creating concern for parents when they notice their baby holding their head at an unusual angle or struggling to turn it fully in both directions.

Understanding Torticollis

Torticollis is a condition where the neck muscles cause the head to twist and tilt to one side. The word comes from Latin roots: “tortus” meaning twisted, and “collum” meaning neck. When someone has torticollis, their head typically tilts toward one side while the chin points toward the opposite side. This creates a rotated appearance that can be quite noticeable, especially as a baby begins to gain more control over their head movements.^[1]

This condition is fairly common, particularly in babies and children. Research suggests that approximately 90 percent of individuals will experience at least one episode of torticollis throughout their lifetime.^[3] For infants, torticollis affects about 3 in 100 babies, making it one of the more frequently encountered conditions in early childhood.^[2]

Torticollis can be classified into two main types based on when it occurs. Congenital torticollis is present at birth or develops shortly after, while acquired torticollis develops later in infancy, childhood, or even adulthood. Congenital muscular torticollis is by far the most common type and is usually painless for infants. Parents may not notice it until their baby is a few weeks old, when the infant starts gaining better control of head movements.^[1]

Causes of Torticollis

The causes of torticollis vary depending on the type. In congenital torticollis, the condition results from the shortening of one of the baby’s sternocleidomastoid muscles, which are two large muscles in the neck. These muscles run on both sides of the neck from the back of the ears to the collarbone and breastbone. When one of these muscles becomes shortened or tightened, it pulls the baby’s head to one side.^[1]

Researchers aren’t entirely certain why one of these muscles shortens in some babies. The most common explanation relates to the baby’s position inside the mother’s womb. If a baby is cramped inside the uterus or positioned unusually, such as in the breech position where the baby’s buttocks face the birth canal, this can put extra pressure on one side of the sternocleidomastoid muscle. This pressure may cause the muscle to tighten, making it difficult for the baby to turn their neck freely.^[5]

Another theory suggests that intrauterine positioning can lead to the head being twisted for a prolonged period. If the fetus remains in that position long enough, it may create a localized lack of blood flow and oxygen, which leads to the development of scar tissue in the sternocleidomastoid muscle. This scarring causes the muscle to shorten and tighten.^[6]

In some cases, congenital torticollis may result from abnormal development of the muscle itself, a collection of blood in the neck muscles called a hematoma, or abnormal thickening of muscle tissue known as fibrosis. Rarely, it can be associated with conditions like Klippel-Feil syndrome, a birth defect that causes the vertebrae in the neck to fuse together.^[1]

Acquired torticollis has different causes. In children, it frequently occurs because of swelling in the throat. This swelling causes the tissues surrounding the upper spine to loosen, allowing the vertebrae to move out of their normal position. This movement causes the neck muscles to spasm, tilting the head to one side. The swelling might result from an infection, an injury, or sometimes an unknown reason.^[1]

Other causes of acquired torticollis include gastroesophageal reflux disease, vision problems, reactions to certain medications, scar tissue, or arthritis of the neck. Some rare conditions like Sandifer syndrome, which combines reflux with neck spasms, or Grisel’s syndrome, a complication of head and neck infections or ear, nose, and throat surgeries, can also lead to torticollis.^[1]

In adults, torticollis can develop from sudden muscle spasms in the neck. These may be due to injury or trauma to a muscle that is so minor the person might not even remember it, such as sleeping in an awkward position or holding the head differently during a flight. Sometimes inflammation in the neck or reactions to certain medicines can trigger the condition.^[4]

Risk Factors

Several factors can increase the risk of developing torticollis. For babies, being a first-born child increases the likelihood of congenital torticollis. This is because first-time pregnancies often have tighter space in the uterus, which can lead to the baby being more cramped or positioned awkwardly. This same crowding can also increase the risk of hip dysplasia, which sometimes occurs alongside torticollis.^[7]

Babies who held their head at an awkward angle inside the womb or were born in the breech position face higher risk. Those with certain genetic mutations, such as GDF6, GDF3, or MEOX1, are also more susceptible to developing congenital torticollis.^[6]

Children are at increased risk of acquired torticollis if they have experienced neck trauma or a brain injury. Having neck burns or scars that restrict neck muscle movement can also contribute. Other risk factors include having neck muscles with excessive muscle tone, abnormalities of the neck vertebrae, juvenile idiopathic arthritis, or certain infections like retropharyngeal abscess.^[6]

For adults, risk factors include experiencing neck trauma, having a brain injury, neck burns or scars, or neck muscles with too much muscle tone. Rare genetic mutations such as CIZ1, ANO3, or GNAL can increase susceptibility. Adults with arthritis or a herniated disk are also at greater risk of developing a form of torticollis called cervical dystonia.^[6]

Symptoms

The symptoms of torticollis are usually quite visible, making the condition relatively easy to recognize. The most obvious sign is the abnormal positioning of the head. In babies with congenital torticollis, the head tilts to one side while the chin tilts to the opposite side. Parents may notice that their baby has limited movement of the head and neck, unable to turn fully in both directions.^[1]

Other symptoms in infants include one shoulder appearing higher than the other, neck muscle tightness or stiffness, and swollen neck muscles. Sometimes a small, pea-sized lump can be felt in one of the baby’s neck muscles. Some babies may also develop uneven or asymmetrical facial features over time if the condition is not treated.^[1]

Babies with torticollis typically act like other babies except during activities that involve turning their head. When they’re about two to four weeks old, they may tilt their head in one direction, have trouble fully turning their head to follow someone, or if breastfed, have difficulty feeding on one side or prefer one breast only. They may also work hard to turn toward a parent or caregiver.^[5]

In children and adults with acquired torticollis, symptoms are similar but may also include severe neck pain, head tremors, and headaches. The pain and stiffness can make it difficult to perform usual daily activities. Some people may also experience headaches from the muscle tension and abnormal positioning.^[1]

Torticollis can twist the head in different directions depending on which muscles are affected. The chin may turn toward the shoulder, the ear may tilt toward the shoulder, or the chin may point straight up or straight down. In most cases involving temporary torticollis in children and adults, symptoms disappear completely within seven to ten days.^[4]

Certain symptoms indicate a more serious cause of torticollis and require urgent medical attention. These warning signs include fever, increased drooling, sore throat, difficulty swallowing, visual changes, or changes in sensation or mobility of the limbs. Children who develop torticollis with neck pain after trauma, even minor trauma, should be evaluated immediately to ensure there is no subluxation of the vertebrae in the upper spine.^[2]

Prevention

While there is no known way to completely prevent congenital muscular torticollis, certain practices can help reduce the risk or severity of the condition. For babies already born with torticollis, early intervention is crucial. Starting treatment as soon as possible, ideally within the first few weeks of life, leads to better outcomes and shorter treatment duration.^[2]

One important preventive measure for infants is ensuring adequate tummy time. This involves placing babies on their stomachs during supervised awake periods. Tummy time helps strengthen neck muscles and encourages babies to lift and turn their heads in both directions. For babies with torticollis, spending time on the stomach is even more important as it helps prevent further muscle tightness and promotes symmetrical head movement.^[1]

Parents should also be mindful of their baby’s positioning during sleep and play. Limiting time in containers such as bouncers, swings, strollers, car seats, and other devices that keep babies in one position for extended periods can help. While these devices are useful, spending too much time in them can contribute to flat head syndrome and worsen torticollis by keeping the baby in the same position.^[24]

Encouraging babies to turn their heads in both directions throughout the day is another effective strategy. Parents can do this by alternating which side they approach their baby from, changing the baby’s orientation in the crib or on the changing table, and positioning interesting toys or objects on the side the baby tends to avoid looking toward. These simple environmental modifications encourage the baby to work the weaker neck muscles and develop more balanced movement.^[5]

For older children and adults, prevention of temporary torticollis involves avoiding sudden awkward movements of the neck, maintaining good posture, and being mindful of sleeping positions. Using proper neck support during sleep and avoiding prolonged periods in positions that strain the neck can help prevent muscle spasms that lead to torticollis.^[4]

How the Body Changes in Torticollis

Understanding what happens in the body during torticollis helps explain why the symptoms occur and why treatment is necessary. In healthy individuals, the muscles on both sides of the neck are of similar length and flexibility. These muscles work together to allow the head to move freely in all directions, turn from side to side, and maintain an upright, centered position.^[6]

In congenital torticollis, one of the sternocleidomastoid muscles becomes shortened and tight. This muscle imbalance creates an unequal pull on the head. The shortened muscle pulls the head toward the affected side while the chin points away. Meanwhile, the muscle on the opposite side becomes looser and weaker from underuse. This creates a cycle where the tight muscle stays tight and the weak muscle stays weak, reinforcing the abnormal head position.^[5]

The shortening of the muscle can occur through several mechanisms. If there was injury to the muscle during birth, bleeding and bruising within the muscle may occur. As this injury heals, scar tissue called fibrosis can develop within the muscle. This scar tissue is less flexible than normal muscle tissue and causes the muscle to shorten and tighten. Sometimes a mass or lump can be felt on the side of the neck where this fibrosis has formed.^[14]

When the head remains tilted to one side for extended periods, gravity exerts uneven forces on the baby’s skull. Since infant skulls are still soft and moldable, this constant pressure can cause flattening on one side of the back of the head. This is why plagiocephaly often accompanies torticollis. The prolonged abnormal positioning can also lead to asymmetry in facial features over time if left untreated.^[2]

In cases of acquired torticollis, particularly in children, the underlying mechanism often involves swelling or inflammation. When the throat or tissues around the upper spine swell, it causes the ligaments and structures that normally hold the vertebrae in place to loosen. This allows the vertebrae to shift slightly out of their normal alignment. The body responds to this instability by causing the neck muscles to spasm, attempting to protect the area. These muscle spasms pull the head into a tilted position.^[1]

In adults, torticollis may involve focal dystonia, where local neuromuscular mechanisms become dysfunctional. This means the signals between the nerves and muscles don’t work properly, causing sustained or intermittent muscle contractions. These contractions force the neck into abnormal positions. Cervical dystonia, a form of torticollis affecting adults, is among the most common focal dystonias, causing tetanus-like contractions of the sternocleidomastoid and trapezius muscles.^[3]

The body’s attempt to compensate for the abnormal head position can create additional problems. Muscles that normally aren’t primary neck movers may try to assist, leading to widespread tension, discomfort, and sometimes headaches. The spine itself may attempt to compensate for the tilted head by creating curves elsewhere, potentially affecting overall posture and alignment.^[1]

Understanding these physical changes helps explain why treatment focuses on stretching the tight muscles, strengthening the weak muscles, and encouraging active movement in all directions. By addressing the muscle imbalance and preventing the development of compensatory patterns, treatment aims to restore normal neck function and symmetrical head positioning.^[5]