Torticollis

Torticollis, also known as wryneck or twisted neck, is a condition where the head tilts to one side, making it difficult to move the neck normally. While this condition can affect anyone from newborns to adults, early recognition and treatment can lead to excellent outcomes for most people.

Table of contents

• What is torticollis?
• Types of torticollis
• Symptoms
• Causes and risk factors
• Associated anatomy
• Diagnosis
• Treatment and management
• Outlook and prognosis
• Prevention

wryneck, twisted neck, wry neck

What is torticollis?

Torticollis is a condition where the head tilts or twists to one side in an abnormal position. The name comes from Latin words meaning “twisted neck.” When someone has torticollis, their head typically tilts toward one shoulder while their chin points toward the opposite shoulder^[1].

This condition is fairly common, with estimates suggesting that about 90% of people will experience at least one episode of torticollis during their lifetime^[3]. In infants, torticollis affects roughly 3 in 100 babies^[13], and about 0.4% of newborns are born with the condition^[6].

Types of torticollis

Torticollis is generally classified into two main categories: congenital (present at birth) and acquired (developing later in life)^[1].

Congenital torticollis is the most common type. It is present when a baby is born, though parents may not notice it until the baby is a few weeks old and starts to gain more control of their head movements. This type is usually painless for the infant^[1]. The most frequent form is congenital muscular torticollis, which responds very well to physical therapy, especially when treatment begins early^[2].

Acquired torticollis develops later in infancy, childhood, or adulthood. It typically occurs in the first four to six months of a baby’s life or later^[1]. In children, it may appear suddenly or develop gradually. Acquired torticollis can be harmless or may signal a more serious health issue^[2].

In adults, a specific form called cervical dystonia can occur. This type typically affects adults and can result from a head or neck injury, medication side effects, or inherited genetic factors^[6].

Symptoms

The symptoms of torticollis vary depending on whether it is congenital or acquired.

For babies with congenital torticollis, the symptoms may include^[1]:

• The baby’s head tilts to one side while the chin tilts to the other side
• Limited movement of the baby’s head and neck
• One shoulder appearing higher than the other
• Tightness or stiffness in neck muscles
• Swollen neck muscles
• A small, pea-sized lump in one of the baby’s neck muscles
• Uneven facial features

Babies with torticollis may have trouble breastfeeding on one side or prefer only one breast. They may also develop a flat spot on the head, a condition called plagiocephaly, from lying in one direction most of the time^[5].

For children and adults with acquired torticollis, symptoms may include^[1]:

• Head tilting to one side with chin tilting to the other
• Limited movement of the head and neck
• One shoulder higher than the other
• Neck muscle tightness or stiffness
• Swollen neck muscles
• Severe neck pain
• Head tremors
• Headaches

In adults, torticollis usually causes pain on one side of the neck. The pain and stiffness can make it difficult to perform usual activities^[4].

Causes and risk factors

The causes of torticollis depend on the type.

Congenital torticollis occurs when one of the baby’s sternocleidomastoid muscles becomes shortened. Researchers are not entirely sure why this happens in some babies. It may be due to^[1]:

• The way the baby was positioned in the womb
• Abnormal development of the muscle
• A collection of blood in the baby’s neck muscles
• Abnormal thickening of muscle tissue
• Rare birth defects like Klippel-Feil syndrome

Being cramped inside the uterus or being in an unusual position, such as the breech position where the baby’s buttocks face the birth canal, can put extra pressure on one side of the neck muscle, causing it to tighten^[5]. The condition may also result from a difficult birth, especially if the baby is delivered breech^[14].

Babies are at greater risk of congenital torticollis if they held their head at an awkward angle in the womb, were born in the breech position, or have certain genetic mutations such as GDF6, GDF3, or MEOX1^[6].

Acquired torticollis frequently occurs because of swelling in the throat. This swelling causes the tissues around the upper spine to loosen, allowing the vertebrae to move out of their normal position. This causes neck muscles to spasm, leading the head to tilt to one side. The swelling may be due to an infection, injury, or unknown reasons^[1].

Other causes of acquired torticollis include^[1]:

• Gastroesophageal reflux (GERD)
• Vision problems
• Reaction to certain medications
• Scar tissue
• Arthritis of the neck
• Sandifer syndrome, a rare condition combining GERD with neck spasms
• Grisel’s syndrome, a rare complication of head and neck infections or ear, nose, and throat surgeries

In children and adults, torticollis may happen because of a sudden muscle spasm in the neck. This may be due to minor injury or trauma that is so subtle you might not remember it, such as sleeping in an awkward position^[4].

Children are at increased risk of acquired torticollis if they experienced neck trauma, have neck burns or scars, have abnormalities of neck vertebrae, have juvenile idiopathic arthritis, or have certain rare conditions^[6].

Associated anatomy

• Sternocleidomastoid muscle (SCM)
• Neck (cervical spine)
• Trapezius muscle
• Scalene muscles
• Vertebrae
• Sternum (breastbone)
• Clavicle (collarbone)

The primary muscle involved in torticollis is the sternocleidomastoid muscle (SCM). This is a large, rope-like muscle that runs on both sides of the neck from the back of the ears to the collarbone. When one SCM becomes tight or shortened, it makes it hard to turn the neck^[5].

The sternocleidomastoid muscle connects the back of the skull to the breastbone and collarbone. Its action is to perform rotation to the opposite side, tilt to the same side, and flexion of the head^[3].

Other muscles in the region that may be involved include the trapezius, the scalenes, and the splenius muscles^[3].

Diagnosis

A healthcare provider can usually diagnose torticollis with a physical examination. For babies, the doctor will examine how far the baby can turn their head^[5]. The doctor will check the range of motion in the head and neck and look for any lumps or swelling in the neck muscles^[1].

In some cases, additional tests may be needed. Your doctor may order an X-ray, CT scan, or other imaging tests to look at the bones and soft tissues of the neck^[4]. These tests help rule out other conditions and identify any abnormalities in the neck vertebrae or surrounding structures.

For babies with congenital torticollis, early diagnosis is important. Although children have this condition when they are born, parents may not notice it until the baby is several weeks old, as they start to gain more control of their head movement^[2].

Treatment and management

Treatment for torticollis depends on the type and cause of the condition. The good news is that most cases, especially congenital torticollis, respond very well to treatment^[2].

Physical therapy is the cornerstone of treatment for congenital muscular torticollis. For babies with torticollis, doctors often teach parents neck stretching exercises to practice at home. These exercises help loosen the tight SCM muscle and strengthen the weaker muscle on the other side. This helps to straighten out the baby’s neck^[5].

Physical therapy includes stretching exercises, massage, local heat application, and sensory biofeedback^[12]. Research has shown that the earlier a baby begins physical therapy, the better their outcomes will be and the shorter their treatment duration will be^[24].

Position changes are crucial for treating torticollis in babies. Parents should encourage the baby to turn their head in both directions. This helps loosen tense neck muscles and tighten the loose ones^[5]. It is important to be mindful of how you position the baby during sleep and play, ensuring they spend time with their head turned to the less-preferred side^[1].

Tummy time is especially important for babies with torticollis. Spending time on their stomach helps strengthen neck muscles and encourages them to lift and turn their head in both directions^[21].

For adults and children with acquired torticollis, treatment may include^[4]:

• Pain relief medications
• Applying gentle heat to the affected area
• Gentle massage
• Rest and avoiding activities that worsen the pain

Medications may include nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, benzodiazepines, or anticholinergics^[12].

Botulinum toxin injections are currently a popular treatment choice for persistent torticollis, particularly in adults with cervical dystonia. These injections help relax the tight muscles^[12].

Surgery may be considered when conservative treatments fail. Surgical options include release of the sternocleidomastoid muscle, selective denervation, or deep brain stimulation procedures^[12]. Research has shown that surgical treatment can lead to significant improvements in both clinical outcomes and quality of life^[15].

Outlook and prognosis

The outlook for people with torticollis is generally very good, especially when treatment begins early.

For babies with congenital muscular torticollis, the condition usually gets better with simple position changes or stretching exercises done at home. Most babies do not feel any pain from it^[5]. When physical therapy is started early, most children recover fully with no lasting effects^[1].

For adults with acquired torticollis caused by muscle spasm, symptoms usually disappear completely within 7 to 10 days^[4].

Research on surgical treatment outcomes shows significant improvement. In one study, patients showed improvement in range of motion, reduction in deformities, and overall subjective satisfaction two years after surgery. Younger patients showed better improvement than older ones, particularly regarding facial asymmetry^[15].

The key to good outcomes is early intervention and consistent treatment. Every small milestone during treatment represents progress toward recovery^[21].

Prevention

There is no known way to prevent congenital muscular torticollis^[7]. However, certain measures can help prevent acquired torticollis or reduce the risk of developing the condition.

For babies, preventive measures include^[21]:

• Ensuring adequate tummy time throughout the day
• Avoiding prolonged time in containers such as bouncers, swings, and car seats
• Changing the baby’s position regularly
• Varying the direction the baby faces in the crib or on the changing table

For adults, prevention strategies may include:

• Maintaining good posture
• Using proper sleeping positions
• Avoiding sudden neck movements
• Managing stress, which can contribute to muscle tension

If you notice signs of torticollis in yourself or your child, it is important to seek medical attention promptly. You should see a doctor if a baby has difficulty feeding on one side, if there are signs of infection, if pain is getting worse, or if symptoms do not improve within 7 to 10 days^[4].

Urgent medical attention is needed if there is fever, increased drooling, difficulty swallowing, visual changes, or changes in sensation or mobility of the limbs, as these may indicate a more serious underlying cause^[4].