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Torticollis

From WikiSM

Other Names

  • Torticollis
  • Wryneck
  • Cervical Dystonia
  • Congenital Muscular Torticollis (CMT)
  • Wry Neck
  • Cervical Dystonia
  • Spasmodic Torticollis
  • Acquired Torticollis

Background

  • This page refers to Torticollis, a condition characterized by abnormal, sustained tilting and rotation of the head and neck

History

  • Needs to be updated

Epidemiology

  • Incidence of CMT ranges from 0.3% to 16% of newborns.[1]
  • Third most common congenital musculoskeletal condition in newborns.

Introduction

General

  • Torticollis is characterized by abnormal, sustained tilting and rotation of the head and neck, most commonly due to unilateral shortening or contracture of the sternocleidomastoid (SCM) muscle.
  • Can be classified as either congenital or acquired, with congenital muscular torticollis (CMT) being the most common form in infants and young children.
  • CMT typically presents at or shortly after birth and is thought to result from perinatal factors such as intrauterine malposition, birth trauma, or vascular compromise to the SCM, leading to fibrosis and muscle shortening.
  • Acquired torticollis can occur at any age and has a broad differential, including trauma, infection, osseous abnormalities, ocular disorders, and dystonic reactions.

Terminology

  • Needs to be updated
  • Need to describe the different types of Torticollis

Pathophysiology

  • Pathophysiology depends on the underlying etiology
  • In CMT, perinatal muscle injury, intrauterine malposition, or vascular compromise results in muscle fibrosis and contracture, causing unilateral shortening or fibrosis of the SCM
  • In acquired torticollis, the pathophysiology varies and may involve musculoskeletal, neurological, infectious, or ocular causes.
    • Musculoskeletal causes include trauma, neck sprain/strain, and vertebral anomalies leading to abnormal cervical alignment.
    • Neurological causes include drug-induced acute dystonic reactions (eg, drug-induced), posterior fossa lesions, and cerebral palsy.
    • Infectious etiologies, such as upper respiratory tract infection, retropharyngeal abscess, and cervical vertebral osteomyelitis.
    • Ocular torticollis arises from compensatory head tilt to maintain binocularity in patients with conditions such as strabismus, nystagmus, and cranial nerve palsy

Associated Conditions

  • Needs to be updated

Anatomy of the Cervical Musculature

  • Needs to be updated

Risk Factors

  • Unclear the etiology of the exact cause but thought to be due to intrauterine deformation which can happen when there is limited uterine space like oligohydramnios, uterine compression syndrome, first pregnancy. Can also result from perinatal injury like with breech delivery[2]

Differential Diagnosis

Differential Diagnosis Neck Pain

Clinical Features

History

  • Evaluation should include a comprehensive medical history including any history of oligohydramnios, traumatic delivery, or pelvic presentation

Physical Exam: Physical Exam Neck

  • Postural preference with chin and head tilted in opposite directions. In muscular and SCM mass type, the head tilts toward the affected SCM
  • Palpable tightening (muscular type) or thickening of the SCM. SCM mass type may have palpable mass in the inferior one-third of the affected SCM
  • Bilateral involvement is rare
  • Assess passive and active cervical ROM
  • Important to assess neurologic and auditory function, but especially visual function as weakness in oculomotor muscles suggest torticollis is compensatory to improve vision
    • Be sure to check eye alignment, red reflex, and pupillary reflexes to evaluate if the eyes fixate and follow objects
      • Refer to ophtho if no muscle contracture on physical exam
      • Red flags: poor visual tracking, abnormal muscle tone[3]

Special Tests

  • Needs to be updated

Evaluation

General

  • Diagnostic studies are not typically required unless red flag signs
  • General approach to

Radiographs

Ultrasound

  • Needs to be updated

CT

  • Needs to be updated

MRI

  • Needs to be updated

Laboratory

  • May be indicated if
    • Infectious etiology is being considered
  • Labs
    • Complete blood count
    • Blood cultures
    • Inflammatory markers

Classification

Congenital Muscular Torticollis (CMT)

  • Postural – infant has a postural preference but no muscle tightness or restriction to passive ROM
  • Muscular – infant has a tight SCM and limited passive ROM
  • SCM mass – infant has a thickened SCM and restricted passive ROM, accounts for 50% of cases[3]

Acquired Torticollis

  • Usually from SCM or trapezius inflammation or injury but can also be due to conditions that cause cervical nerve irritation or muscle spasm
  • Can also occur due to infections like viral URI, pharyngitis, retropharyngeal abscess
  • Atlantoaxial rotary subluxation is also a common cause as kids have a larger torso to head ratio, weaker neck muscles, and more ligamentous laxity[4]

Management

Nonoperative

  • Nonoperative management includes changes in positioning and handling, environmental changes, and physical therapy if needed[5]
  • Position and handling:
    • Hold the infant in a way that has them rotate their chin toward the affected side while feeding. So if the head is tilted to the right and chin rotated to the left, hold the child in the left arm so they title the head to the left and chin rotated to the right
    • Prone positioning (aka tummy time) should be utilized while awake and being watched by the caregiver. Helps stretch the SCM and increase neck muscle strength
  • Environmental changes:
    • Have the crib or changing table positioned in a manner that has the child rotate towards the affected side in order to see the rest of the room
    • Similarly, position toys or a mobile in a manner that has the child tilt/rotate to the affected side to better see/engage
  • Passive and active stretching also recommended. Physical therapy referral is recommended if home exercises are not effective after 4-6 weeks
  • Acquired: treat the underlying cause

Operative

  • Referral to orthopedic or pediatric surgery if symptoms persist after 6 months of physical therapy
  • Indications for CMT[2]
    • Marked shortening of the SCM
    • persistent fibrotic muscle
    • persistent asymmetry of the head and face
    • restriction of rotation or lateral flexion in the C-spine region by more than 15 degrees
  • Acquired
    • Dependent on the underlying cause

Rehab and Return to Play

Rehabilitation

  • Needs to be updated

Return to Play/ Work

  • Needs to be updated

Prognosis and Complications

Prognosis

  • Majority of cases resolve with first-line interventions like manual stretching. When treatment is started before 6 months, 97% of patients improve[3]
    Complications
    • Delayed treatment can lead to permanent anatomic abnormalities like disfigurement (craniofacial asymmetry) and functional impairment

Complications

  • Needs to be updated

See Also

References

  1. ↑ Heidenreich E, Johnson R, Sargent B. Informing the update to the physical therapy management of congenital muscular torticollis: evidence-based clinical practice guideline. Pediatr Phys Ther. 2018;30(3):164–175. doi:10.1097/PEP.0000000000000517.
  2. ↑ 2.0 2.1 Płomiński J, Olesińska J, Kamelska-Sadowska AM, Nowakowski JJ, Zaborowska-Sapeta K. Congenital Muscular Torticollis-Current Understanding and Perinatal Risk Factors: A Retrospective Analysis. Healthcare (Basel). 2023 Dec 20;12(1):13. doi: 10.3390/healthcare12010013. PMID: 38200919; PMCID: PMC10778664.
  3. ↑ 3.0 3.1 3.2 Gundrathi J, Cunha B, Tiwari V, et al. Congenital Torticollis. [Updated 2024 Mar 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK549778/
  4. ↑ Kempeneers MA, Buis DR, Feller RE, et al. Torticollis with Atlantoaxial Rotatory Subluxation in Children: A Clinical Review. Neuropediatrics. 2024;55(6):349-355. doi:10.1055/a-2312-9994
  5. ↑ Kaplan SL, Coulter C, Sargent B. Physical Therapy Management of Congenital Muscular Torticollis: A 2018 Evidence-Based Clinical Practice Guideline From the APTA Academy of Pediatric Physical Therapy. Pediatr Phys Ther. 2018;30(4):240-290. doi:10.1097/PEP.0000000000000544
Created by:
At108 on 19 August 2025 04:01:29
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Last edited:
23 June 2026 14:47:34
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