Hey everyone, it’s Medicine Mondays and this post is probably a little late. However, I wanted to take today to talk about something that is not uncommon, but is probably not well understood by the general public. Most physicians will have at least heard about this entity during their clinical rotations, but may have forgotten. That said, let’s talk about “What is Torticollis?”

Stock Photo from: Pexels

What is Torticollis?

Torticollis has a variety of other names like “crick in the neck” and “wry neck”. It is kind of a nonspecific term for “abnormal head position”.

However, in the medical field it is usually used to refer to the pediatric population, meaning congenital muscular torticollis (CMT). This is a specific type of torticollis, related to a shortening of the sternocleidomastoid muscle. The actual mechanism of movement for the sternocleidomastoid muscle is somewhat complex. To put it simply, it’s not just one muscle, it “splits” into different “heads”, allowing for different types of movement.

In short, there is asymmetry of the position of the neck because of an asymmetric shortening of one of the sternocleidomastoid muscles. This may be present at birth or can take as long as 3 months to develop.  As to exactly why this happens, no one really understands for sure. However, it is postulated that in the womb if the baby is positioned a certain way, extra pressure maye be exerted on one side of the neck, causing that side would tighten, making movement more difficult.

There is also an approximately 20-30% association of congenital muscular torticollis and development dysplasia of the hip.

This diagnosis is not uncommon, somewhere between 1-2%. However, I think this diagnosis can be anxiety-inducing to new parents and so I wanted to take the time to explain it here, as simply as possible.

How does it present?

Well, you can visualize it with motion.

The baby will have a more difficult time turning their head to a certain side as well as have decreased range of motion compared to the other side. This is sometimes hard to pick up on visual inspection, but you may notice:

• head tilt (difficult in young infants since they can’t lift their heads yet)
• will track one side with eyes over the shoulder, rather than turning their head
• preference for a certain breast when breast feeding
• noticeable difficulty in turning to one side, possibly with frustration

However, during a physical examination your pediatrician will do their own evaluation.

On physical examination, there may be a:

• head tilt to one side (to the affected side, 75% of the time to the right)
• decreased range of motion, both side/side and up/down
• palpable lump
• flattening of one side the head/face from always sleeping on one side
  • such as plagiocephaly (flat back of head, from laying supine)

Is there any imaging needed for the diagnosis?

Imaging is not usually necessary for the diagnosis. However, a targeted ultrasound of the sternocleidomastoid muscle for torticollis will demonstrate that one side is shorter (and maybe “fatter”) than the other side.

An x-ray may also be obtained to evaluate for other bony abnormalities that would cause torticollis (that aren’t congenital muscular torticollis). I won’t get into all the other bony abnormalities, but they would include occipitoatlanto fusion, Klippel-Fiel syndrome, and craniofacial abnormalties. Depending on the x-ray, more imaging may be required for further evaluation.

There are three types of congenital muscular torticollis:

• fibromatosis coli
  • “pseudotumor of infancy” (has a palpable mass)
• muscular torticollis
  • tightness, but no mass
• postural torticollis
  • no tightness, and no mass

So what is the treatment/followup?

Normally, congenital muscular torticollis is diagnosed early on in the infant’s life, less than 3 months of age. Treatment is usually pretty conservative. The parents are normally given guidance on doing neck stretching exercises for their children to be done daily. Depending on your pediatrician, they may also want you to take your baby to physical therapy.

Your doctor or physical therapist will provide you with guidance for both passive and active stretches.

For passive stretching

• Tilt head away from affected side.
• Turn head toward affected side.

If the baby has right torticollis, his/her head will tilt toward the right.

• You will want to tilt the head (passively) away from the affected side to stretch that part of the sternocleidomastoid muscle.

If the baby has right torticollis, his/her head will have decreased range of motion to turn toward the affected side.

• You will want to turn head (passively) toward the affected side to stretch that part of the sternocleidomastoid muscle.

For active stretching

This mostly revolves around trying to position your baby to move their heads in the same way as passive stretches, but under their own power.

For example, if your baby has right torticollis, he/she will have difficultly turning right, so try to set toys to their right side.

This sounds… confusing…

I know it’s hard to visualize what I mean,  and it sounds a lot more complex than it is.

It is much easier to understand when visualized. So here is a good pictorial representation from Nationwide Children’s:

• Right Torticollis
• Left Torticollis

Am I hurting my baby when doing these stretches?

Well, you’re not hurting them, but it may be uncomfortable for them.

For example, can you touch your toes? If you can’t, go ahead and try to touch your toes. That sensation of “pulling” is what your baby feels. It doesn’t hurt, but I imagine it could be uncomfortable. Even if not “uncomfortable” it’s not any fun. I think it is normal for your baby to be unhappy or even cry a little when you do the stretches, because they probably don’t like it.

Just remember that they should have the same range of motion on both sides. That will guide you. Also, there a lot of videos online:

I think these ones from Advanced Physical Therapy are pretty good:

How long do I have to do this for?

Treatment times can vary and your pediatrician/physical therapist will guide you. Most patients (~90%) do well with just physical therapy. However, this number can vary widely based on when diagnosis occurs and treatment is started. In general, the earlier the diagnosis and treatment, the better the outcome. Diagnosis and treatment before 1 year of age is preferred.

However, if there is not significant improvement (usually after >12 months of physical therapy), then surgery becomes a consideration.

This surgery is a “muscle-release” surgery. It involves dissecting out the two heads of the sternocleidomastoid muscle and then dividing it. It is usually performed during the preschool years and does require general anesthesia. However, it is considered an outpatient procedure, and your child can usually go home the same day.

After surgery, children are followed to make sure the torticollis resolves.

TL;DR

Congenital muscular torticollis (CMT) is a not uncommon diagnosis in children (1-2%).

However, I think this can be anxiety-inducing to new parents, since it is usually diagnosed so early in life.

Additionally, there are associations of “torticollis” to a multitude of other entities, which are less common, and outside the scope of this post.

I’ve discussed the diagnosis and treatment of congenital muscular torticollis above, with some links to documentation and videos I think are helpful.

In general, with early diagnosis and treatment (<1 year of age), outcomes are pretty good with just physical therapy.

However, some may require muscle-release surgery and need to be followed.

-Sensei

Agree? Disagree? Questions, Comments and Suggestions are welcome.

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