Torticollis

What is torticollis?

Unlike many health conditions that develop silently inside the body, torticollis is easy to see from the outside. You can recognize it when your child’s head persistently tilts to one side.

The word “torticollis” itself comes from two Latin root words, “tortus” and “collum,” that together mean “twisted neck.” This condition, sometimes called wryneck, is relatively common in children.

In general, torticollis is classified as either congenital (present at birth) or acquired (occurring later in infancy or childhood). By far the most common type is congenital muscular torticollis. Although children have this when they are born, parents may not notice it until children are several weeks old, as they start to gain more control of their head movement.

  • Congenital muscular torticollis responds very well to physical therapy, especially when it’s started early. Sometimes it is associated with plagiocephaly, a common and treatable condition in which there is asymmetry in the shape of the head and face. This happens because the forces of gravity pull unevenly on a baby’s tilted head, causing a flattened appearance on one side of the skull or face.
  • Acquired torticollis typically occurs in the first four to six months of childhood or later. It may come on quickly or slowly. In contrast to congenital muscular torticollis, there is usually no facial asymmetry with acquired torticollis.
  • Acquired torticollis can be benign (not serious) or a sign of more serious health issues. Because the causes can be so different, it is very important to act quickly so that your child can get the proper care and treatment.

Note: Pediatric torticollis is different from another condition, called spasmodic torticollis, that affects adults.

What are the symptoms of torticollis?

Congenital muscular torticollis

  • The child has a limited range of motion in the head and neck.
  • The head tilts to one side while the chin tilts to the other.
  • A small, pea-sized lump (or “pseudo tumor”) is sometimes found on the sternocleidomastoid (SCM) muscle.
  • Asymmetries of the head and face, indicating plagiocephaly, may also be present.
  • Musculoskeletal problems, such as hip dysplasia, are sometimes present.

Acquired torticollis

  • There is limited range of motion in the head and neck.
  • The head tilts to one side while the chin tilts to the other.
  • With a condition called benign paroxysmal torticollis, there may be recurrent episodes, or “attacks,” of head tilting; often these attacks are accompanied by other symptoms, such as vomiting, irritability, and/or drowsiness.
  • Additional symptoms vary according to the cause of the torticollis.

Note: Children who develop torticollis that is associated with neck pain after trauma (even minor trauma) should be evaluated right away to make sure they do not have any subluxation of the C1 or C2 vertebrae. In addition, children who develop painful torticollis at the same time as a fever that is caused by an infection in the pharynx (cavity behind the nose, mouth, and larynx) or retropharyngeal space (the area behind the pharynx) need to see a doctor immediately. If left untreated, these complications can lead to a rare disorder called Grisel’s syndrome.

What are the causes of torticollis?

Because there are different types of torticollis, it is important to know the root cause so that your child can get the proper care and treatment as quickly as possible.

Congenital muscular torticollis

For children with congenital muscular torticollis, the most common form of pediatric torticollis, the SCM muscle becomes shortened and contracted. The SCM muscle runs along each side of the neck and controls how the head moves — side to side, and up and down.

There are a few common reasons why the SCM muscle may have become contracted and cause your child’s head to tilt to one side:

  • the way your baby was positioned in the womb before birth
  • abnormal development of the SCM muscle
  • trauma or damage to the muscle during birth

In far less common cases, congenital muscular torticollis may occur as a symptom of other underlying conditions, including:

  • congenital bony abnormalities of the upper cervical spine, with subluxation (abnormal rotation) of the C1 vertebrae over the C2 vertebrae in the cervical spine (the part of the spine that encompasses the neck).
  • congenital bony abnormalities of the upper cervical spine, which are most often associated with other congenital skeletal anomalies
  • shortened neck
  • short limbs (arms and legs)
  • dwarfism
  • congenital webs of skin running along the side of the neck
  • Klippel-Feil syndrome, a rare birth defect that causes some of the neck vertebrae to fuse together
  • achondroplasia, a bone growth disorder
  • multiple epiphyseal dysplasia, a disease that affects the development of bone and cartilage in the long bones of the arms and legs
  • Morquio syndrome, an inherited metabolic disorder that prevents the body from breaking down sugar molecules

Acquired torticollis

For children who have acquired torticollis, the causes vary widely and range in severity from benign (not serious) to very serious. Some causes of acquired torticollis include:

  • a mild (usually viral) infection
  • minor trauma to the head and neck
  • gastroesophageal reflux (GERD)
  • respiratory and soft-tissue infections of the neck
  • abnormalities in the cervical spine (such as atlantoaxial subluxation)
  • vision problems (called ocular torticollis)
  • abnormal reaction to certain medications (called a dystonic reaction)
  • spasmus nutans (a usually benign condition that causes head bobbing along with uncontrolled eye movements)
  • Sandifer syndrome (a rare condition combining gastroesophageal reflux with spasms in the neck)

How we care for torticollis

At Boston Children’s Hospital, we are dedicated to acting quickly to find out the root cause of torticollis and coming up with a treatment approach that’s customized for your child. In most cases, our clinicians deal with congenital muscular torticollis. We’ve found that most children with this type of torticollis respond very well to physical therapy programs, usually within a matter of months. Our dedicated team of physical therapists will provide an exercise plan that actively involves you in your child’s care.

We’ll also provide treatment plans designed for children who do not respond to physical therapy. Our orthopedic, neurosurgical, and plastic surgery experts work closely together to develop a customized treatment approach that meets all of your child’s health needs.

Frequently asked questions

How common is congenital muscular torticollis?

It is fairly common, occurring in about 1 in 300 births.

My child has congenital muscular torticollis. What can I do help stretch the sternocleidomastoid (SCM) muscle?

Your child’s physical therapist will teach you certain exercises to do at home that will manually and passively stretch the SCM muscle. These exercises are usually very effective, especially when started as soon as possible.

How long will it take before we see an improvement in our son’s congenital muscular torticollis?

In general, the majority of children with congenital muscular torticollis show improvement after a few months of physical therapy, especially when it is started early. Every child is different, so be sure to discuss any concerns you may have with your son’s doctor and physical therapist. Your son may need a referral to a specialist if he has no or limited improvement after physical therapy.

Does congenital muscular torticollis affect some infants more than others?

It may affect firstborn children and twins more often because there is a greater chance of too little space, or “crowding,” in the uterus and birth canal. This can cause damage or constriction to the SCM muscle. It may also happen after a difficult birth, especially when babies are very large or have a breech delivery.

My son has been diagnosed with benign paroxysmal torticollis. Is this the same as congenital muscular torticollis?

No, they are separate conditions. Be sure to talk to your son’s neurologist to discuss the differences. In general, benign paroxysmal torticollis is noted by periodic bouts, or “attacks,” of torticollis, typically lasting for hours or days. Some children who are affected by this type of torticollis go on to develop migraine headaches later in life.