Torticollis, commonly referred to as wry neck, is a condition where the neck is held in an abnormal position due to involuntary muscle contraction or shortening. This typically causes the head to tilt to one side and rotate to the opposite direction. Torticollis can affect people of all ages and varies widely depending on its cause, onset, and severity.
Torticollis is broadly classified as congenital or acquired. Congenital torticollis is present at birth or develops within the first few months of life, while acquired torticollis occurs later in childhood or adulthood and has a wide range of potential causes. These may include muscular spasm, joint dysfunction, neurological conditions, trauma, infection, or medication reactions.
Physiotherapy plays a central role in the assessment and management of torticollis, particularly in congenital and musculoskeletal cases. Early identification and appropriate physiotherapy intervention are critical in restoring normal neck movement, reducing pain, and preventing long-term postural or structural changes.
Key Facts
- Congenital muscular torticollis is one of the most common musculoskeletal conditions seen in infants and responds well to early physiotherapy intervention.
- Acquired torticollis is common in adults, with most people experiencing at least one episode related to muscle spasm or neck dysfunction during their lifetime.
- Early physiotherapy management reduces the risk of persistent muscle shortening and postural asymmetry in torticollis.
Risk Factors
- Birth trauma or intrauterine constraint
- Poor posture or prolonged forward head posture
- Previous neck injury or whiplash
- Neurological conditions
- Certain medications
- Stress and anxiety
- Degenerative cervical spine changes
Symptoms
- Head tilted to one side with the chin rotated to the opposite side
- Restricted neck range of motion
- Neck pain or discomfort
- Muscle tightness, commonly in the sternocleidomastoid muscle
- Raised shoulder on the affected side
- Head tremor in some cases
- Asymmetry of the face or head, particularly in infants
- Difficulty maintaining a neutral head position
Aggravating Factors
- Sustained or awkward neck postures
- Poor sleeping positions
- Stress-related muscle tension
- Prolonged sitting or screen use
- Repetitive neck movements
Causes
The causes of torticollis depend on whether the condition is congenital or acquired.
Congenital Torticollis
Congenital torticollis typically presents at birth or within the first few months of life. It most commonly involves shortening or fibrosis of the sternocleidomastoid muscle. Proposed mechanisms include intrauterine positioning, vascular compromise to the muscle, or birth-related trauma.
Infants with congenital torticollis often present with the head laterally flexed toward the affected side and rotated away. Reduced neck mobility can contribute to craniofacial asymmetry, including positional plagiocephaly, which is often a source of concern for parents.
Acquired Torticollis
Acquired torticollis is more common in adolescents and adults and has a broader range of causes, including:
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Muscle spasm or strain due to poor posture, overuse, or sudden movement
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Cervical spine conditions such as disc herniation, arthritis, or joint dysfunction
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Neurological disorders including cervical dystonia
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Drug-induced dystonic reactions, particularly from antipsychotic medications
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Infection involving the throat, ear, or surrounding lymph nodes
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Trauma, burns, or tumours affecting the neck
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Inflammatory or degenerative joint disease
Physiotherapists assess the likely contributing factors to determine whether torticollis is primarily muscular, joint-related, neurological, or secondary to another condition.
How Is It Diagnosed?
Diagnosis of torticollis is primarily clinical and based on a thorough history and physical examination. A physiotherapist will assess neck posture, range of motion, muscle length and tone, joint mobility, and functional movement patterns.
In infants, assessment focuses on head positioning, neck mobility, muscle tightness, and craniofacial symmetry. In adults, examination may also include screening for neurological signs, visual disturbances, or dystonic features.
Imaging may be requested to rule out underlying pathology when symptoms are atypical, progressive, or associated with neurological signs. Imaging is not considered first-line in uncomplicated muscular torticollis.
Investigations & Imaging
- Ultrasound
- Commonly used in infants to assess sternocleidomastoid muscle structure
- X-ray
- May be used to assess cervical spine alignment or rule out bony abnormalities
- MRI
- Considered when neurological symptoms, trauma, or structural pathology is suspected
Grading / Classification
- Congenital Muscular Torticollis
- Present from birth or early infancy due to sternocleidomastoid muscle shortening
- Acquired Muscular Torticollis
- Caused by muscle spasm or strain in adolescents or adults
- Neurological Torticollis
- Associated with dystonia or nervous system disorders
Physiotherapy Management
Exercise
Exercise therapy is central to torticollis rehabilitation. In infants, this includes gentle stretching of the shortened sternocleidomastoid muscle and exercises to encourage active neck movement. In adults, exercises focus on restoring range of motion, strengthening neck and shoulder muscles, and improving postural control.
Activity Modification
Physiotherapists guide activity modification to reduce aggravating postures and movements. For infants, this includes repositioning strategies during feeding, play, and sleep. For adults, ergonomic and work habit adjustments are commonly required.
Manual Therapy
Manual therapy may be used to address muscle tightness and joint stiffness in the cervical spine. Techniques include soft tissue massage, gentle joint mobilisation, and muscle lengthening techniques. These are applied carefully, particularly in irritable or neurological presentations.
Postural Retraining
Postural retraining is essential, especially in acquired torticollis. Physiotherapists address forward head posture, asymmetrical loading, and habitual positioning patterns that perpetuate muscle shortening.
Bracing & Taping
In selected cases, taping may be used to provide postural feedback or assist muscle activation. Bracing is rarely required.
Dry Needling
Dry needling may be considered in adults with persistent muscular torticollis to reduce muscle spasm and pain.
Heat & Ice
Heat may be used to reduce muscle tension, while ice can assist in managing acute pain or inflammation.
Education
Education is a critical component of physiotherapy for torticollis. Physiotherapists provide reassurance regarding prognosis, explain contributing factors, and empower patients or parents with self-management strategies.
Other
For infants, supervised tummy time is encouraged to promote symmetrical neck and shoulder strength. Parents are educated on positioning and play strategies to encourage movement toward the non-preferred side.
Other Treatments
Medications such as muscle relaxants or anti-inflammatory drugs may be prescribed in selected cases. Botulinum toxin injections may be used in dystonic torticollis to temporarily reduce muscle overactivity. These treatments are typically used alongside physiotherapy rather than as standalone management.
Surgery
Surgery is rarely required for torticollis. In severe congenital cases that do not respond to conservative management, surgical release or lengthening of the sternocleidomastoid muscle may be considered. Surgery may also be required if torticollis is secondary to significant structural pathology.
Prognosis & Return to Activity
The prognosis for torticollis is generally very good, particularly when physiotherapy is commenced early. Infants with congenital torticollis often achieve full correction with conservative management. Adults with acquired muscular torticollis usually recover well, although recurrence can occur if contributing factors are not addressed.
Return to normal activity is guided by symptom resolution, movement quality, and functional confidence.
Complications
- Persistent neck stiffness
- Chronic pain
- Craniofacial asymmetry in infants
- Postural imbalance
- Reduced neck function
Preventing Recurrence
- Address neck stiffness early with physiotherapy
- Maintain good posture during daily activities
- Encourage symmetrical movement and play in infants
- Optimise workstation ergonomics
- Manage stress to reduce muscle tension
When to See a Physio
- Persistent head tilt or neck stiffness
- Reduced neck movement
- Infant head preference or asymmetry
- Recurrent episodes of neck spasm
- Neck pain affecting daily activities