Introduction 

Torticollis, also known as twisted neck or wryneck, is a common condition which is estimated to be diagnosed in 90% of humans at least once in their lifetime.¹ It is characterised by an abnormal head posture when the neck muscles contract involuntarily or become shortened. As a result, the head tilts to one side with the chin facing the opposite direction, causing a restriction to motion and instigating pain and discomfort. 

Torticollis can be either congenital or acquired. Although both result in abnormal head posture and limited neck movement, they differ in causes and management. Congenital muscular torticollis (CMT) occurs at birth. It is often due to a birth trauma such as vacuum extraction or the use of forceps during delivery.² Additionally, in-utero positioning can lead to CMT when excess pressure is applied to the sternocleidomastoid muscle, leading to a tightening or shortening.³ Whereas, acquired torticollis is a condition that can arise later in life due to factors like infections, trauma, or neurological conditions.^4,5 

Early diagnosis and treatment are crucial to address the condition and prevent long-term complications. Untreated torticollis can result in severe complications, primarily muscle imbalances and skeletal deformities, which significantly impact quality of life and physical function.

Types of torticollis 

Congenital muscular torticollis (CMT)

CMT occurs in the neonatal period or within the first weeks of birth. It can be triggered by the tightening or the fibrosis of the sternocleidomastoid muscle (SCM).⁴ 

Acquired torticollis

Acquired torticollis results from inflammatory processes in the nerves or cervical muscles. It can be developed at any age and is secondary to the congenital skeletal abnormalities. Factors that can cause acquired torticollis include trauma (sternocleidomastoid injury), infections (retropharyngeal abscesses, upper respiratory tract infections), inflammation or neurological disorders (spasmodic torticollis).^5,6

Further complications of acquired torticollis include a manifestation of benign paroxysmal torticollis. It is a rare condition, typically benign and episodic. Clinical characteristics of this condition are similar to CMT and acquired torticollis with the head tilt; however, it comprises a migraine.⁷ Diagnosis is often made during the first few months after birth, lasting around 2-8 hours.⁵ 

Symptoms 

In infants:⁸

• Vision problems 
• Gastroesophageal reflux disease 
• Scar tissues
• Swelling in the child's throat or neck
• Arthritis in the neck 

In adults: 

• Head or neck injury
• Side effects from medication (e.g. depression, mental health conditions) 
• Genetic inheritance

Identification of the condition can be detected by the notice of a head tilt, sometimes accompanied by a soft lump in the neck. Additionally, breastfeeding can become difficult as the babies prefer looking over one shoulder and have limited neck mobility. 

If left untreated or undetected, it can lead to long-term complications such as positional plagiocephaly (flat head syndrome) developed by a constant positioning on a flat surface for a prolonged time.⁹ Furthermore, the infant can develop facial asymmetry.¹⁰ 

Diagnosis

A physical examination is required for diagnosis. It includes an observation of the baby’s head to examine for a tilt or twist, alongside swelling or stiffness of the muscle. 

X-ray or CT scans and other tests can be carried out. A negative result in the CT scan may also lead to an additional test using a magnetic resonance imaging (MRI) scan of the brain and cervical spine.¹¹ 

• X-ray: A test which produces images of the structure in the body, especially bones, using high-energy electromagnetic waves
• CT scans: A type of scan which presents a more detailed image of the inside of the body. It uses a combination of X-rays and a computer to create detailed images of your organs, bones, and other tissues, providing more information than a regular X-ray.¹²

Pharmacological treatments are available to minimise pain and symptoms. For instance:

• Benzodiazepines: treatment of anxiety and spasms
• Muscle relaxants
• Anticholinergics: counteract acetylcholine, a neurotransmitter

Injections can also be viable, such as botulinum toxin. This is a safe procedure for babies and is most commonly used in severe cases of congenital muscular torticollis.¹³ 

Muscle imbalance: a primary complication

Muscle imbalance occurs when one side of a muscle pair is weaker or less developed than the other, leading to uneven movement patterns, reduced stability, or increased risk of injury.¹⁴ Muscle imbalances can be a complication of untreated torticollis as a result of the discomfort and limited flexibility of the neck.¹⁵ It primarily affects the sternocleidomastoid (SCM) muscle, which is responsible for head rotation and neck flexion. It can be developed in different ways: 

Overuse and shortening of the affected SCM muscle

The affected SCM muscle is typically on the side where the head tilts. It can lead to muscle shortening and stiffness due to prolonged contraction, which contributes to a reduction in flexibility and a restricted range of motion.¹⁶

Weakening of the contralateral muscle

The side where the head is not tilted, where the contralateral SCM becomes weak due to the lack of activation, is a cause of the abnormal posture. The weakness leads to an imbalance of tension.

Functional impact of muscle imbalance in torticollis 

Muscle imbalances can contribute to developing functional impairments, which can affect mobility and performance in activities such as: 

Range of motion and flexibility

The ability to turn the head is limited by the shortening of the SCM muscle, which in turn restricts the range of motion as well as maintains posture. This can prevent the ability to carry out tasks such as turning the head or interacting in physical activities.¹⁶

Chronic muscle pain and spasticity

Overuse of the affected SCM muscle can lead to chronic pain, discomfort, and muscle spasms. This can turn into frustration, particularly in babies who are unable to communicate their discomfort effectively

This can be problematic for children, especially when they are walking, as it can increase the chances of falls or accidents. 

Long-term consequences 

Over time, the strain on muscle stiffness can also affect other areas, contributing to imbalances and discomfort throughout the body. Fatigue may also extend to other parts of the body, including the arms or legs, as the compensatory overuse continues to spread.17 A secondary issue can also be developed, such as headaches or jaw misalignments, which can lead to temporomandibular joint dysfunction (TMJ).

Temporomandibular disorders (TMD) can be painful, and difficulties can come about, such as difficulty in chewing, clicking or popping sounds in the jaw, and even ear discomfort.¹⁸ Additionally, the misalignment of the head and neck can affect postural alignment and increase the risk of developing conditions like scoliosis or spinal issues as the child grows.¹⁹

These long-term consequences underscore the importance of early intervention to prevent the progression of muscle imbalances and avoid the onset of further physical complications. Without treatment, the impact on quality of life can become progressively more severe, making it harder to manage pain, mobility, and daily activities.

Skeletal deformities: a secondary and severe outcome

Untreated torticollis can lead to skeletal deformities impacting a child's physical development and quality of life. These deformities can include craniofacial asymmetry, spinal deformities, and growth and development issues.

Craniofacial asymmetry

Common in newborns if the SCM muscle remains contracted. Typically associated with congenital torticollis.¹⁶ Adults with craniofacial asymmetry are common if congenital torticollis was neglected during their childhood.²⁰  

Spinal deformities 

Abnormal curvatures or alignments of the spine, such as scoliosis, kyphosis, and lordosis, can result in pain, limited mobility, or postural imbalances.²¹

Growth and development issues

A child with torticollis can struggle with achieving basic developmental milestones such as rolling over, sitting up, or crawling, due to restricted movement and abnormal posture.²²

Broader implications of untreated torticollis

Impact on neuromuscular coordination

The abnormal head posture and muscle imbalances interfere with the child’s sensory input and the brain's ability to properly coordinate movements. This can lead to difficulties with balance and spatial orientation, which are essential for motor development and coordination.¹

Psychosocial and developmental effects

Facial asymmetry can significantly affect a child's psychological well-being as they grow older, particularly as they become more self-aware and conscious of their appearance, potentially leading to lowered self-esteem or social anxiety.²³

Strategies to prevent and mitigate complications of torticollis

Importance of early diagnosis and intervention

Physical therapy can be utilised to target SCM muscles to improve neck and head movement. Therapists use stretching exercises to reduce muscle tightness and strengthening exercises to improve the function of the opposing muscles.²⁴ Furthermore, orthotics can be helpful. They are also known as neck braces, and they can help correct posture by supporting proper head alignment and encouraging symmetrical movement, especially in children still developing muscle control. 

Advanced treatment options

Botulinum toxin (Botox) injections can be used to relax the overactive SCM. This can reduce symptoms such as muscle spasm and increase flexibility, which, in turn, improves head posture.¹³ Additionally, spinal deformities such as scoliosis may require spinal corrections by undergoing surgery.

Conclusion

If torticollis remains untreated, the condition can worsen and manifest into severe complications as well as affect an individual's psychological well-being. For example, their self-esteem and social isolation. Characteristics such as limited neck movement and tilt of the head at an early stage must be identified to prevent long-term effects, such as skeletal deformities (craniofacial asymmetry, spinal misalignments) and functional impairments. For infants, if the condition is not treated, their neuromuscular coordination can be disturbed. They are more likely to fall and get injured.

Treatments such as physical therapy, exercise and braces can help improve neck alignment and motion. Although botulinum toxin injections are not a cure, they can help reduce symptoms such as pain.