Treatment of Torticollis
Start with multimodal analgesia combining NSAIDs and muscle relaxants, along with heat therapy and gentle stretching exercises, as first-line treatment for acute torticollis. 1
Initial Conservative Management
Pharmacological Approach
- NSAIDs are the first-line agents for pain control and inflammation reduction 1
- Add muscle relaxants to control pain and reduce muscle spasm 1
- For severe cases with significant pain, consider a short course of oral corticosteroids to rapidly reduce inflammation 1
- Acetaminophen or ibuprofen can be added for additional pain relief during the first 24-48 hours, particularly in pediatric patients 1
- Avoid benzodiazepines as they are conditionally recommended against in musculoskeletal pain conditions 1
Physical Interventions
- Apply heat therapy to relax tense muscles and improve blood circulation to the affected area 1
- Implement gentle stretching exercises to gradually restore normal range of motion 1
- Ensure proper positioning during rest and sleep to prevent symptom worsening 1
Physical Therapy Protocol
Manual Therapy Techniques
- Gentle manual therapy including mobilization and trigger point therapy reduces muscle tension 1
- Supervised postural exercises and stretching with or without manual trigger point therapy have demonstrated benefit 1
- Implement home exercise programs focusing on gentle stretching and strengthening of neck muscles 1
Specialized Approaches
- For congenital muscular torticollis (CMT), observation and physical therapy, with or without bracing, is effective in most cases, especially if instituted within the first year of life 2
- Frequency-specific microcurrent combined with massage, stretching, and strengthening may achieve excellent outcomes in exceptionally short timeframes 3
Advanced Treatment Options
Botulinum Toxin Injection
- Botox has been shown to be effective as an intermediate treatment method for more resistant cases of congenital muscular torticollis 2
- This represents a bridge between conservative management and surgical intervention 2
Surgical Management
- For CMT presenting after age 1 year, there is an increased rate of sternocleidomastoid muscle lengthening 2
- Surgical indication is reserved for patients with mild fibrotic band in the SCM muscle with minimal length discrepancy between muscles 4
- Minimal-incision myotomy under local anesthesia offers an alternate option for adult CMT patients with mild symptoms 4
- Subperiosteal lengthening of the sternocleidomastoid muscle at its mastoid insertion, combined with division of lower fibrotic bands, provides immediate benefit and good long-term results 5
- Note: Lengthening may improve range of motion but not necessarily plagiocephaly, facial asymmetry, or cranial molding 2
Critical Diagnostic Considerations
Rule Out Serious Causes
- Rule out ocular causes such as eye muscle weakness that may present as torticollis 1
- Consider imaging studies if no improvement with initial management or if neurological symptoms develop 1
- Perform thorough physical and neurologic examination with cervical spine radiographs 2
- MRI of brain and neck is no longer considered cost-effective or necessary in congenital muscular torticollis 2
Red Flags Requiring Urgent Evaluation
- Progressive neurological symptoms or signs suggesting spinal cord compression 1
- Giant cell arteritis should be suspected in elderly patients presenting with scalp tenderness and jaw claudication 6
- Torticollis of neurogenic origin requires surgical decompression when indicated (Arnold-Chiari malformation, syringomyelia, posterior fossa neoplasms) 7
Key Clinical Pitfall
It is critical to differentiate muscular from nonmuscular torticollis 2. Congenital muscular torticollis is benign, but missing a case of nonmuscular torticollis (inflammatory, ocular, neurologic, or orthopedic causes) could be potentially life-threatening 2. The differential diagnosis includes sequelae to inflammatory, ocular, neurologic, or orthopedic diseases requiring systematic work-up 2.