Can a 65-year-old patient with Chronic Kidney Disease (CKD) and neck pain localized to the left trapezius muscle be diagnosed with torticollis?

Can Neck Pain Localized to the Left Trapezius in a 65-Year-Old with CKD Be Torticollis?

No, isolated trapezius pain in a 65-year-old patient is far more likely to represent cervical radiculopathy, facet joint arthropathy, or myofascial pain rather than torticollis, which presents with abnormal head positioning and involuntary muscle contractions causing visible neck deviation.

Understanding Torticollis vs. Trapezius Pain

Torticollis is fundamentally a disorder of abnormal head posture, not simply neck pain. The defining features include:

• Sustained involuntary muscle contractions causing twisting movements, abnormal head positioning, or repetitive movements - not just localized pain 1
• Visible neck deviation with combinations of rotation (rotatory torticollis), flexion (anterocollis), extension (retrocollis), or head tilt (laterocollis) 1
• Tonic, clonic, or tremulous neck posturing that may result in permanent fixed contractures 1
• Characteristic "sensory tricks" (geste antagonistique) where patients touch their chin, back of head, or top of head to temporarily ameliorate dystonic movements 1

What Your Patient More Likely Has

The American College of Radiology identifies the primary mechanical causes of unilateral trapezius pain as:

• Cervical radiculopathy from nerve root compression (herniated disc or osteophyte) - the most common neuropathic cause of neck pain radiating to upper back/trapezius 2
• Facet joint arthropathy causing localized mechanical pain that may be unilateral and radiate to the trapezius region 2
• Myofascial pain from cervical spondylosis or degenerative disc disease, which affects 53.9% of adults and increases with age 2

Critical Red Flags Requiring Urgent Evaluation

Before assuming benign mechanical pain, screen for these indicators that mandate immediate MRI:

• Constitutional symptoms: fever, unexplained weight loss, night sweats 3, 4
• Elevated inflammatory markers: ESR, CRP, WBC 3, 4
• History of malignancy or immunosuppression 3, 2
• Neurological deficits: weakness, sensory changes, gait disturbance 3, 2
• Intractable pain despite appropriate conservative therapy 3, 2
• Vertebral body tenderness on palpation 3, 2

The presence of CKD is particularly relevant - musculoskeletal pain is reported by up to two-thirds of mobile CKD patients, though not more frequently than the general population 5. However, pain in CKD patients significantly impacts quality of life and physical function 5.

Diagnostic Approach Algorithm

For acute pain (<6 weeks) without red flags:

• Defer imaging and pursue conservative management with NSAIDs, physical therapy, and activity modification 3, 2
• Most acute cervical neck pain resolves spontaneously, with 75-90% of cervical radiculopathy cases resolving with conservative therapy 2

For persistent symptoms (>6-8 weeks) or any red flags present:

• Obtain MRI cervical spine without contrast immediately - this is the most sensitive imaging modality for detecting disc herniation, nerve root impingement, inflammatory processes, infection, and tumor 3, 2
• MRI is superior to CT for identifying degenerative cervical disorders and soft tissue abnormalities 3, 2

Common Pitfalls to Avoid

• Do not order imaging immediately in the absence of red flags - this leads to overdiagnosis of incidental degenerative changes that correlate poorly with symptoms 3
• Do not interpret degenerative changes on imaging as causative without clinical correlation - spondylotic changes are present in 85% of asymptomatic individuals over 30 years, with only 34% developing symptoms 6, 3
• Do not confuse localized trapezius pain with torticollis - torticollis requires visible abnormal head positioning, not just pain 1

When to Consider Actual Torticollis

Consider torticollis only if the patient demonstrates:

• Visible abnormal head positioning that is sustained and involuntary 1
• Structural causes ruled out through appropriate imaging 1
• Congenital presentation (though this would have been identified much earlier in life) 7
• Acute traumatic torticollis from sternocleidomastoid rupture following significant neck trauma 8
• Secondary causes including exposure to dopamine receptor antagonists, neurodegenerative disease, or basal ganglia dysfunction 1