Acute wry neck or torticollis is relatively uncommon and precipitated typically by the sudden onset of significant neck pain which leads to reflex neck muscle contractions and the maintenance of an abnormal neck position. This abnormal posture is known as torticollis and is a sign of an underlying problem of some kind, but this article discusses an acquired torticollis secondary to an acute neck pain of mechanical origin. It is typical for patients to report they woke with severe neck pain and torticollis, with the process often assumed to be secondary to sleeping in an inappropriate position during the night.
Typical initial presentation a high level of neck pain with muscle spasms and the inability to restore the head to the central posture. A few days or up to a fortnight is enough to resolve most of these pains and treatment is analgesia, collar if needed, physiotherapy such as neck massage, neck stretching and neck exercises. When examined a patient exhibiting torticollis will keep their head flexed to the painful side to some degree and also rotated away from the painful side. The usual symptoms are stiff neck, limited range of motion and neck and scapular pain, with onset often sudden such as when hair drying with a towel or turning the head fast.
The first thing a person is aware of is the sudden pain on one side of the neck, often severe and lower in the neck. There may be pain radiating also down over the scapula and out over the shoulder. If a considerable amount of arm pain is present then this should raise the suspicion of a lesion of one of the cervical nerve roots. Nerve root problems are usually somewhat slower in onset but if the symptoms presented on waking this could be the diagnosis. The outcome is very likely to be just as good as the muscle or joint strain which is more common, but recovery typically takes longer over a period of weeks.
On examination by a physiotherapist the patient will be distressed by the severity of the pain and may have found it hard to sleep. They may guard the head by moving carefully to avoid jarring the aggravated structures. The head will be stuck in the typical abnormal posture and any attempt to bring it back towards normal will be met with a significant increase in pain. The posture of the head will be recorded by the physio with ranges of motion achievable and the resulting symptoms. The physiotherapist will take the history including previous episodes and how this one came on, either suddenly or during the night.
Any thoracic, shoulder blade, shoulder or arm pain will also be recorded. The physio may decide to test the reflexes of the biceps and triceps muscles to check if the C6 or C7 nerve roots are involved should the symptoms indicate the possibility. The sensibility of the skin to light touch can also be investigated for similar reasons. The physiotherapist is less likely to choose to test the muscle power in the shoulders and arms as this would cause an increase in pain and not reflect the patient’s true muscle strength. The usual questioning to exclude potentially serious underlying causes or complicating medical conditions will be undertaken.
Physiotherapy management of an acute wry neck is based on the same principles for all injuries of soft tissues. Firstly the physio attempts to reduce the inflammation and pain of the injury and thereby the muscle spasms which exacerbate the pain. Analgesics and anti-inflammatory drugs can be very useful as the pain is the primary problem and not some anatomical abnormality of the neck. Typical physiotherapy management includes ice, use of a collar if indicated and gentle tractioning of the neck relax the neck muscles and settle pain.
Progression on to further therapy techniques is planned once the pain is under control such as neck massage, gentle muscle neck stretches for muscle tightness and mobilisation of the joints. The patient is asked to perform active movements within reasonable pain limits. On restoration of more normal neck ranges of motion and head position the next stage of physiotherapy is to increase the neck muscle strength and endurance so that the person can return to normal.