Wry Neck (Discogenic)
(Also known as Torticollis, Discogenic Wry Neck, Acute Wry Neck, Herniated Cervical Disc, Bulging Disc, Herniated Disc, Cervical Disc Bulge, Slipped Disc, Prolapsed Disc, Intervertebral Disc Injury, Sprained Disc, Disc Protrusion)
N.B. Although a wry neck may originate from either the discs or facet joints of the neck, the term 'wry neck' will be used in this article to describe a wry neck originating from the disc.
What is a wry neck?
A wry neck is a relatively common condition characterized by a sudden onset of pain and stiffness in the neck or upper back. The injury originates from damage to one of the discs in the neck and results in a noticeable limitation of movement and postural deformity.
The cervical spine (i.e. neck) comprises of many bones known as vertebrae, each of which is separated by a disc (figure 1). The disc comprises of many layers of strong connective tissue wrapping around the disc. In the middle of the disc lies a soft jelly-like substance which is capable of changing shape. When this jelly-like substance protrudes from the disc due to a tear in several layers of the connective tissue, this is known as a bulging disc and, if severe enough, can result in a wry neck.
To understand the mechanism of injury in a wry neck, it is useful to liken the disc to a vanilla slice. Imagine a vanilla slice wrapped in five layers of sandwich wrap. The top and bottom layers of pastry represent the vertebra (bones), the custard represents the jelly-like substance of the disc and the sandwich wrap represents the connective tissue around the disc. If you were now to pinch the front of that vanilla slice, you could imagine, the custard would squeeze towards the back of the vanilla slice and may tear two or three layers of sandwich wrap at the back of the vanilla slice. As a result the custard is no longer supported as effectively at the back of the vanilla slice and therefore bulges out at this location. In the disc, the situation is the same. Bending the neck forward closes down the front of the disc, pushing the jelly-like substance within the disc towards the back. Overtime or suddenly, this may tear several layers of connective tissue at the back of the disc resulting in a disc bulge. When this disc bulge results in sharp neck pain, with resultant limitation of movement and postural deformity, it is known as a wry neck.
Causes of a wry neck
A wry neck usually occurs either upon waking in the morning or due to a specific activity often involving a sudden, quick movement of the neck or heavy lifting. In some cases symptoms may be of gradual onset.
There are four main activities in everyday life which typically contribute to the development of a wry neck provided they are forceful, repetitive or prolonged enough. These include: bending the neck forwards, poor posture (slouching) especially during sleep or sitting (figures 2 & 3), activities using your arms in front of the body (e.g. washing dishes, driving etc.) and lifting.
Occasionally, a wry neck may occur following a trivial movement involving bending or twisting of the neck such as picking up a small object or sneezing. In these instances, the disc has normally been subject to repetitive or prolonged bending, slouching or lifting forces leading up to the incident. Often a wry neck will occur upon waking after a long sleep in an awkward position (figure 2).
Signs and symptoms of a wry neck
Patients with a wry neck typically experience severe one sided sharp neck pain which is most common in the lower neck region. There is usually an inability to turn the head to the painful side and often a resultant postural deformity due to pain. The postural deformity is usually positioned with the head held away from the side of pain with the patient unable to correct this due to muscle spasm and pain.
In some cases, symptoms may be felt centrally or on both sides of the neck. The symptoms associated with a wry neck are sometimes accompanied with pain radiating down the arm or into the shoulder blade region, or in some cases, headaches. Muscle spasm, pins and needles, numbness or weakness may also be present.
Patients with this condition often first notice their symptoms upon waking in the morning. Occasionally there may be a sudden onset of pain during the causative activity. Some patients may notice no identifiable reason as to why the symptoms have started, although a thorough history and examination from the treating physiotherapist will usually be able to identify the likely cause.
The symptoms associated with this condition are often worse with sustained postures such as reading, driving, sitting at a computer or watching television. Symptoms may also be exacerbated by activities using the arms in front of the body, prolonged sitting (especially if slouched), heavy lifting and certain neck movements involving rotation, side bending, bending forwards or backwards. Sneezing may also aggravate symptoms. Patients with a wry neck will often experience pain that is worse first thing in the morning.
Diagnosis of a wry neck
A thorough subjective and objective examination from a physiotherapist is usually sufficient to diagnose a wry neck. Investigations such as an MRI or CT scan may be required to confirm diagnosis.
Treatment for a wry neck
Most patients with this condition heal quickly and have a full recovery with appropriate physiotherapy. The initial goal of treatment is to relocate the bulging disc back into its original position and then keep it there so the torn connective tissue at the back of the disc can heal.
The time it takes to push the disc back into its original position varies from person to person depending on their activities and compliance with physiotherapy advice. Since certain activities push the disc out and others push the disc back in, the balance of these activities dictates recovery time. If there are more activities pushing the disc out than in, these injuries will get worse and will only improve once activities pushing the disc in exceed the activities pushing the disc out. Activities typically pushing the disc out include: bending the neck forward or slouching (figures 2 & 3), activities whereby the shoulders or arms are forward of the body (e.g. cooking, cleaning etc), lifting, and sneezing. Activities which help to push the disc back in include: lying, standing and walking with good posture (figure 4), and certain exercises determined by a physiotherapist (commonly chin tucks, shoulder blade squeezes or neck arches).
Generally, sitting for prolonged periods should be avoided. However, if inevitable, optimal sitting posture is vital to minimize stress on the disc. Sitting slouched (figure 3) should be avoided as it places your lower neck into considerable bend, this will rapidly aggravate a wry neck. Optimal sitting posture can be obtained by sitting tall on an appropriate chair, with your bottom in the back of the chair and a lumbar support (or a pillow / rolled up towel) in the small of your back (figure 5). A lumbar roll can significantly help to improve your whole spinal posture.
Patients should follow the R.I.C.E. Regime in the initial phase of injury. The R.I.C.E. regime is beneficial in the first 72 hours following injury or when inflammatory signs are present (i.e. morning pain or pain with rest). The R.I.C.E. regime for a wry neck primarily involves resting from aggravating activities and regular icing. Anti-inflammatory medication may also significantly hasten the healing process by reducing the pain and swelling associated with inflammation. When inflammation has settled, heat treatment may be beneficial to reduce muscle spasm and pain associated with this condition.
Once the disc is back in its original position, patients should perform pain free flexibility, strengthening and postural exercises to prevent stiffness and weakness from developing and to ensure the neck is functioning correctly. Clinical Pilates exercises are also often recommended. The treating physiotherapist can advise which exercises are most appropriate and when they should be commenced.
Prognosis of a wry neck
In patients who receive appropriate treatment and maintain the perfect balance of activities, the injured disc may be pushed back into position in as little as three days. Typically, however, patients will take approximately 2 to 3 weeks to push their disc back 'in'. Once the disc is 'in', the patient should be pain free and have full movement. However, the torn connective tissue at the back of the disc continues to heal from this point. It takes approximately six weeks of consistently keeping the disc 'in' to allow the torn tissue to heal to an adequate level before resumption of full activities can take place. Care must therefore be taken when returning to activity during this period.
Contributing factors to the development of a wry neck
Several factors may contribute to the development of a wry neck. These need to be assessed and, where possible, corrected with direction from the treating physiotherapist. They may include:
- poor posture
- poor core stability
- a sedentary lifestyle
- muscle tightness
- muscle weakness
- joint stiffness
- poor lifting technique
- a lifestyle or occupation involving large amounts of sitting (particularly at a computer or driving), excessive neck movements (such as bending forwards), slouching, shoulders forwards activities or heavy lifting
Physiotherapy for a wry neck
Physiotherapy treatment for patients with this condition is vital to hasten healing, ensure an optimal outcome and prevent recurrence. Treatment may comprise:
- soft tissue massage
- joint mobilization
- electrotherapy (e.g. ultrasound)
- postural taping
- postural bracing
- dry needling
- the use of a cervical collar
- the use of a lumbar support for sitting
- exercises to push the disc back 'in' and to improve strength, core stability, flexibility and posture
- activity modification advice
- ergonomic advice
- clinical Pilates
Other intervention for a wry neck
Despite appropriate physiotherapy management, a small percentage of patients with a wry neck fail to improve and may require other intervention. This may include further investigations such as an X-ray, CT scan or MRI, pharmaceutical intervention, assessment from a specialist or sometimes surgery. The treating physiotherapist can advise if this is required and will refer to the appropriate medical authority if it is warranted clinically. In cases of persisting or worsening neurological symptoms (pins and needles, numbness and weakness), surgery may be indicated.
Exercises for a wry neck
The following exercises are commonly prescribed to patients with this condition. You should discuss the suitability of these exercises with your physiotherapist prior to beginning them. Generally, they should be performed 5 times daily and only provided they do not cause or increase symptoms.
Begin sitting or standing tall with your back and neck straight, shoulders should be back slightly (figure 6). Tuck your chin in until you feel a mild to moderate stretch pain-free. Keep your eyes and nose facing forwards. Hold for 2 seconds and repeat 10 times provided there is no increase in symptoms.
Figure 6 – Chin Tucks
Shoulder Blade Squeezes
Begin sitting or standing tall with your back straight (figure 7). Squeeze your shoulder blades together as hard and far as possible pain-free. Hold for 5 seconds and repeat 10 times provided there is no increase in symptoms.
Figure 7 – Shoulder Blade Squeezes
Find a Physio for a wry neck
Find a physiotherapist in your local area who can treat a wry neck.
Physiotherapy products for a wry neck
Some of the most commonly recommended products by physiotherapists to hasten healing and speed recovery in patients with a wry neck include:
- Postural Supports
- Therapeutic Pillows
- Ice Packs and Heat Packs
- Lumbar Rolls for Sitting
- Sports Tape (for postural taping)
- McKenzie Treat Your Own Neck Books
- TENS Machine (for pain relief)
- Cervical collars
To purchase physiotherapy products for a wry neck click on one of the above links or visit the PhysioAdvisor Shop.
More Information for a wry neck
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