Most PCPs tend to think of orthomuscular causes for AHPs like muscular torticollis. All strabismologists know of children who were sent for physical therapy when in fact they had a fourth cranial nerve palsy. Conversely, strabismologists may tend to think that all patients with an AHP have an ocular cause. The truth lies somewhere in between. In one prospective multidisciplinary study of 63 children presenting to PCPs with an AHP [1], the cause of the AHP was orthopedic in 35 (56%), ocular in 25 (40%), and neurologic in 5 (8%). No specific cause could be found in the remaining eight (13%) patients (total is more than 100% as some patients had multiple etiologies). Congenital muscular torticollis was the most common orthopedic cause accounting for 31 patients (49%). The most common ocular cause was superior oblique muscle palsy, which accounted for 12 patients (19%). In two patients (3%) with fourth cranial nerve palsy there was secondary neck muscle contracture suggesting an orthopedic cause.