Congential Muscular Torticollis: An Overview

Pediatric Rehabilitation Center
Hospital for Special Surgery


Shevaun Mackie Doyle, MD

Shevaun Mackie Doyle, MD

Associate Attending Orthopaedic Surgeon, Hospital for Special Surgery
Associate Professor of Orthopaedic Surgery, Weill Cornell Medical College

1. What is Torticollis? How is it Diagnosed?
2. Possible Causes
3. Symptoms
4. Impact
5. What Can Be Done at Home?
6. Plagiocephaly in Torticollis
7. Treatment of Congenital Muscular Torticollis

What is Torticollis? How is it Diagnosed?

The term torticollis is used to describe the tilting of an infant's head to one side with rotation to the opposite side. This posture may be a result of muscular, skeletal, neurological, or visual conditions.

Congenital muscular torticollis (CMT) is a musculoskeletal condition observed at birth or in infancy characterized by shortening of the sternocleidomastoid (SCM) muscle on the side of the neck. The infant will have a persistent head tilt to the involved side with the chin rotated toward the opposite shoulder. Clinical signs also include an infant's strong preference to look to one side, as well as flattening of the back of the baby's head.

Torticollis is typically diagnosed by a pediatrician or orthopedist upon clinical presentation of head/neck position. Other diagnostic tests may include ultrasound and x-rays.

Symptoms

If you notice any of the following, you may wish to speak with a pediatrician, pediatric orthopedist, or physical therapist about torticollis:

1. Does your baby prefer to turn his/her head to one side over the other?
2. When looking at your baby's pictures, does his/her head always seem tilted to one side?
3. Is there flattening on the back or side of your baby's head?
4. Does your baby's posture look similar to the babies below?
5. Does your baby prefer to nurse on one side?

 
Notice the tilt of the head; this is a common sign of torticollis.

Possible Causes

The cause of torticollis is unknown. Theories for the cause of CMT occurring in utero or at birth include crowded position in the womb and/or decreased blood supply - or trauma - to the sternocleidomastoid (SCM) muscle. After birth, torticollis may be caused by the infant spending too much time with his/her head turned one particular way. This may cause or may be due to head flattening (a form of plagiocephaly, which is described in greater detail below).

The reported incidence of torticollis is 0.4%-2.0%. Recent research studies, however, have noted an incidence as high as 16%. This "pseudoepidemic" in torticollis may possibly be due to the Back to Sleep Program to prevent Sudden Infant Death Syndrome. Despite this possible linkage, it is critical to continue to place your infant on his/her back for sleeping and on his/her tummy to play during waking hours.

Impact

The early months of a child's life are crucial for his/her development. Torticollis can impact an infant's development of vision, sensory processing, feeding, and fine and gross motor skills.

Examples may include:

  • Decreased head control
  • Limited visual tracking
  • Limited reaching on affected side
  • Preference for rolling to one side only
  • Delayed sitting
  • Asymmetrical crawling
  • Delayed walking
  • Poor balance
  • Difficulty feeding
  • Decreased tolerance to movement in space, such as swinging or sliding

It is important to seek treatment as early as possible, to avoid potential developmental delay and facial asymmetry.

What Can Be Done at Home?

1. Carry your baby. Carriers such as car seats, swings, strollers, and bouncers create contact with the back of the baby's head. While this is appropriate for short periods of time, it is important for the baby to change positions in order to avoid prolonged pressure on the back of the head.

It is also recommended that you change the position of these carriers to encourage your baby to look in different directions. Front baby carriers can be used when support is provided for the head and neck for young infants. Once good head control is achieved, the child may be placed facing away from parent in the carrier. It is recommended to carry your child in your arms often.

2. More tummy time! Tummy time promotes strengthening of the neck, shoulder, arm, and back muscles, in addition to preventing flattening of the back of your baby's head. Tummy time is recommended for at least 15 minutes, 4 times a day. If your baby is unable to tolerate this position for the full time, use shorter intervals of tummy time, with increased frequency throughout the day.

Supporting your child on your chest, across your lap, or propped on a pillow helps your baby tolerate tummy time more easily. It is important that your baby is always awake and supervised during tummy time.

3. Engage your child in play activities that promote the use of both hands and both legs. Babies commonly play by bringing their hands together and their feet up to their hands. You can help your baby bring their feet up towards their hands to strengthen their belly muscles and prepare them for rolling. Encourage your baby to reach for toys and rattles equally with either hand.

4. Encourage your child to turn his/her head to look to both sides. Toy placement influences the direction in which your baby looks. You want to place toys on both sides of your baby so that they are able to actively look to both sides. Perform this activity with your baby on his/her belly and back. Toys with sounds and lights are especially helpful. Your baby should be able to actively turn his or her head from side to side without limitations. When you place your baby on his/her back to sleep, alternate the side to which the head turns.

5. Interchange the arm with which you hold the baby during feeding. Whether breast or bottle feeding, it is important to change positions for each feeding session in order to provide an opportunity for the baby to turn his or her head to either side.

Treatment of Congenital Muscular Torticollis

Your doctor will recommend x-rays of the neck (AP and lateral views) if your baby does not respond to the traditional physical therapy regimen. After x-rays are taken to rule out any underlying bony cause of the condition, physical therapy can continue.

Physical Therapy

The traditional physical therapy approach to the treatment of CMT includes passive and active range of motion exercises, active strengthening, and a positioning program. The success rate of children treated conservatively with physical therapy is excellent, ranging between 90-99%.

A physical therapy evaluation includes taking your baby's history and assessing his/her gross motor skills and mobility of his/her neck, arms, and legs. The therapist will demonstrate and teach you a home exercise program designed for your baby.

The home exercise program consists of stretches for the baby's neck, active and passive range of motion of the neck, positioning for play and sleep, and play activities to promote symmetrical development. It is important to only perform stretching once instructed by your therapist or doctor.

The length of therapy varies from child to child. Studies have found that the earlier a child is referred to therapy, the shorter the duration of treatment. Other factors that may affect treatment duration include severity of muscle tightness, the presence of a pseudotumor (a type of tissue enlargement) within the SCM muscle, and family compliance with the home exercise and positioning program.

On average, babies require approximately 4 to 6 months of therapy. The goal is to restore normal range of motion of the neck by one year of age.

Surgery

In the unlikely case of persistent congenital muscular torticollis that does not respond to a regular regimen of physical therapy, surgery may be necessary to correct the condition. Under general anesthesia, the pediatric orthopedist will lengthen the tight muscle. Physical therapy will resume after surgery.

Secondary Issues: Plagiocephaly in Torticollis

The term "plagiocephaly" refers to an asymmetric appearance of an infant's head. Plagiocephaly is seen commonly with torticollis, because infants tend to keep their heads turned to one side. Plagiocephaly appears in 27-61% of those with torticollis. Other associated facial asymmetries may include uneven eyes and ears and a fuller cheek on one side.

Plagiocephaly may present in several ways. True plagiocephaly is an oblique flattening of one side of the baby's head with a protruding forehead on one side. Other craniofacial asymmetries include brachycephaly, where the entire back of the head is flat, and scaphocephaly, where the head shape is long and narrow with flattening on both sides. A child can also have a combination of more than one craniofacial asymmetry.


Flattening of the top of the head, as shown by the white arrow

Positional plagiocephaly is caused by prolonged and asymmetric pressure on the head. This may happen because of intrauterine positioning (in the womb), prolonged time in any reclined positioner or carrier, decreased tolerance for tummy time, or torticollis.

Diagnosis of plagiocephaly or other cranial asymmetries is based on clinical observation by the child's healthcare professional. A visit to a specialist, such as a craniofacial specialist or neurosurgeon, may be recommended to rule out other diagnoses.

Treatment of plagiocephaly includes positioning and/or use of a helmet. With a positioning approach, pressure is relieved by turning the head away from the flat side.

As mentioned above, encouraging tummy time throughout the day takes pressure off of the back of the head. Tummy time is recommended at least 15 minutes 4 times per day.

Placing your baby in different positions throughout the day (on his/her side or sitting) and using different carriers, such as front carriers or slings, can also alleviate this pressure. It is still important to follow the Back to Sleep guidelines and have your baby sleep on his/her back.

Some children may benefit from wearing a helmet. Research studies show that the helmet works faster and is more effective than positioning alone. It must be prescribed by a healthcare professional. The helmet is made by an orthotist, and it is made of a lightweight plastic material. It is to be worn 23 hours per day. The helmet makes contact with the fuller side of the head and does not make contact with the flatter side of the head. Therefore, as the baby grows, the head will grow more symmetrical.

Helmets are most effective when started early (4-6 months) when there is rapid growth of the cranium. They can be used up until 18 months of age.


Helmet, made of a lightweight plastic material, to be worn 23 hours per day

If you think your child may have signs of torticollis as described here and would like to have your child seen by a pediatric orthopedist, please visit the HSS Pediatric Orthopedic Service or contact the Physician Referral Line at 877.606.1555. If physical therapy is recommended, please call the HSS Pediatric Rehabilitation Department at 212.606.1137 to up an evaluation.

With special thanks to Julia Munn Hale, PA-C, MHS.


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