Congenital Muscular Torticollis (CMT) is a condition where a child’s head tilts and turns due to a shortened or tightened sternocleidomastoid (SCM) muscle on one side of the neck. The SCM runs from behind the ear down to the collarbone and breastbone. This condition causes the head to be laterally tilted toward the affected muscle while the chin rotates toward the opposite shoulder. CMT is a highly manageable musculoskeletal problem. Early detection and consistent treatment, which focuses on lengthening the tight muscle, offer an excellent prognosis for full correction.
Recognizing the Signs and Initial Diagnosis
Parents are often the first to notice the characteristic physical signs of torticollis, typically apparent within the first six to eight weeks of life. The most obvious symptom is a consistent head tilt to one side and a preference for looking only in one direction. This limited range of motion, which makes it difficult for the child to follow a visual stimulus to the non-preferred side, indicates a tight SCM muscle.
A small, firm lump, sometimes called the “olive,” may be felt in the middle of the tightened neck muscle. This lump is scar tissue within the SCM and is not painful, usually resolving on its own before the child reaches six months of age. Because the infant prefers resting their head in one position, an associated condition called positional plagiocephaly, or flattening on one side of the skull, can develop. Diagnosis is generally clinical, based on a physical examination and visual assessment.
Physical Therapy: The Primary Treatment Approach
Physical therapy (PT) is the established first-line treatment for CMT, ideally beginning before the infant reaches six months of age. Early initiation of treatment is a strong predictor of success; studies show the condition resolves in over 90% of cases when therapy starts early. A pediatric physical therapist conducts a thorough evaluation to assess the severity of muscle tightness, the degree of head tilt, and the infant’s overall motor development.
The core of the PT treatment plan involves manual techniques performed by the therapist and a structured home exercise program for parents. These exercises are designed to achieve two primary goals: lengthening the shortened SCM muscle and strengthening the opposing neck muscles. Passive Range of Motion (PROM) exercises gently stretch the tight muscle, increasing the range of lateral flexion and rotation.
Active rotation exercises encourage the infant to voluntarily turn their head toward the restricted side, strengthening the weaker, underused muscles. The therapist provides specific instructions for these stretches, emphasizing that they must be performed gently and without forcing movement past the child’s tolerance. The objective is to ensure the child achieves symmetrical movement and age-appropriate motor skills.
Positional Adjustments and Home Care Strategies
Successful correction of torticollis relies heavily on consistent positional adjustments and home care strategies throughout the infant’s daily routine. These techniques reinforce the work done in formal physical therapy sessions by encouraging active movement toward the non-preferred side. Repositioning techniques manipulate the infant’s environment to motivate them to turn their head away from the favored position.
Tummy Time is a useful strategy, as it naturally strengthens the neck and shoulder muscles. During supervised awake periods, placing the infant on their stomach and positioning toys, mirrors, or the caregiver to the restricted side encourages them to lift and turn their head in the corrective direction. This purposeful placement of visual and auditory stimuli is an effective form of active exercise.
Environmental manipulation extends to the crib; placing the infant with their head toward the end of the bed that forces them to look out into the room encourages rotation toward the tight side. During feeding, parents should hold the infant in a position that requires the child to turn their head away from the preferred side to engage with the breast or bottle. When carrying the infant, methods such as the “football hold” naturally provide a gentle, sustained stretch to the tight muscle, integrating therapy into routine care.
Advanced Options for Persistent Torticollis
For the small percentage of infants whose torticollis does not resolve with intensive physical therapy and home care, typically after six to twelve months of consistent treatment, advanced interventions may be considered. One supplemental approach is Kinesiology Taping, which involves applying specialized elastic tape to the neck muscles. Applied with a muscle-relaxing technique, the tape provides sensory input to encourage muscle relaxation and support proper head posture, acting as an adjunct to the exercise program.
Another effective option for infants over six months of age who are unresponsive to conservative therapy is Botulinum Toxin Type A (BoNT-A) injections. This treatment involves injecting the toxin directly into the tight SCM muscle, which temporarily blocks nerve signals to relax the muscle and improve the range of motion. BoNT-A injections can successfully resolve persistent torticollis in refractory cases, often helping to avoid the need for surgery.
Surgical intervention, specifically a sternocleidomastoid muscle release, is reserved as a last resort for children over 12 to 18 months. This is typically considered for those who have a severe, persistent contracture limiting neck rotation by more than 15 to 20 degrees. The procedure involves lengthening the tight muscle and is followed by rigorous post-operative physical therapy to prevent recurrence. If significant plagiocephaly has developed, a cranial orthotic device, or helmet, may be recommended to help reshape the skull, often concurrently with continued physical therapy.