Torticollis is a common musculoskeletal condition in infants characterized by an abnormal tilt or twist of the head and neck. This position, often called wryneck, occurs because of a shortened or tight neck muscle on one side, typically the sternocleidomastoid (SCM) muscle. While often noticeable soon after birth, this condition is highly treatable, and early intervention significantly improves the likelihood of a full resolution.
Recognizing Torticollis
The most visible indication of torticollis is the head consistently tilting to one side while the chin rotates toward the opposite shoulder. This asymmetry is caused by the tight SCM muscle, which runs along the side of the neck from the collarbone to the skull base behind the ear. Parents may also notice the infant strongly prefers looking in only one direction, which signals a limited range of neck motion.
A small, pea-sized lump, sometimes called a pseudo-tumor, may be palpable within the tight SCM muscle. This lump is harmless and usually resolves on its own as the muscle lengthens. The persistent head positioning can also lead to positional plagiocephaly, which is a flattening of the skull on one side due to the constant pressure on the same spot.
Torticollis is broadly classified as either congenital or acquired, developing later in infancy or childhood. Congenital muscular torticollis is the most common type and is thought to result from restricted space in the womb or trauma during birth. Identifying these signs early is important, as timely treatment can prevent long-term complications like facial asymmetry or delayed motor development.
Positional Adjustments and Daily Care
Environmental adjustments encourage the baby to turn their head toward the non-preferred side. These strategies empower parents to incorporate them into their child’s daily routine. The goal is to naturally coax the shortened muscle into stretching and the weaker muscle into strengthening.
“Tummy Time” is a foundational activity that helps strengthen the neck and upper body muscles. Parents should aim for multiple, short periods of supervised Tummy Time throughout the day, placing toys or their own faces just out of reach on the side the baby avoids looking toward. Doing this on the floor, on a parent’s chest, or over a small, firm pillow helps build the muscular strength needed to lift and turn the head against gravity.
Environmental positioning should also be manipulated to make looking the non-preferred way more enticing or necessary. When placing the baby in the crib, change the orientation so that the door, a window, or the parent’s side of the bed is on the side the baby needs to turn toward. During feeding, whether bottle or breast, ensure the baby is held and positioned so they must rotate their head to the restricted side to latch or make eye contact. Limiting the time spent in restrictive devices like car seats and swings is also beneficial, as these can reinforce the preferred head position.
Therapeutic Stretching and Strengthening
A targeted program of stretching and strengthening exercises is prescribed and supervised by a pediatric physical therapist (PT). The physical therapist will first assess the degree of muscle tightness and range of motion limitations to create an individualized home exercise program. This program is typically performed several times a day and is the cornerstone of conservative therapy.
The PT will teach caregivers stretching techniques. One common stretch involves rotation, where the child’s head is carefully turned until the chin aligns with the shoulder on the opposite side of the tight muscle. Another technique is lateral neck bending, where the ear on the unaffected side is gently brought toward the shoulder, stretching the shortened muscle. Each stretch is held briefly and repeated in a controlled manner, never forcing the movement to the point of causing distress.
Beyond stretching, strengthening the opposing neck muscles is necessary to maintain the corrected head position. This is often achieved through active movement and play, encouraging the baby to lift and hold their head in a neutral or rotated position. Activities such as playing while lying on their side (sidelying) or encouraging reaching across the midline of the body help engage the weaker muscles. Consistency in performing these exercises at home is paramount to achieving a successful outcome.
Advanced Treatment Options
While most cases of congenital muscular torticollis resolve completely with physical therapy and positional changes, if conservative treatment does not yield full correction within several months, re-evaluation is necessary. A lack of improvement in neck mobility after six to twelve months of dedicated physical therapy warrants a re-evaluation by the medical team. This may involve further imaging to rule out underlying skeletal issues.
In some instances, specialized neck collars or soft bracing may be used to provide a constant, gentle stretch to the shortened muscle or to encourage a more neutral head posture. If the associated positional plagiocephaly is severe and does not improve with repositioning, a cranial remolding orthosis, or helmet, may be prescribed. The helmet works by guiding the growth of the skull into a more symmetrical shape.
For a small percentage of children who have severe SCM tightness that resists all non-surgical methods, a surgical procedure may be recommended. The most common procedure is a sternocleidomastoid release, where the tight muscle is lengthened to restore full range of motion. Surgery is usually performed after the child has reached preschool age and is followed by a period of rigorous physical therapy to maintain the correction and strengthen the neck muscles.