Version May 2024
INTRODUCTION — Torticollis is the term for the clinical finding of a twisted or rotated neck. In Latin, the word "tortus" means "twisted," and "collum" means "neck." Torticollis, also called wryneck, is a common complaint in children and may be congenital or acquired.
The management and prognosis of congenital muscular torticollis will be reviewed here. The clinical features and diagnosis of congenital muscular torticollis, acquired torticollis in children, and neck stiffness in children are discussed separately. (See "Congenital muscular torticollis: Clinical features and diagnosis" and "Acquired torticollis in children" and "Approach to neck stiffness in children".)
DEFINITION — Congenital muscular torticollis is a postural deformity of the neck that is usually evident by two to four weeks of age; it is characterized by lateral neck flexion (head tilted to one side) and neck rotation (chin pointed to the opposite side) (picture 1). There are three types, in order of increasing severity [1-3]:
●Postural – Infant has a postural preference but no muscle tightness or restriction to passive range of motion
●Muscular – Tightness of the sternocleidomastoid (SCM) muscle and limitation of passive range of motion
●SCM mass (also called fibromatosis colli) – Thickening of the SCM muscle and limitation of passive range of motion
NATURAL HISTORY — Congenital muscular torticollis may resolve spontaneously, but the incidence of spontaneous resolution is not known [3]. Untreated persistent congenital muscular torticollis may lead to cosmetically significant craniofacial asymmetry [4-6]. (See "Congenital muscular torticollis: Clinical features and diagnosis", section on 'Associated conditions'.)
GENERAL PRINCIPLES — The goals of treatment for congenital muscular torticollis include achievement of midline head position, symmetric posture and gross motor skills, prevention/improvement of craniofacial asymmetry, and resolution of restricted cervical range of motion (ie, <5° limitation in active and passive cervical rotation (figure 1) and lateral flexion) [3].
Earlier initiation of treatment is associated with increased effectiveness and shorter duration of therapy [5,7-9]. (See 'Response to therapy' below.)
Caregivers should be educated about the expected course of congenital muscular torticollis. Given that they are responsible for performing the home exercise program, it is crucial that they understand factors that contribute to asymmetry (eg, lack of prone positioning, excessive time in car seats or infant carriers, not alternating sides when feeding the infant or placing the infant to sleep) and know how to safely and effectively provide the interventions.
INDICATIONS FOR REFERRAL
Physical therapy — Decisions regarding referral to a physical therapist and the timing of referral are individualized according to the age of onset and severity of congenital muscular torticollis, the ability of the caregivers to perform passive stretching correctly, and the availability of a physical therapist who is experienced in treating congenital muscular torticollis. The physical therapist can instruct the caregivers to perform the stretching exercises safely and effectively and/or provide ongoing physical therapy and assessment [10].
We refer infants to outpatient physical therapy if the home regimen is not successful after four to six weeks. (See 'First-line interventions' below.)
Additional indications for referral to a physical therapist in an infant or young child with congenital muscular torticollis include:
●Instruction in or reinforcement of proper techniques for passive stretching exercises
●More severe forms of torticollis (eg, sternocleidomastoid [SCM] tumor, more than 30° restriction in cervical rotation (figure 1))
●Age >3 months at initiation of intervention
●Need for adjunctive interventions (see 'Adjunctive interventions' below)
●Associated asymmetries or motor delays that require additional management (eg, deformational plagiocephaly, metatarsus adductus, brachial plexus palsy)
The American Physical Therapy Association clinical practice guideline suggests that all infants with congenital muscular torticollis be referred to a physical therapist [3]. In a randomized pilot study in 20 infants with congenital muscular torticollis, symmetric head posture was achieved earlier when stretching exercises were performed by an experienced physical therapist than by caregivers [11]. However, additional studies are needed to confirm these findings.
Other specialists — Indications for referral to other pediatric specialists include:
●Deformational plagiocephaly and/or craniofacial asymmetry (refer to a craniofacial team)
●Developmental dysplasia of the hip or cervical spine abnormalities (refer to orthopedic surgeon)
●Limited movement of the extraocular muscles, nystagmus, or other abnormality on eye examination (refer to ophthalmology)
●Abnormalities on neurologic examination, including macrocephaly, cranial nerve palsy, abnormal tone or strength (refer to neurology)
●SCM cyst (refer to pediatric surgeon)
FIRST-LINE INTERVENTIONS — The first-line interventions for congenital muscular torticollis include a combination of positioning and handling changes, environmental adaptations, and physical therapy interventions to facilitate passive range of motion of the neck, active range of motion of the neck and trunk, and development of symmetric posture, function, and movement [3]. These interventions make up the home exercise program, which can be implemented and monitored by the primary care provider or the physical therapist.
The first-line interventions are supported by observational studies, randomized trials [12], and consensus guidelines [1,3-5,13]. In a case series of 1086 infants who initiated treatment before 12 months of age, >90 percent of infants who were treated with these interventions at home or received manual stretching performed by a trained physical therapist had progressive improvement in head tilt and range of motion and did not require surgery [1].
Positioning and handling — Infants with congenital muscular torticollis can be positioned and held to facilitate passive range of motion of the neck and strengthening of the neck muscles. Positioning and handling interventions may be used to prevent or treat congenital muscular torticollis and deformational plagiocephaly [3,14,15].
Caregivers should be instructed to hold the infant so that the infant rotates the chin toward the shoulder of the affected side during feeding [13]. For example, for the child with head/ear tilted to the right and chin rotated to the left (ie, torticollis involving the right sternocleidomastoid [SCM]), cradle the child in the left arm so the head is tilted to the left and the chin is rotated to the right while drinking a bottle.
Caregivers should also be instructed about the importance of prone positioning ("tummy time") when the infant is awake and being watched by an adult [6]. Prone positioning with the head up stretches the SCM and strengthens the neck muscles [10,16]. In an observational study in infants with congenital muscular torticollis, prone positioning at least three times per day was associated with higher scores on the Alberta Infant Motor Scale at two and six months of age [17].
In observational studies and a small randomized trial, positioning interventions were associated with improved development of active and passive neck motion, symmetric head shape, achievement of motor milestones, and tolerance of prone positioning [2,14,15,18-20].
Environmental adaptations — The home environment can be adapted to encourage the infant to turn the head in the direction that stretches the SCM. Environmental adaptations are part of the home exercise program [3]. Examples include:
●Placing the infant in the crib or on the changing table so that they must rotate the chin toward the shoulder of the affected side to view the room. For example, for the infant with torticollis with head/ear tilt to the left and chin rotation to the right, place the infant in the crib supine with their right side closest to the wall. The infant must then rotate the chin to the left to view the room.
●Similarly, place toys or a mobile on the right side of a supine infant with torticollis with head/ear tilt to the right and chin rotated to the left. To view the objects in the right upper visual field, the infant must tilt their head toward the unaffected side (thus improving the head tilt component) and rotate the chin to the affected side (improving the chin rotation component).
Passive stretching — Passive stretching is performed to elongate the shortened SCM [5,21,22]. However, there is no consensus regarding the technique [3]. The intensity of stretching exercises (ie, number of repetitions, duration of stretches, frequency of sessions) varies from study to study, and the optimal intensity has not been determined [21]. However, randomized and observational studies suggest that greater intensity regimens are associated with more rapid resolution [3,5,12]. Greater intensity regimens generally are suggested for children with more severe forms of congenital muscular torticollis, later initiation of therapy (eg, after 3 months of age), and those with associated asymmetries (eg, deformational plagiocephaly, facial asymmetry).
Passive stretching exercises are easier to perform in infants younger than two months – before the neck muscles are strengthened; infants younger than two months can also be distracted more easily than older children [5,8,14].
●Contraindications – Cervical spine abnormalities are the primary contraindication to stretching exercises. Anterior-posterior and lateral radiographs of the cervical spine may be warranted before the exercises are recommended. (See "Congenital muscular torticollis: Clinical features and diagnosis", section on 'Imaging'.)
●Technique – For infants who are initially managed by the primary care provider, we suggest that the following stretching exercises be performed in sets of four to five repetitions, each held for approximately one to two minutes. Caregivers may be encouraged to identify a regular time to perform the exercises, such as every time they change a diaper.
•To address the rotational component of the torticollis – With the infant in the supine or sitting position, the caregiver should place one hand on the shoulder of the unaffected side (ie, the side toward which the chin is rotated). The other hand should gently rotate the infant's chin so that the chin touches the tip of the shoulder of the affected side (figure 2). For example, for the child with torticollis with the head/ear tilted to the right and chin rotated to the left, stabilize the left shoulder and rotate the chin toward the right.
•To address the head tilt component of the torticollis – With the infant in the supine or sitting position, the caregiver should place one hand on the shoulder of the affected side (ie, the side to which the head is tilted). The other hand should tilt the head away from the side of the shortened muscle until the child's ear touches the shoulder of the unaffected side (figure 3). For example, for the child with torticollis with head/ear tilted to the right, stabilize the right shoulder and tilt the head and ear to the left shoulder.
For the exercises to be effective, the infant must be relaxed and providing no resistance; the exercise should be stopped if the infant resists [15,23].
Infants who are initially referred to a physical therapist for instruction and ongoing care should follow the stretching regimen provided by the physical therapist. (See 'Indications for referral' above.)
●Complications – Few complications to correctly performed stretching exercises have been reported. Snapping (partial or complete rupture) of the SCM may occur. In a prospective study of 455 infants with congenital muscular torticollis who were treated with a manual stretching program, snapping occurred in 9 percent [24]. The group with snapping had a more severe SCM tumor, higher incidence of hip dysplasia, earlier clinical presentation, and shorter duration of treatment than the group without snapping. No long-term deleterious effects of snapping were noted during a mean follow-up of 3.5 years.
Facilitation of active movements — Facilitation of active neck and trunk movements is an essential component of treatment of congenital muscular torticollis [3].
In young infants, active neck movement is facilitated through positioning and handling and environmental adaptations. (See 'Positioning and handling' above and 'Environmental adaptations' above.)
Facilitation of active neck movements is particularly important in infants older than six to eight months of age because they have more independent motor function and may no longer tolerate passive stretching.
Examples of active stretching in older infants include [5,13,15,22,25]:
●Incorporating righting reactions (eg, holding the infant at eye level and then slowly tilting them toward the affected side [eg, for a child with right head/ear tilt and left chin rotation, tilting the child to the right])
●Placing the infant in the prone position so that they will lift the head, which strengthens the neck flexors and neck and spine extensors
●With the infant in the supported sitting position, using visual or auditory stimuli to encourage head turning toward the affected side (eg, for a child with right head/ear tilt and left chin rotation, the stimulus is presented on the right)
ADJUNCTIVE INTERVENTIONS — Adjuncts to the first-line interventions may be warranted for infants who do not have adequate improvement with first-line interventions, when access to first-line interventions is limited, and/or when the infant is unable to tolerate first-line interventions [3].
Adjunctive interventions reported to have benefit in small unblinded randomized or comparative observational studies include microcurrent [26,27], soft tissue mobilization [28], soft tissue massage [9,29,30], therapeutic ultrasonography [9,26,29,30], and myokinetic stretching [31]. Studies evaluating kinesiologic taping (which provides sensory feedback) have inconsistent results [32,33]. When indicated, these interventions generally are provided by physical therapists with appropriate training [3].
The use of the Tscharnuter Akademie for Movement Organization approach, tubular orthosis for torticollis, or soft foam collars is described in case reports and/or advocated by some experts but has not been evaluated in comparative trials [3,5,34,35]. These interventions may be added at the discretion of the treating physical therapist.
INTERVENTIONS THAT ARE NOT RECOMMENDED — Interventions that are not recommended for the treatment or adjunctive treatment of congenital muscular torticollis in infants because of unproven efficacy and/or concerns about adverse effects include cervical manipulation, craniosacral therapy, Total Motion Release, and the Feldenkrais method [3,36,37].
FOLLOW-UP — Infants being treated for congenital muscular torticollis should be evaluated at two- to four-week intervals. More frequent follow-up may be necessary for infants with more severe forms of congenital muscular torticollis (eg, sternocleidomastoid mass), infants who are >3 months when treatment is initiated, and caregivers who need reinforcement of stretching techniques; less frequent follow-up may be warranted for infants with improved range of motion and developmental progression [38].
RESPONSE TO THERAPY — Successful therapy results in midline head position and full range of active and passive motion of the neck. Criteria for discontinuation of therapy include [3]:
●Full passive range of motion (ie, within 5° of the unaffected side)
●Symmetric active movement patterns
●Age-appropriate motor development
●No visible head tilt
We refer infants to outpatient physical therapy if the home regimen is not successful after four to six weeks. (See 'Indications for referral' above.)
The majority of cases of congenital muscular torticollis resolve after four to five months of first-line interventions [1,4,5,13,21]. The duration of treatment increases with increasing age at initiation [5,7,8]. In a series of 980 infants with congenital muscular torticollis, the duration of treatment ranged from 1.5 months in infants who initiated treatment at <1 month of age to 10.3 months in those who initiated treatment at >12 months of age [8].
MANAGEMENT OF REFRACTORY TORTICOLLIS
Evaluation — For children with congenital muscular torticollis that is not improved after six months of first-line interventions, other causes of torticollis must be considered (or reconsidered) (table 1) [10]. (See "Congenital muscular torticollis: Clinical features and diagnosis", section on 'Differential diagnosis'.)
Additional evaluation of such children depends upon associated clinical findings and may include:
●Referral to ophthalmology (in children with limited extraocular movements or nystagmus)
●Referral to a craniofacial team if there are findings suggestive of craniosynostosis (figure 4) (see "Overview of craniosynostosis", section on 'Diagnosis')
●Radiographs of the cervical spine (anteroposterior and lateral) if there are findings suggestive of cervical spine abnormalities (eg, low posterior hairline, asymmetry of the scapulae)
●Magnetic resonance imaging of the cervical spine if there is concern for Chiari II malformation (see "Chiari malformations", section on 'Chiari II clinical features')
Treatment
Surgery — We suggest referral to an orthopedic or pediatric surgeon experienced in the management of congenital muscular torticollis for children with congenital muscular torticollis who are 6 to 12 months of age and continue to have [39-41]:
●Limited range of motion of the neck (ie, deficit in rotation of >15°) (figure 1)
●Clinically significant plagiocephaly or facial asymmetry
The goal of surgical intervention is to provide long-term restoration of neck mobility while minimizing the craniofacial deformity and upper cervical scoliosis.
Surgical procedures for congenital muscular torticollis include simple myotomy, bipolar release of the sternocleidomastoid (SCM), open unipolar release with partial resection of the SCM, myoplasties, combined subperiosteal lengthening of the SCM at its mastoid insertion with division of the fibrotic band, or radical resections [42,43].
Postoperative physical therapy is indicated to maintain range of motion and regain muscle strength. Postoperative orthoses with multiple adjustable joint mechanisms are also being used in some centers [44].
In a study of long-term outcome in 84 children who underwent surgical treatment of congenital muscular torticollis, 88 percent of children achieved excellent outcomes (ie, no head tilt, residual rotational and flexion limitation <5°, and no or only mild craniofacial asymmetry and scar) [45]. In this and other case series, better outcomes were obtained in younger patients (ie, less than five years of age) [46,47]. However, results of other series suggest that adequate rehabilitation is another important factor in outcome [48,49].
The complications of surgery include loss of the SCM column, scarring lateral band formation, and poor clinical outcome necessitating a second operation. Scalp irritation may result if the postoperative orthosis, which is used to help maintain head and neck position, is not properly adjusted. Restriction of activity is unnecessary after postoperative physical therapy to regain muscle strength and range of motion.
Botulinum toxin — We do not suggest botulinum injections for the treatment of congenital muscular torticollis.
Sufficient comparative effectiveness studies of botulinum toxin injection and surgical treatment for congenital muscular torticollis are lacking. In a meta-analysis of nine case series and one experimental study, botulinum toxin injection appeared to be safe and effective [50]. However, there was insufficient evidence to definitively describe the rates of rare adverse events. Larger, rigorous studies are necessary to adequately assess the optimal use of botulinum toxin for congenital muscular torticollis (eg, indications for specific types of torticollis, dose and frequency of injections, location/technique for delivery).
LONG-TERM FOLLOW-UP — Long-term follow-up of children with congenital muscular torticollis includes routine developmental surveillance, particularly for asymmetry and impairments in motor function [51]. (See "Developmental-behavioral surveillance and screening in primary care", section on 'Approach to surveillance'.)
PROGNOSIS — The majority of cases of congenital muscular torticollis resolve with first-line interventions [1,4,5,13,21]. Prognosis is affected by the age at initiation of treatment and the type and severity of congenital muscular torticollis:
●In a series of 57 cases, all those who initiated therapy before three months of age had full resolution with first-line interventions [7]. Surgical release was required in 25 percent of those who initiated therapy between three and six months, 70 percent of those who initiated therapy at 6 to 18 months, and all who initiated therapy at >18 months of age.
●In a series of 1086 cases that presented before one year of age [1]:
•99 percent of infants with postural torticollis had good/excellent results (based on a score that included limitation in rotation and lateral flexion, craniofacial asymmetry, residual head tilt, and caregiver assessment) with first-line interventions; none required surgery
•94 percent of infants with muscular type had good/excellent results with first-line interventions; 3.2 percent required surgery
•88 percent of infants with sternocleidomastoid mass type had good/excellent results with first-line interventions; 7.6 percent required surgery
●In the same series of 1086 cases, all infants with lateral flexion deficits of ≤10° had excellent outcomes with first-line interventions; 9 percent of patients with lateral flexion deficits >10° required surgery.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Congenital muscular torticollis".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient education" and the keyword[s] of interest.)
●Basics topics (see "Patient education: Torticollis in children (The Basics)")
SUMMARY AND RECOMMENDATIONS
●Congenital muscular torticollis is a postural deformity of the neck that is usually evident by two to four weeks of age; it is characterized by lateral neck flexion (head tilted to one side) and neck rotation (chin pointed to the opposite side) (picture 1). (See 'Definition' above.)
●The goals of treatment include achievement of midline head position, symmetric posture and gross motor skills, prevention/improvement of craniofacial asymmetry, and resolution of restricted cervical range of motion. Earlier initiation of treatment is associated with increased effectiveness and shorter duration of therapy. (See 'General principles' above.)
●Decisions regarding referral to a physical therapist and the timing of referral are individualized according to the age of onset and severity of congenital muscular torticollis, the ability of the caregivers to perform passive stretching correctly, and the availability of a physical therapist who is experienced in treating congenital muscular torticollis. (See 'Physical therapy' above.)
●Indications for referral to other specialists include deformational plagiocephaly and/or craniofacial asymmetry, developmental dysplasia of the hip, cervical spine abnormalities, abnormalities on eye examination (eg, limited extraocular movements nystagmus), and abnormalities on neurologic examination. (See 'Other specialists' above.)
●The first-line interventions for congenital muscular torticollis include a combination of positioning and handling changes, environmental adaptations, and physical therapy interventions to facilitate passive range of motion of the neck, active range of motion of the neck and trunk, and development of symmetric posture, function, and movement. (See 'First-line interventions' above.)
●Infants being treated for congenital muscular torticollis should be evaluated at two- to four-week intervals. Successful therapy results in midline head position and full range of active and passive motion of the neck. We refer infants to outpatient physical therapy if the home regimen is not successful after four to six weeks. (See 'Follow-up' above and 'Response to therapy' above.)
●Other causes of torticollis must be considered (or reconsidered) (table 1) in children with congenital muscular torticollis that is not improved after six months of first-line interventions. Additional evaluation of such children depends on associated clinical findings and may include referral (eg, to a craniofacial team) or imaging studies (eg, radiographs of the cervical spine). (See 'Evaluation' above and "Congenital muscular torticollis: Clinical features and diagnosis", section on 'Differential diagnosis'.)
●We suggest referral to a pediatric orthopedic surgeon or pediatric surgeon experienced in the management of congenital muscular torticollis rather than botulinum toxin injections for children with congenital muscular torticollis who are 6 to 12 months of age and continue to have limited range of motion of the neck (ie, deficit in rotation of >15°) or clinically significant plagiocephaly or facial asymmetry (Grade 2C). (See 'Surgery' above and 'Botulinum toxin' above.)
●The majority of cases of congenital muscular torticollis resolve with first-line interventions. Prognosis is affected by the age at initiation of treatment and the type and severity of congenital muscular torticollis. (See 'Prognosis' above.)
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