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Congenital muscular torticollis
What's new
Updated 2024 APTA guidelines for the diagnosis and management of congenital muscular torticollis .
Background
Overview
Definition
Congenital muscular torticollis is a benign congenital musculoskeletal disorder characterized by unilateral shortening of the sternocleidomastoid muscle leading to ipsilateral head tilt and contralateral rotation of the face and chin.
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Pathophysiology
The exact cause of congenital muscular torticollis is unknown. Several theories have been proposed including intrauterine crowding, muscle trauma during a difficult delivery, soft tissue compression leading to compartment syndrome, and congenital abnormalities of soft tissue differentiation within the sternocleidomastoid muscle.
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Epidemiology
The incidence of congenital muscular torticollis ranges from 0.3% and 2%.
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Risk factors
Risk factors include breech presentation, prolonged labor, and difficult birth. Associated conditions may include developmental dysplasia of hip and plagiocephaly.
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Disease course
Clinical manifestations include ipsilateral head tilt and contralateral rotation of the face and chin, plagiocephaly, palpable pseudotumor, and tightness of the muscle. Untreated congenital muscular torticollis in infancy may lead to craniofacial growth deformity in adults.
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Prognosis and risk of recurrence
Congenital muscular torticollis is not associated with increased mortality.
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Guidelines
Key sources
The following summarized guidelines for the evaluation and management of congenital muscular torticollis are prepared by our editorial team based on guidelines from the American Physical Therapy Association (APTA 2024).
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Classification and risk stratification
Severity assessment: as per APTA 2024 guidelines, classify and document congenital muscular torticollis severity using the Congenital Muscular Torticollis Severity Grading Scale.
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Congenital Muscular Torticollis Severity Grading Scale
Age at examination
≤ 6 months
7-9 months
10-12 months
> 12 months
Sternocleidomastoid mass
Present
Absent
Postural preference
Yes
No
Difference in cervical rotation passive ROM between the left and right sides
< 15 degrees
15-30 degrees
> 30 degrees
Grade cannot be fully assessed
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Prognosis
Diagnostic investigations
Initial assessment
As per APTA 2024 guidelines:
Assess and document the presence of neck and/or facial or cranial asymmetry within the first 2-3 days of life, using passive cervical ROM and/or visual observation as their respective training or experience supports.
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Elicit a general medical and developmental history of the infant before initial screening, including the following specific health history factors:
chronological and corrected age
age of onset of symptoms
pregnancy and birth history
head posture/preference
other known or suspected medical conditions
developmental milestones
B
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Physical examination
Nonpharmacologic interventions
Physical therapy: as per APTA 2024 guidelines, provide the following five components as the first-choice intervention in infants with congenital muscular torticollis:
neck passive ROM when passive ROM is limited
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neck and trunk active ROM
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symmetrical movement
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environmental adaptations
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parent/caregiver education.
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Patient education
Parent counseling: as per APTA 2024 guidelines, educate all expectant or new parents/caregivers of infants before or within the first 2-3 days of life on the importance of supervised prone/tummy play 2-3 times daily when the infant is awake, full active movement throughout the body, prevention of postural preferences, and the role of pediatric physical therapists in the comprehensive management of postural preference and optimizing motor development if concerns are noted.
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Follow-up and surveillance
Indications for referral
As per APTA 2024 guidelines:
Refer infants with postural preference, reduced cervical ROM, a sternocleidomastoid mass, and/or craniofacial asymmetry to primary care providers and a physical therapist with expertise in infants as soon as the asymmetry is noted.
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Refer infants to primary care providers for additional diagnostic evaluation when a systems review identifies any of the following:
nonmuscular causes of asymmetry (such as poor visual tracking, spinal conditions, abnormal muscle tone, extramuscular masses, and gastroesophageal reflux disorder)
associated conditions (such as craniofacial asymmetry)
asymmetries inconsistent with congenital muscular torticollis (such as head lateral flexion and rotation to the same side or the side of torticollis changes)
changes in the color during screening of neck passive ROM
history of acute torticollis
history of late-onset torticollis at ≥ 6 months
a sternocleidomastoid mass at ≥ 6 months
a sternocleidomastoid mass changing shape and location or increases in size at any age
age > 12 months and either facial asymmetry and/or 10-15 degrees of difference exists in passive or active cervical rotation or lateral flexion ROM
B
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Follow-up