Congenital Muscular Torticollis

Steve Lane, DPT

What is congenital muscular torticollis?

Right CMT

Congenital muscular torticollis (CMT) or torticollis as it is often referred to, literally means a condition that is present at birth that causes the neck to twist. It is caused by a shortened muscle on one side of an infant's neck which produces a tilting of the neck to the affected side and a rotation of the head to the opposite side. The incidence is about 1 in 250 births. There are other causes of torticollis such as vertebral abnormalities which is different from CMT in that it is quite rigid, and resists any attempt at correcting it passively. Spasmodic and hysterical torticollis are also different than CMT and should therefore be treated differently.

What causes congenital muscular torticollis?

The muscle that is involved in CMT is called the sternocleidomastoid (SCM). There are two of these muscles which are found on the front sides of the neck. The SCM muscle extends from the skull, just behind the ear, to the collarbone and sternum. The right SCM is involved in 75% of cases. Although the exact cause of torticollis remains unclear, it is thought to possibly occur due to a blood flow disruption in the womb, poor positioning during gestation, or a difficult birth, particularly if the infant is very large or is delivered breech. If the SCM muscle is stretched or pulled, it may tear, causing bleeding and bruising within the muscle. The injured muscle develops fibrosis (scar tissue) which causes the muscle to shorten and tighten, pulling the infant's head to one side with a rotation to the opposite side. The fibrosis occasionally forms a lump that can be felt on the side of the neck. This lump usually will become a little bigger after it is first noted and then slowly diminish over time. Although torticollis may be caused by birth trauma, it is not painful and is usually first noticed in the first two to three weeks after birth. Torticollis may present itself differently in each case, however, the most common symptoms include:

Treatment of Congenital Muscular Torticollis:

Conservative management of CMT is generally recommended during the first 12 months. Conservative management includes positioning and handling techniques, gentle range of motion, and strengthening through activation of head and trunk muscles as the infant gains control of upright postures.

The most common from of treatment is passive stretching of the involved SCM and upper trapezius muscles. Although the optimal course needed to maximally stretch the muscle is unclear, most studies are in the vicinity of a hold of 20-30 seconds repeated 8-12 times per session and done 4-5 times per day. However, the infant may not initially tolerate the entire program and may need to work up to the full treatment. If the infant does not tolerate the entire session it appears the most important aspect of the program is the length of the hold needing to be close to 30 seconds. The average length of time for conservative treatment to resolve CMT is approximately 5 months with a little longer treatment often required for infants with an initial palpable mass. Many studies show complete resolution of symptoms at or before 12 months of age in 70-99% of children who receive conservative treatment.

The stretches should never be painful and often a massage of the tight neck muscles prior to stretching is commonly used to promote an increase in pain free range of motion. Other commonly used treatments are active rotation of the head toward the involved side, and handling and positioning during feeding and sleeping to promote active rotation or stretch of the SCM. During breastfeeding, various positions are attempted in order to encourage positions where the baby can suck optimally and attain some gentle stretching to the neck muscles.

One of the most important methods to promote stretching of the shortened muscle and strengthening of the opposite muscles is with “tummy time.” However, infants with CMT often do not tolerate tummy time very well and will need repetition and encouragement to increase their tolerance. This home program should be incorporated into your family's routines and include: feeding, carrying, and positioning the baby; activities to encourage midline head and trunk postures; and gentle active and/or passive neck range-of-motion exercises opposite to the torticollis posture. Parental compliance is mandatory for successful outcomes.

A condition that may accompany CMT is plagiocephaly, or flattening of the head, which is reported in up to 90% of children with CMT. Mild to moderate facial asymmetries are also common because of the unequal force of the muscles. Both of these typically resolve with conservative treatment primarily consisting of positioning.

Although the average treatment time lasts approximately 5 months, an important reminder is that CMT may reappear during periods of growth. The reason for this is that the involved SCM may not grow at the same rate as on the uninvolved side, creating a risk of return of contracture. Torticollis may also reappear during periods of illness, teething, and acquisition of new motor functions.

The overall goals for an infant with CMT may include: 1) age-appropriate active and passive range of motion of neck and trunk movements; 2) prevention of contractures or further loss of motion; 3) symmetry of shape in the face, head, and neck; 4) development of postural reactions in all directions; and 5) symmetry of gross motor patterns throughout development.

Intervene Early

Many studies report that the earlier the intervention, the more effective it is. Intervention beginning at birth or soon after the diagnosis increases developmental gains and decreases the chances of developing problems. Treatment before age 1 greatly improves the outcome.

If the condition is not properly treated and corrected, the infant may be unable to move his/her head properly and have a continued limitation in neck range of motion. This can ultimately lead to delayed cognitive development because of decreased ability to see, hear, and interact with their environment. Permanent muscle tightening with asymmetry of the neck and face can also result from not properly correcting the condition.

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