See also

Acquired torticollis

Key Points

1. Congenital torticollis is usually diagnosed within the first month of life. Diagnosis after 6 months is rare and other causes should be considered
2. Muscular torticollis is most common. If the examination supports a diagnosis of congenital muscular torticollis, no further investigations are required
3. Mild cases of congenital torticollis are managed at home by the care giver with simple stretching exercises
4. More severe cases require referral to physiotherapy and rarely orthopaedics

Background

Congenital torticollis is a postural deformity of the neck that develops prenatally 
It is usually noted within the first month of life, however, diagnosis can be delayed

There are 2 types:

• Muscular: tightness of the sternocleidomastoid (SCM) muscle and limitation of passive range of motion. This is the most common type
• Muscular with SCM mass: Thickening of the SCM muscle and limitation of passive range of motion
• Postural: infant has a preferred head posture but no muscle tightness or restriction to passive range of motion

Assessment

Red flag features in Red

Congenital muscular torticollis should be suspected in infants with a preferred head position or posture, reduced range of motion of the cervical spine, SCM mass, and/or craniofacial asymmetry

History

• Onset: noticed at birth or shortly after supports diagnosis
  • Torticollis diagnosed after 6 months should prompt consideration of acquired causes (see Acquired torticollis)
  • Acute onset torticollis should prompt further investigation (see Acquired torticollis)
• Infants may have difficulty feeding on one side
• Time spent in prone position (lack of tummy time may contribute to persistence)
• Developmental milestones, especially gross motor, may be delayed
  • Delays appear to be more strongly related to infrequent prone positioning while awake and resolve by preschool age (3.5–5 years)

Examination

• Head position: the head and ear are tilted toward the affected SCM and the chin points to the opposite side
• Normal passive neck movements: when stabilised in the supine position, the examiner should be able to passively rotate the chin past the shoulders and laterally flex the neck so that the top of the ear touches the shoulder. Limitation suggests torticollis
• Palpate for tightening or SCM mass: the characteristic SCM mass is well circumscribed, firm and found in the inferior one-third of the affected SCM
• Head shape and sutures (plagiocephaly and facial asymmetry are common)
• Eye movements, back and spine, upper and lower limbs and a neurological examination should be performed to identify rare non-muscular causes 
• Note that Developmental Dysplasia of the Hip (DDH) is a common association and hips should be assessed

Differential Diagnosis
Consider an alternative diagnosis if no muscle tightness or mass is palpated on examination

• Rarely congenital torticollis may be secondary to vertebral anomalies, clavicle fractures, plagiocephaly, craniosynostosis, ocular pathology or CNS lesions

Management

Investigations

• Routine neck imaging is not recommended
• If a mass is present but not characteristic of SCM, ultrasound (US) may be helpful
• A cervical spine X-ray may detect vertebral anomalies in atypical torticollis
• A hip US in infants with congenital muscular torticollis is recommended

Treatment

• Educate caregiver on infant positioning during feeding, sleeping and playing (including the importance of supervised prone positioning) and making environmental modifications to encourage head and neck movement
• Passive stretching exercises 4–5 times a day
• GP follow up within 4 weeks for monitoring
• Consider referral to physiotherapy when there is:
• no improvement with home exercises by 4–6 weeks 
• severe torticollis: limited ROM at diagnosis (e.g. <30 degrees rotation)
• a child older than 3 months at diagnosis with more than minimal torticollis
• associated moderate to severe plagiocephaly

A majority of cases will resolve after four to five months. If no significant improvement by 6 months of age, re-consider the diagnosis or refer to paediatric orthopaedic surgeon   

Consider consultation with local paediatric team when

• Diagnosis unclear
  
• Red flag identified

Consider transfer when

Care required beyond the comfort level of the local healthcare facility

For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services.

Consider discharge when

Patients can be discharged from follow up once they have:

• improved range of motion
• age-appropriate motor development
• no visible head tilt

Parent Information

Kids Health Info on Plagiocephaly

 Last updated May 2020