Torticollis is a term that literally means “twisted neck,” from the Latin words tortus (twisted) and collum (neck). It is a condition defined by an abnormal, asymmetrical head or neck position. While there are several types, the vast majority of cases seen in infancy are Congenital Muscular Torticollis (CMT).

To understand CMT, it is essential to know about the sternocleidomastoid (SCM) muscle. You have one of these large, rope-like muscles on each side of your neck, running from the bone behind your ear (the mastoid process) down to your collarbone (clavicle) and breastbone (sternum). These muscles allow you to bend your neck and rotate your head.

A helpful analogy is to think of the two SCM muscles on either side of the neck as two identical, balanced elastic bands.

• When they are working together, they allow your head to stay centered and to turn and tilt freely and symmetrically in all directions.
• In congenital muscular torticollis, it is as if one of these elastic bands is abnormally tight, shortened, or has a small knot in it.
• This tight band constantly pulls the head, causing it to tilt toward the side of the tight muscle and rotate toward the opposite shoulder.

A baby with torticollis is not choosing to hold their head in this position. The tight and shortened muscle is physically pulling it into that posture.

While CMT is the most common form, it is important to know that torticollis can also be acquired later in life due to other medical issues.

In my experience, parents often bring in infants with a head tilt they first notice during feeding or when the baby looks around, this is commonly due to congenital torticollis.

The specific cause depends on the type of torticollis.

Causes of Congenital Muscular Torticollis (CMT)

In most CMT cases, the exact cause is unknown. It is thought to be related to the positioning of the baby in the womb or minor trauma to the SCM muscle during the birthing process. The leading theories include:

• In-utero Positioning: The baby’s head may have been held in a cramped or tilted position in the womb for a prolonged period, leading to a shortening of the SCM muscle on one side.
• Birth Trauma: A difficult or assisted delivery (e.g., with forceps or vacuum) can sometimes cause a minor injury or tearing of the SCM muscle fibers. As this tiny injury heals, it can form a small amount of scar tissue, causing the muscle to tighten.
• SCM Hematoma: Sometimes, a small collection of blood (a hematoma) can form within the muscle due to birth trauma. This often presents as a small, pea-sized, benign lump in the neck, which resolves as the muscle heals and tightens.

Causes of Acquired Torticollis

This type of torticollis develops after the newborn period and is a symptom of another underlying issue. Causes can range from minor to serious and include:

• Minor trauma, such as from sleeping in an awkward position.
• A throat or neck infection that causes the lymph nodes to become very swollen and inflamed, irritating the neck muscles.
• Gastroesophageal reflux (in infants, a condition called Sandifer syndrome can cause unusual posturing and neck twisting).
• Vision problems, such as a type of strabismus (eye misalignment) that causes a child to tilt their head to see properly.
• Rarely, a tumor or structural abnormality of the cervical spine or the brain.

Clinically, the most common cause I’ve encountered in infants is congenital muscular torticollis, often related to birth trauma or cramped positioning in the womb.

Congenital muscular torticollis is a condition a baby is born with or develops in the first few weeks of life. It is not contagious. While the exact cause is often unclear, several factors are associated with an increased risk of developing CMT.

Risk factors include:

• Being a first-born child (the uterus and abdominal muscles are often tighter).
• Breech presentation.
• A difficult or assisted delivery.
• A large birth weight.

The “Back to Sleep” Campaign and Torticollis

In recent decades, public health campaigns like “Back to Sleep” have been incredibly successful at reducing the risk of Sudden Infant Death Syndrome (SIDS). However, this has led to an increase in the number of babies diagnosed with torticollis and an associated condition, plagiocephaly (a flat spot on the head). While back sleeping is essential for safety, spending extended periods on their back can cause babies with a pre-existing slight muscle tightness to develop a stronger preference for turning their head one way, which can exacerbate the torticollis and lead to flattening of the skull on that side.

Clinically, I’ve also seen torticollis emerge suddenly in adults due to whiplash injuries, infections, or as a side effect of certain medications that affect muscle control.

Parents or a pediatrician usually notice the signs of congenital muscular torticollis within the first weeks or months of life.

The hallmark sign is the characteristic head posture:

• A persistent head tilt to one side.
• The chin is often pointed slightly toward the opposite shoulder.

Other common signs and symptoms in an infant include:

• Limited head and neck movement. The baby will have a strong preference for looking in one direction and will resist or become frustrated when you try to turn their head to the non-preferred side.
• Difficulty with breastfeeding on one side, as the baby may struggle to turn their head comfortably.
• A small, firm, pea-sized lump or mass may be felt in the side of the neck. This is a benign collection of fibrous tissue within the SCM muscle and typically resolves on its own.
• Plagiocephaly: The development of a flat spot on one side of the back of the head from consistently lying in the same position.
• Facial Asymmetry: If the torticollis is severe and goes untreated, the constant muscle pull can lead to a slight asymmetry in the development of the face and skull.

Parents usually notice their baby always turning their head to one side, or an adult may report neck pain, stiffness, or difficulty moving the head fully.

The diagnosis of congenital muscular torticollis is made clinically. This means a doctor or a pediatric physical therapist can diagnose the condition based on a thorough physical examination and a review of the baby’s history.

• Physical Examination: The provider will observe the baby’s resting head posture and will gently assess the passive and active range of motion of the neck. They will carefully feel (palpate) the SCM muscles on both sides to check for tightness or the presence of a mass.
• Ruling Out Other Causes: In a typical case of CMT, no further testing is needed. However, if the presentation is atypical (e.g., the head tilts to the right, but also rotates to the right), if the child is in pain, or if there are any other neurological concerns, the doctor will order further tests to rule out the rarer and more serious causes of torticollis. This may include:
  • X-rays of the neck to check for any bony abnormalities of the cervical spine.
  • An ultrasound or MRI to rule out any spinal or brain problems.

In my experience, I consider underlying causes like cervical spine anomalies or infections if the condition appears suddenly or worsens rapidly, especially in older patients.

For congenital muscular torticollis, the prognosis is excellent, especially when treatment is started early. The vast majority of cases (over 95%) resolve completely with non-surgical treatment. The goal of treatment is to stretch and lengthen the tight SCM muscle, strengthen the opposing SCM muscle, and achieve a full, symmetrical range of neck motion.

1. Physical Therapy: The Cornerstone of Treatment

The primary and most effective treatment for CMT is physical therapy.

2. The Home Exercise Program

Consistent home program performance by parents is key to success. The main components include:

• Stretching Exercises: The therapist will teach you how to perform gentle, passive stretching exercises. The two main stretches are:
  • A side-bending stretch, where you gently tilt the baby’s ear on the unaffected side down toward their shoulder, stretching the tight SCM muscle.
  • A rotational stretch, where you gently turn the baby’s chin toward the shoulder on the affected (tight) side.
  • It is crucial that parents are taught how to perform these stretches safely and correctly by a trained professional.
• Positioning and Environmental Encouragement: This involves actively encouraging the baby to turn their head and look toward their non-preferred side.
  • During tummy time, place all interesting toys on the side you want the baby to turn toward.
  • When placing the baby in the crib, position them so that they have to turn their head to the non-preferred side to look out into the room or at you.
  • During feeding, hold the baby in a position that encourages them to turn away from their preferred side.
• Tummy Time: Tummy time is absolutely critical. When awake and supervised, the baby should spend as much time as possible on their stomach.

3. Other Treatments

For the small percentage of children who do not respond to several months of intensive physical therapy, other options may be considered.

• Botox Injections: In some cases, an injection of botulinum toxin into the tight SCM muscle can help it to relax, making stretching more effective.
• Helmet Therapy: If a child has developed significant plagiocephaly (a flattened head shape), a doctor may prescribe a custom-molded helmet or cranial orthosis to help gently reshape the skull as it grows.
• Surgery: Surgery is a last resort, reserved for children with severe torticollis who have not improved after at least six months of dedicated physical therapy. A surgeon will perform a procedure to surgically lengthen the tight SCM tendon, allowing for a better range of motion.

I’ve seen excellent outcomes in infants with early physical therapy, stretching exercises and positioning techniques often correct the head tilt without surgery.

Discovering that your baby has a persistent head tilt can be a source of significant worry for parents. It is reassuring to know that the most common cause, congenital muscular torticollis, is a highly treatable condition with an excellent prognosis. It is not a sign of a serious neurological disease but is a musculoskeletal issue caused by a tight neck muscle. The key to success is early diagnosis and a strong commitment to the treatment plan. Through a partnership with a pediatric physical therapist and a dedication to daily home stretching and positioning exercises, parents are the most important members of the therapy team. Clinically, I emphasize prompt evaluation and a tailored approach to care, as the underlying cause and age of onset significantly influence treatment success.

American Academy of Pediatrics (AAP). (n.d.). Torticollis in Infants. Retrieved from https://www.healthychildren.org/English/health-issues/conditions/orthopedic/Pages/Torticollis.aspx

American Academy of Orthopaedic Surgeons (AAOS). (n.d.). Torticollis (Wryneck) in Infants and Children. Retrieved from https://orthoinfo.aaos.org/en/diseases–conditions/torticollis-wryneck-in-infants-and-children/

The National Institutes of Health, MedlinePlus. (2023). Torticollis. Retrieved from https://medlineplus.gov/ency/article/000749.htm