What is the recommended treatment for a 4-year-old patient with torticollis?

Treatment of Torticollis in a 4-Year-Old Child

For a 4-year-old with congenital muscular torticollis (CMT), initiate intensive physical therapy with stretching exercises immediately, and if no improvement occurs within 3-6 months, proceed with surgical release of the sternocleidomastoid muscle before school age to optimize craniofacial symmetry and functional outcomes. 1, 2

Initial Assessment and Differential Diagnosis

Before initiating treatment, rule out non-muscular causes of torticollis that could be life-threatening:

• Examine for ocular causes including eye muscle weakness, which can present as compensatory head tilt 3, 1
• Obtain cervical spine radiographs to exclude bony abnormalities or atlantoaxial instability 4
• Perform complete neurological examination looking for signs of central nervous system pathology, spinal cord compression, or infectious processes 2, 4
• Assess for facial asymmetry and plagiocephaly, which indicate long-standing CMT and suggest the need for earlier surgical intervention 4, 5

Conservative Management (First-Line Treatment)

At age 4, this child has already missed the optimal window for conservative therapy (first year of life), but a trial is still warranted before surgery:

Physical Therapy Protocol

• Implement aggressive stretching exercises targeting the shortened sternocleidomastoid muscle with manual trigger point therapy 3, 1
• Educate caregivers on proper positioning during sleep and daily activities to prevent contracture progression 6
• Apply heat therapy to the affected neck area for 15-20 minutes, 3-4 times daily to relax muscle tension 3, 1
• Duration: 3-6 months of intensive therapy before considering surgical options 6, 4

Pharmacological Support

• NSAIDs (ibuprofen or naproxen) for pain control if the child experiences discomfort during stretching 1
• Acetaminophen as adjunctive analgesia during the first weeks of therapy 3, 1
• Avoid benzodiazepines as they are not recommended for musculoskeletal conditions in children 3, 1

Emerging Option: Botulinum Toxin

• Consider botulinum toxin injections into the affected sternocleidomastoid muscle for resistant cases before proceeding to surgery 4, 5
• This has shown effectiveness in adult CMT cases and may serve as an intermediate treatment option 5

Surgical Intervention (Indicated at This Age)

Surgery should be strongly considered at age 4, especially if conservative therapy fails, as this is approaching the critical window before school age when craniofacial asymmetry becomes increasingly difficult to reverse:

Surgical Indications

• Failure of 3-6 months of intensive physical therapy 6, 4
• Presence of significant facial asymmetry or plagiocephaly, which worsens with age 2, 4
• Palpable cord-like sternocleidomastoid muscle indicating significant fibrosis 4, 5
• Age approaching school entry (ideally completed before age 6) 2

Recommended Surgical Technique

• Bipolar tenotomy (inferior open tenotomy) releasing both sternal and clavicular heads of the sternocleidomastoid muscle 6, 2, 7
• Incision placement low in the neck along skin lines, not over the clavicle, to minimize hypertrophic scarring 2
• Intraoperative verification that the head and neck move through full range of motion before closure 2
• Release all restricting bands, not just the sternocleidomastoid, if other neck structures are involved 2

Post-Surgical Management

• Resume physical therapy within 2 weeks of surgery to prevent recurrent scar contracture 2
• Immobilization with brace for the first 2 weeks post-operatively 7
• Manual stretching exercises after brace removal 7

Critical Timing Considerations

The age of 4 years represents a critical decision point:

• Maximum growth potential for reversing craniofacial asymmetry exists before school age 2
• Delayed treatment beyond age 6-7 results in progressively worse outcomes, with only modest improvement in facial asymmetry even after successful surgery 2, 7
• Early surgical intervention (before school age) provides the best opportunity for complete resolution of both functional limitations and aesthetic deformities 6, 2

Red Flags Requiring Urgent Evaluation

Return immediately if any of the following develop:

• Progressive neurological symptoms including weakness, numbness, or tingling in extremities 3, 1
• Signs of spinal cord compression 3, 1
• Worsening pain despite treatment 1
• New onset of systemic symptoms suggesting infectious or inflammatory etiology 2, 4

Prognosis and Expectations

• If treated conservatively at age 4: Lower success rate compared to infants, with increased likelihood of requiring surgery 4
• If surgery is performed: Good functional outcomes expected, but facial asymmetry may only partially improve at this age 2, 4
• Neglected cases treated in adulthood: Only modest cosmetic and functional improvement possible 2, 7