Treatment of Infant Torticollis
Physical therapy with stretching exercises should be initiated immediately upon diagnosis, ideally within the first year of life, as this is the most effective treatment for congenital muscular torticollis and significantly improves outcomes when started early. 1, 2, 3
Initial Assessment and Differential Diagnosis
Before initiating treatment, you must rule out non-muscular causes of torticollis, as missing these could be life-threatening 4, 5:
- Obtain cervical spine radiographs to exclude congenital anomalies of the occipital condyles and upper cervical spine 5
- Perform ocular examination to rule out eye muscle weakness causing compensatory head positioning 2, 5
- Assess for neurological symptoms including weakness, numbness, or signs of spinal cord compression 1, 2
- Consider Sandifer's syndrome (gastroesophageal reflux), benign paroxysmal torticollis, or neural axis abnormalities in the differential 5
Important caveat: MRI of the brain and neck is no longer considered cost-effective or necessary for congenital muscular torticollis 4. Reserve imaging for cases with neurological symptoms or failure to improve with initial management 2.
Primary Treatment: Physical Therapy
Stretching exercises performed by an experienced physical therapist achieve results approximately 2 months faster than parent-performed stretching alone 6:
- Begin manual cervical stretching immediately, targeting both rotation (goal ≥90°) and lateral flexion (goal: no side difference) 6
- Treatment by physical therapist is superior to parent-only stretching, particularly for achieving symmetric head posture 6
- Continue therapy until full range of motion is restored in both rotation and lateral flexion 6
Timing-Based Treatment Algorithm
If Diagnosed Before Age 1 Year:
- Initiate observation and physical therapy immediately 4, 3
- This approach is usually effective in most cases when started within the first year 4
- Exercise programs work best when: restriction of motion is <30 degrees and facial asymmetry is minimal or absent 7
If Diagnosed After Age 1 Year:
- Non-operative therapy is rarely successful after age 1 7
- Increased rate of surgical intervention required (sternocleidomastoid muscle lengthening) 4, 7
- Surgery may improve range of motion but not necessarily plagiocephaly or facial asymmetry 4
Critical finding: Torticollis persisting beyond age 1 year does not resolve spontaneously 7. This underscores the importance of early identification and intervention 3.
Pain Management (for Acute Presentations)
If the infant presents with apparent discomfort:
- NSAIDs (ibuprofen) as first-line for pain control and inflammation reduction 2
- Acetaminophen for additional pain relief during first 24-48 hours 1, 2
- Avoid benzodiazepines - not recommended for musculoskeletal pain in children 1, 2
- Apply heat therapy to affected area for 15-20 minutes, 3-4 times daily 1, 2
Adjunctive Treatments for Resistant Cases
- Botulinum toxin injection has shown effectiveness as an intermediate treatment for resistant congenital muscular torticollis 4
- Consider bracing in conjunction with physical therapy for select cases 4
Home Care Instructions
- Ensure proper positioning during rest and sleep to prevent symptom worsening 1, 2
- Limit activities requiring prolonged neck positioning 2
- Provide written discharge instructions as verbal instructions alone are poorly retained 2
Red Flags Requiring Urgent Re-evaluation
Return immediately if:
- Progressive neurological symptoms (weakness, numbness, tingling in extremities) 1, 2
- Signs of spinal cord compression 1, 2
- Worsening pain despite medication 2
- Development of new neurological symptoms 2
Prognosis and Long-term Outcomes
- Children treated during first year of life have significantly better results than those treated later 7
- Established facial asymmetry and >30 degrees limitation at treatment onset usually preclude good cosmetic results 7
- Approximately 31% of patients have noticeable cosmetic deformity at long-term follow-up, though functional abnormality is minimal 7