Congenital Muscular Torticollis (CMT) is a postural deformity of the neck evident at birth or shortly thereafter, characterized by a preferential head tilt to one side and rotation to the opposite side. This condition is primarily attributed to unilateral tightness and/or shortening of the sternocleidomastoid (SCM) muscle. CMT is one of the most common musculoskeletal conditions in infancy, with an incidence estimated to be between 0.3% and 16%, showing a notable increase in recent decades. Factors contributing to its development include intrauterine constraint, birth trauma, and a predisposition to SCM fibrosis.
The clinical presentation typically involves the infant holding their head tilted towards the affected SCM and rotated away from it. For example, a shortened right SCM would result in a right head tilt and left rotation preference. Associated conditions often include plagiocephaly (flattening of the skull on one side), facial asymmetry, and potential delays in gross motor development due to asymmetric head control and weight-bearing. Early identification and intervention are paramount to achieving optimal outcomes, preventing secondary complications, and minimizing the need for more invasive treatments.
Physical therapy, with a strong emphasis on therapeutic stretching and strengthening, is the cornerstone of conservative management for CMT. The primary goal of treatment is to restore full, symmetrical passive and active cervical range of motion (ROM), achieve symmetrical strength, promote age-appropriate motor development, and resolve any associated compensatory patterns or secondary deformities. This guide outlines a structured, phased approach to torticollis stretching, integrating evidence-based principles for clinicians.
Understanding the functional anatomy of the neck musculature is critical for effective intervention in CMT. The sternocleidomastoid (SCM) muscle is the primary muscle implicated in torticollis. It is a large, superficial muscle that extends from the sternum and clavicle to the mastoid process of the temporal bone and the lateral half of the superior nuchal line of the occipital bone.
In CMT, the SCM muscle on one side becomes shortened and fibrotic, leading to the characteristic head tilt and rotational preference. For instance, tightness in the right SCM causes the head to tilt to the right (ipsilateral lateral flexion) and rotate to the left (contralateral rotation). This sustained asymmetrical posture can lead to adaptive shortening of other cervical extensors and rotators on the affected side and elongation/weakness of their antagonists on the contralateral side.
While the SCM is the primary focus, other cervical muscles can be involved secondarily or contribute to compensatory patterns. These include the scalenes, upper trapezius, splenius capitis, and semispinalis capitis. A comprehensive assessment considers the interplay of these muscles and their impact on overall cervical mobility and function.
Rehabilitation for torticollis stretching follows a progressive, phased approach, adapting to the infant's age, severity of tightness, and developmental stage. Consistency and parental adherence to the home exercise program are crucial for success.
This phase focuses on thorough assessment, parent education, and gentle, caregiver-performed passive stretching.
Stretches should be performed gently, slowly, and within the infant's comfort range. Never force a stretch or cause pain.
As passive ROM improves, the focus shifts to encouraging active head movements and strengthening the neck and trunk muscles.
This phase integrates symmetrical head and neck control into functional movements and addresses any lingering motor delays.
The final phase focuses on ensuring sustained correction and preparing for discharge from physical therapy services.
The efficacy of physical therapy, particularly early intervention with stretching and strengthening, for CMT is well-supported by robust clinical evidence and systematic reviews. The American Physical Therapy Association (APTA) published clinical practice guidelines for CMT, which strongly advocate for conservative management as the first line of treatment. These guidelines emphasize the importance of early referral (ideally before 1 month of age), parent education, and a comprehensive home exercise program.
Research consistently shows that infants who begin physical therapy before 3 months of age have significantly shorter treatment durations and higher success rates (often exceeding 90-95%) compared to those who initiate treatment later. Delayed intervention (beyond 6 months) is associated with increased treatment duration, higher likelihood of needing adjunctive therapies, and in some refractory cases, surgical intervention (SCM release). Adherence to the prescribed home exercise program, particularly the stretching regimen, is a critical predictor of successful outcomes.
While stretching targets the restricted SCM, concomitant strengthening activities are vital for establishing active head control and preventing recurrence. Studies also highlight the importance of addressing associated conditions like plagiocephaly, emphasizing a holistic approach to care. Ongoing research continues to refine best practices, including optimal stretching parameters, use of adjunct modalities, and long-term outcomes for children with CMT.