What every family should know

Congenital muscular torticollis

What is congenital muscular torticollis (CMT)?

Congenital muscular torticollis (CMT) is a postural disorder of the neck caused by one-sided shortening or an imbalance in the sternocleidomastoid muscle (SCM), the muscle that allows the head to turn and tilt.

Clinically, CMT is characterised by the baby's head being tilted towards the affected side (the ear moves closer to the shoulder) while the chin is turned towards the opposite side.

In some cases, this tightness comes with a small benign fibrous lump or nodule in the SCM muscle (fibromatosis colli).

It is one of the most common musculoskeletal conditions in infants.

Baby lying on their back on a light-coloured blanket, with their head tilted to one side.
Illustrative image.

Causes and risk factors

The exact cause of CMT is multifactorial. Several prenatal, intrauterine and birth factors are closely linked to its onset:

Intrauterine and positional factors

  • Feeling of being ‘trapped’ (stuck baby): The mother's perception that the baby stayed fixed in the same position in the womb during the last 6 weeks of pregnancy.
  • Footling or breech presentation.
  • Multiple pregnancies.

Birth and newborn factors

  • First-time mothers (primiparity).
  • Assisted or difficult delivery: Use of forceps or vacuum extraction (ventouse) during birth.
  • Maternal perineal trauma.
  • Babies of greater body length (+51 cm) or macrosomic babies.
  • Low birth weight.
  • History of neonatal abstinence syndrome (NAS).
  • Pre-existing craniofacial asymmetry or plagiocephaly at birth: Increases the risk of ultrasound abnormalities in the SCM muscle by up to 22 times.

Signs of CMT: how can you spot it at home?

Families are the first to observe their baby's development. You may suspect CMT if you notice one or more of the following signs:

  1. Fixed positional preference

    The baby always looks to the same side (e.g. always to the right) or turns their head towards the other side with great difficulty.

  2. Usual head posture

    The head stays tilted towards one shoulder while the chin points towards the opposite shoulder.

  3. A nodule or lump in the neck

    A small nodule or firm muscle thickening (benign and painless) can be felt on the side of the neck.

  4. Difficulties with feeding

    The baby cries, becomes unsettled or refuses the breast when placed on one particular side, or shows a clear preference for taking the bottle in only one position.

  5. Asymmetrical neck folds

    The skin folds on the side/front of the neck are deeper and more marked on the affected side.

  6. Flattening of the head (plagiocephaly)

    A flat area can be seen at the back or side of the skull from constantly resting on that side.

What should I do if I notice signs?

If you notice any of these signs, it is essential to act quickly:

Immediate consultation

Book a paediatric physiotherapy assessment directly. If anything points to another cause, I will tell you and point you towards the right person.

Do not wait for it to ‘go away on its own’

Scientific evidence shows that CMT does not resolve spontaneously, nor does it improve with just 1 or 2 one-off tips.

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Possible problems associated with CMT

If torticollis is not addressed properly and in good time, the lack of mobility and the muscle imbalance can trigger secondary problems:

  • Positional plagiocephaly and brachycephaly In up to 90% of cases, CMT is associated with flattening of the skull.
  • Facial and jaw asymmetry
  • Delay in motor development milestones Because neck movement is restricted, babies with CMT have a higher risk of temporary motor delays at 2 and 6 months.
  • Postural compensations Permanent elevation of the affected shoulder, trunk imbalances and pelvic tilts.
  • Other coexisting conditions CMT often occurs alongside developmental dysplasia of the hip (DDH), brachial plexus injuries or gastro-oesophageal reflux (GOR).
  • Long-term bone changes

The importance of early diagnosis and the role of paediatric physiotherapy

How early treatment starts is the most decisive prognostic factor in how CMT progresses:

The impact of time

Treatment started before the 1st month of life

Achieves up to 99% full recovery with an average treatment time of only 1.5 months.

Treatment started between the 1st and 3rd month

The success rate drops to 89% and the average length of treatment extends to 6 months.

Treatment started between 3 and 6 months

Good outcomes fall to 62%, requiring an average of 7 months of intervention.

Treatment started after 6 months

Only 19% achieve an optimal recovery, needing 9 months or more of therapy.

In addition, starting physiotherapy early drastically reduces the risk of needing invasive interventions in the future, such as botulinum toxin injections or surgery (SCM tenotomy).

Source

Sargent, B., Coulter, C., Cannoy, J., & Kaplan, S. L. (2024). Physical therapy management of congenital muscular torticollis: A 2024 evidence-based clinical practice guideline from the American Physical Therapy Association Academy of Pediatric Physical Therapy. Pediatric Physical Therapy, 36(4), 370–421. https://doi.org/10.1097/PEP.0000000000001114

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