Physical Therapy Guide to Torticollis
Torticollis is a condition that occurs when the muscle that runs from the breastbone and collarbone up and toward the back of the neck becomes tight, weakened, or thickened, causing the chin to point toward one shoulder, while the head tilts toward the opposite shoulder. The most common form of the condition is congenital muscular torticollis (CMT), which affects infants and is generally observed within the first 2 months of life.
In 1992, the American Academy of Pediatrics began its "Back to Sleep" campaign to reduce Sudden Infant Death Syndrome (SIDS). The campaign successfully decreased SIDS by 40% in the United States, but it had an unintended result of contributing to the development of CMT in approximately 1 in every 250 infants. (Talk to your family physician and/or pediatrician if you have questions about the "Back to Sleep" campaign.)
Torticollis also can occur in adults. Head tilt in children or adults also can accompany other symptoms of more serious conditions.
If symptoms such as trouble breathing or swallowing, weakness in the arms or legs, impaired speech, difficulty walking, a pins-and-needles feeling or numbness in the arms or legs, or urinary or fecal incontinence accompany the head tilt, seek immediate medical attention.
What is Torticollis?
Torticollis is the tilt and/or rotation of the head because of tight and weak neck muscles. It occurs when the muscle that runs up and toward the back of the neck (the sternocleidomastoid muscle) becomes tight, weakened, or thickened. There are 5 forms of the condition:
- Congenital muscular torticollis (CMT) is the most common form of the condition. It affects infants and is generally diagnosed within the first 2 months of life. CMT is often caused by birth trauma, or by sleeping or remaining in 1 position for a prolonged period of time.
- Postural torticollis is diagnosed when the infant’s head tilt comes and goes. It is diagnosed within the first 5 months of life and often is the result of a lack of a variety of positions, such as when the child is consistently placed in a car seat or other baby “container” for extended periods of time.
- Ocular torticollis is caused by a vision problem in one eye, causing the individual to tilt his or her head to see better.
- Spasmodic torticollis (wryneck) occurs in older children and adults. It can be caused by infection, inflammation, trauma, or the side effects of certain medications and/or drugs, such as amphetamines.
- Acute torticollis occurs when a child or adult bends or twists the neck too far, or experiences some type of trauma. There may be pain when the head is moved from side to side or up and down; the neck muscle may be tender to touch.
Abnormalities associated with torticollis include:
- Osseous abnormalities, caused by improper alignment of the cervical spine (at the spinal points C1-C2) when ligaments are damaged due to an infection. The types of infection that can cause this condition include severe upper respiratory, ear, or sinus infections; cervical adenitis; or cervical abscess. Any inflammatory process that irritates the muscles, nerves, or vertebrae—including surgery or trauma—can produce a reflex spasm resulting in this form of torticollis.
- Neurogenic abnormalities, such as a spinal cord tumor or progressive spinal cord diseases, which can cause an acute episode of torticollis, usually in older children. Children may experience headaches, vomiting, and positive neurological signs, like limb weakness (either one side or both sides) and speech difficulties. Seek immediate medical attention if any of these symptoms occur.
Torticollis may lead to additional problems, such as:
- Flattening of the skull (plagiocephaly or brachycephaly) in infants.
- Movement that favors one side of the body, affecting the arms, trunk, and hips. This can lead to strength imbalances, such as an elevated shoulder and side-bending of the trunk. This movement pattern can lead to delayed gross motor development.
- Developmental hip dysplasia.
- Limited ability to turn the head to see, hear, and interact with surroundings, which can lead to delayed cognitive development.
- Delayed body awareness or lack of self-awareness and interaction.
- Difficulty with balance.
- Asymmetrical vision changes.
Signs and Symptoms
An infant, child, or adult with torticollis may keep the head tilted and toward one side of the body and rotated to the other side of the body, as attempting to straighten the neck is difficult or painful. For example, if the muscle on the left side of the neck is shortened, weak, or in spasm, the head may tilt toward the left shoulder and rotate toward the right.
There may be tightness in the neck or a noticeable lump in the neck muscle called a pseudotumor. Pain may or may not be present, depending on the type of torticollis involved.
How Is It Diagnosed?
Torticollis in adults is generally diagnosed by a physician. Experienced pediatric physical therapists may diagnose the need for treatment of congenital muscular torticollis and positional torticollis in infants and children; however, most states in the United States require a prescription from a physician in order for the physical therapist to provide treatment.
Once the type of torticollis is determined, your physical therapist can provide treatment. In most cases, torticollis is a muscular problem, and physical therapists are musculoskeletal experts.
How Can a Physical Therapist Help?
Regardless of the patient’s age, physical therapy is the primary treatment for all forms of torticollis. Physical therapists provide treatment to address the impairments caused by torticollis. Early treatment produces the best outcomes. If not treated, torticollis can become a permanent condition.
The physical therapist will work with a child’s caregiver or an adult patient to develop and reach mutual goals. The physical therapist will design an individualized treatment plan to:
- Strengthen neck muscles
- Correct muscle imbalance
- Gain pain-free movement (range of motion)
- Improve postural control and symmetry
- Improve the body’s alignment by easing muscle tension
These goals may be achieved through:
- Gentle stretching of the neck and back muscles
- Strengthening of the neck and back muscles
- Massage of the affected area
- Guidance for correct positioning of infants
- Taping to elongate the muscles to facilitate stretching
- A home-exercise program to continue gentle rehabilitation at home
Real Life Experiences
Ben is a 4-month-old infant who was born at full-term. Ben’s mom has noticed that since his birth, Ben seems to only like to look to the left with his head tilted to the right. She notices his position never changes in family photos. She decides to ask Ben’s pediatrician about it at his next well-child checkup.
At the checkup, Ben’s pediatrician identifies Ben as having congenital muscular torticollis caused by a traumatic childbirth, and refers him and his mom to a local pediatric physical therapist for an evaluation and treatment.
Ben’s physical therapist asks his mom questions about her pregnancy, his birth, how he sleeps and eats, and his favorite positions at home. Ben’s mom reports that he is her first child, and the pregnancy and birth were uneventful. She says he sleeps well, but prefers to only chew food on one side of his mouth. Ben does not like tummy time and prefers to look only to the left.
Ben’s physical therapist conducts a thorough evaluation, looking at his neck rotation, his trunk, and his positioning on his back, his tummy, on his side, and sitting up. He also examines Ben’s head shape. The physical therapist agrees with the physician that Ben has right torticollis, indicated by the right tilt of his neck and his preference to look left.
The physical therapist begins treatment with gentle stretching of Ben’s neck; he teaches his mom how to position and hold him to help stretch his neck. He also begins to help Ben start to look to the right, using lights and sounds to his right that make him want to look in that direction. The physical therapist teaches Ben’s mom to complete some positioning and stretching exercises at home, multiple times per day, to help stretch his neck. He also encourages her to position Ben so he has to turn to the right in order to see what his family is doing, or to look at toys.
Ben’s physical therapy treatments consist of weekly visits to the physical therapist, who helps him stretch out his neck and look to the right. He also encourages his movement with fun tummy time, rolling, and sitting up. His focus is on stretching and strengthening the neck muscles.
After a few weeks of treatment, Ben’s mom reports that he can look to the right more and he is holding his head up straighter to look forward. His physical therapist treats Ben weekly for another 2 months to help him and his mom continue to improve his head position and gross motor skills, and advance his home-exercise program.
After 2 more months of treatment, Ben only has to see his physical therapist once a month to ensure that his neck continues to remain stretched and that he holds his head straight, as he progresses through crawling and creeping.
When Ben is 8-months old, he is discharged from physical therapy, thanks to his mom’s faithful completion of his stretching and positioning program at home. She is proud to report that Ben is a happy, healthy baby who now gets compliments about his alert behavior and straight posture!
This story was based on a real-life case. Your case may be different. Your physical therapist will tailor a treatment program to your specific case.
What Kind of Physical Therapist Do I Need?
All physical therapists are prepared through education and experience to treat a variety of conditions, including torticollis. However, you may want to consider:
- A physical therapist who is experienced in treating individuals with torticollis.
- A pediatric physical therapist for a child who is affected by the condition.
- A physical therapist who is a board-certified clinical specialist or who has completed training in pediatric or neurologic physical therapy. This type of physical therapist has advanced knowledge, experience, and skills that may apply to your condition.
You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.
General tips when you are looking for a physical therapist (or any other health care provider):
- Get recommendations from family and friends or from other health care providers.
- When you contact a physical therapy clinic for an appointment, ask about the physical therapist’s experience in helping people who have torticollis.
- During your first visit with the physical therapist, be prepared to describe your or your child’s symptoms in as much detail as possible, including what makes the symptoms worse.
The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and prepare them for a visit with their health care provider.
The following articles provide some of the best scientific evidence related to physical therapy treatment of torticollis. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.
American Physical Therapy Association. Guide to Physical Therapist Practice 3.0. Accessed October 2, 2018.
Stringer H. PTs offer hope for treating flat head syndrome in babies. Today in PT. June 7, 2010:30–31. (Article summary is not available.)
Gray GM, Tasso KH. Differential diagnosis of torticollis: a case report. Pediatr Phys Ther. 2009;21:369–374. Article Summary in PubMed.
Ohman AM, Beckung ER. Reference values for range of motion and muscle function of the neck in infants. Pediatr Phys Ther. 2008;20:53-58. Article Summary in PubMed.
Freed SS, Coulter-O’Berry C. Identification and treatment of congenital muscular torticollis in infants. J Prosthet Orthot. 2004;16:S18–S23. (Article summary is not available.)
Mezue WC, Taha ZM, Bashir EM. Fever and acquired torticollis in hospitalized children. J Laryngol Otol. 2002;116:280-284. Article Summary in PubMed.
Long T, Tascano K. Handbook of Pediatric Physical Therapy. 2nd ed. Baltimore, MD: Lippincott Williams and Wilkins; 2002.
*PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.
Revised by Heidi Nelson, PT, DPT, and board-certified pediatric clinical specialist. Authored by Judy Lindsay, PT. Reviewed by the editorial board.