Congenital torticollis

You've just noticed that your baby always keeps his or her head tilted to one side. This can be a cause for concern. The prevalence of congenital torticollis varies among newborns depending on the study and diagnostic criteria.¹

• Congenital torticollis may be barely noticeable at rest, but the discomfort and reaction to movement vary from one baby to another¹
• Follow-up tends to be shorter when it begins early, although there is no specific timeframe that applies to every^{baby4, 5, 3}
• Pediatric physical therapy is one of the treatments recommended in clinical guidelines²
• What you do at home between sessions—such as tummy time—is part of the treatment

This guide will help you understand this condition, recognize the signs in your baby, and discover how physiotherapy can help. To learn more about our services, visit our page on pediatric physiotherapy.

What is congenital torticollis in infants?

Congenital muscular torticollis is an asymmetrical neck posture observed early in life. The head is often tilted to one side and turned toward the other; the evaluation determines whether there is also a restriction of the sternocleidomastoid (SCM) muscle, located on the side of the neck. The condition affects a variable proportion of newborns, depending on the study; it is one of the most common congenital musculoskeletal anomalies in infants.^{6, 7, 8, 1}

The SCM muscle extends from the bone behind the ear (the mastoid) to the clavicle and the sternum. Normally, this muscle allows the head to tilt to one side and turn to the other. Depending on the baby, a preferred position, restricted movement, or changes in the muscle may be observed; the evaluation distinguishes among these possibilities.

This posture may not be very bothersome when the baby is at rest, but some babies show signs of discomfort or protest when their neck is moved. Discomfort and reactions to movement vary from baby to baby. A movement that elicits a strong reaction should not be forced.

This condition may be present at birth or develop within the first few weeks of life. Physical therapy is part of the treatment plan once congenital muscular torticollis has been confirmed; the treatment plan and progress vary depending on the evaluation.

What are the three types of congenital torticollis?

Three forms are described: postural torticollis (a preferred position), muscular torticollis (a shortening of the muscle without a palpable mass), and torticollis with a nodule (a small lump in the muscle). The type is one of the factors that guide the treatment plan and follow-up evaluations; it does not, on its own, predict the course of the condition.^{5, 3} The proportion of the three forms varies from one study to another.^{5, 7} The observed form is part of the evaluation, but it does not, on its own, predict the duration of follow-up or the outcome.

Postural torticollis is the mildest form. The baby prefers to turn his or her head to one side but can still move it in the other direction. The plan may include a variety of awake positions and appropriate activities, and can then be reassessed based on the baby’s response.

Muscle-related torticollis involves an actual shortening of the muscle. The physical therapist may feel tension in the muscle during the evaluation, but there is no lump. The treatment plan may include active movements, postural exercises, and, if indicated, stretching exercises taught based on the findings of the examination.

Torticollis with a nodule (also called a pseudotumor) presents as a small mass in the neck muscle. A mass consistent with a muscle nodule may be observed early in life. Its size and progression are monitored; a mass that grows rapidly or an atypical presentation requires further medical evaluation.¹ Physical therapy may be recommended, with reassessment of mobility, posture, and the nodule throughout the course of follow-up.

The physiotherapist determines the type during the first evaluation to tailor the treatment plan to your baby's needs.

What are the causes of congenital torticollis?

The exact cause of congenital muscular torticollis often remains unknown. Factors related to pregnancy, birth, and positioning preferences are primarily associations or hypotheses; they do not establish the cause in an infant.^{9, 7, 1}

In some cases, no specific cause can be identified despite a thorough evaluation. The good news is that the next steps depend on the findings. Unusual symptoms may lead to a medical consultation or a referral to another professional.

How to recognize congenital torticollis in your baby?

Possible signs include frequently tilting the head to one side, a preference for looking in one direction, difficulty drinking from one side, a flattened skull, or uneven use of both hands.

• Always looks to the same side
• Often has their head tilted in their car seat
• Head always tilted to the same side
• Appears to have a flat spot on the back or side of their head
• Always uses the same hand to reach for toys or their mouth
• Dislikes tummy time
• Difficulty breastfeeding from one breast (always prefers the same side)

If you notice a persistent preference for a certain position, a tilted head, or difficulty turning the neck, a consultation with a pediatric physical therapist is recommended. An early evaluation allows for an assessment of range of motion, posture, and development, and can lead to appropriate intervention if the baby’s condition appears atypical.

Congenital torticollis may be accompanied by plagiocephaly, also known as flat head syndrome. Repeated pressure on the same side, among other factors, can contribute to cranial asymmetry.^{9, 10, 3} The shape of the skull, neck mobility, and positioning habits are evaluated together; no single position is sufficient to explain the asymmetry. You may also notice slight facial asymmetry or one ear that appears to protrude more than the other.

In cases of torticollis with a nodule, parents or the doctor may sometimes feel a small, firm lump in the neck muscle. A mass consistent with a muscle nodule can be monitored during treatment. A mass that grows rapidly, changes, or does not match the expected presentation requires further medical evaluation.

What is the link between torticollis and plagiocephaly (flat head syndrome)?

Torticollis may be accompanied by plagiocephaly, also known as flat head syndrome. Monitoring the neck can be combined with advice on positioning while the baby is awake; the progression of flat head syndrome varies from one baby to another.³

An infant's skull can change shape depending on how it is supported. A persistent preference for one side can contribute to asymmetry, along with other factors; neck mobility and skull shape are assessed separately.

1. Reduced neck mobility can contribute to a preference for one side
2. Repeated pressure on the same area can contribute to skull asymmetry
3. A persistent preference can maintain similar levels of support during certain periods of wakefulness
4. This preference may continue
5. Cranial asymmetry may then become more pronounced in some babies

The goal of this monitoring is to vary movements and positions while the baby is awake and to promote neck mobility. The skull's development is observed separately, without guaranteeing the shape it will take.

If your baby already has plagiocephaly, the physiotherapist will evaluate both conditions and adapt the exercise program accordingly.

Why is it important to treat congenital torticollis early?

Early intervention is generally associated with a shorter treatment duration. It also helps teach appropriate positions and movements. The duration of intervention varies widely, and there is no specific timeframe that applies to every baby.³

The key takeaway: Early assessment helps identify needs, but each person's progress is unique.

• An accurate assessment of whether neck mobility is limited
• Skull shape and positional preferences can be observed separately
• The engine speed and movements on both sides can be checked
• Unusual symptoms may lead to a doctor's visit or a referral to another specialist
• The plan is revised if the results do not match expectations

You do not need a doctor's referral to see a physical therapist in Quebec. As soon as you notice signs of torticollis in your baby, you can make an appointment directly. Direct access allows you to request an evaluation as soon as you have concerns about any asymmetry.

How does physiotherapy treat congenital torticollis?

Pediatric physical therapy may include active movements, positions that promote alertness, gentle stretching when indicated, and education for parents. The frequency and components of follow-up care are tailored to the baby’s mobility, development, the family’s goals, and the baby’s response.³

• Assessment of neck mobility (rotation and tilt)
• Measurement of neck muscle strength
• Observation of overall motor development
• Check of the neurological and visual systems
• Examination of skull shape (to check for a flat head)

A home exercise program can supplement your sessions when it is realistic for your family and well tolerated by the baby. The physical therapist will teach you:

• The specific activities to include, depending on the baby's schedule and tolerance
• Play positions that encourage development
• Strategies for breastfeeding or bottle-feeding
• Changes to make to the baby's environment

At Physioactif, we take the time to practice each exercise with you so that you feel confident and comfortable reproducing the techniques at home.

The at-home program complements the sessions. It should be realistic for your family and tailored to your baby’s response. The physical therapist will show you the exercises and adjust the program based on your baby’s progress.

What exercises can you do at home for baby torticollis?

Home exercises may include short periods of tummy time, stimulation of the non-preferred side, a variety of positions during wakeful periods, and gentle stretches taught by the physical therapist. The content and frequency of these exercises are tailored to the baby’s assessment and tolerance.

If the baby is crying loudly, refuses to turn his or her head, or if you notice a bump that is growing rapidly, talk to your doctor or physical therapist before continuing the exercises at home.

While the baby is awake and under direct supervision, tummy time can be tried in a position that the baby finds comfortable. The duration, frequency, and adjustments are determined based on the baby’s response and the family’s routine.

• Place your baby on your chest only when you are fully awake and watching over him or her
• While the baby is awake and only under direct supervision, support provided by a professional may sometimes be tried; no pillows or bolsters should be left with the baby while sleeping
• Place colorful toys in front of them
• Stay on the floor with them, at their eye level.
• Gradually increase the duration.

• Position yourself on the side where your baby has difficulty turning their head.
• Place toys, mobiles, and light sources on this side.
• When breastfeeding or bottle-feeding, alternate sides.
• Talk to your baby from this side to attract their gaze.

• During supervised wake time, vary the baby’s positions on the floor and in your arms according to the baby’s abilities; tummy time should only be done while the baby is awake and under supervision
• Vary the places where the baby plays on the floor during playtime, depending on the baby's tolerance and abilities
• Alternate the side of the room where the crib is located.
• For every nap, always put your baby to sleep on his or her back in a clear sleeping space; instead, vary the direction of stimulation while the baby is awake

The physical therapist will show you safe stretching techniques. These stretches should always be gentle—never forced. Do only the movements shown for your baby, and stop if there is a strong reaction, apparent pain, or an unusual change.

How long does congenital torticollis treatment last?

The duration depends on several factors, including the baby’s age at the start of follow-up, the type of torticollis, and the baby’s response. There is no specific timeframe that applies to all babies.³

The necessary monitoring varies from baby to baby. Assessments of mobility, posture, and activity guide adjustments, without comparing the child to others.

The first few sessions are used to choose a realistic program and identify the measures that will be reassessed. The timing and extent of the changes vary. The physical therapist regularly reassesses progress and adjusts the program as needed.

The frequency of visits is reassessed based on the baby’s mobility, posture, activities, response, and the family’s ability to follow the plan.

When is surgery necessary for congenital torticollis?

Surgery is considered in certain persistent cases, following a specialized evaluation. The decision depends on the clinical presentation and is not based on a universal six-month threshold.^{5, 2}

• A significant limitation that persists despite treatment may lead to a discussion about surgery.
• If a patient's condition does not align with the initial diagnosis, a medical reevaluation is required first.¹
• Any lump or unusual asymmetry requires a specialist evaluation first.
• After the examination, the medical team discusses the appropriateness of surgery with the family.

The surgery generally involves releasing or lengthening the neck muscle. The choice of technique depends on a specialist evaluation.³ After surgery, the medical team will determine whether physical therapy is recommended and advise on appropriate movements and precautions.

Treatment usually begins with conservative measures.^{9, 5} If significant impairment persists or if the clinical picture is atypical, a specialized team discusses other options with the family.

What should you do if you suspect your baby has torticollis?

If you are concerned about your posture or neck movements, an evaluation can help clarify the situation. See a doctor right away if the asymmetry appears suddenly, seems painful, follows an injury, or is accompanied by fever, weakness, unusual eye movements, or a loss of motor skills.

At Physioactif, our pediatric physical therapy team gently evaluates your baby and supports you every step of the way. We practice the exercises with you so you can do them at home.

You do not need a doctor's prescription to make an appointment.

References

The following references provide information on congenital torticollis, its management, and positioning recommendations.

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1. Gundrathi J, Cunha B, Tiwari V, Mendez MD. Congenital Torticollis. [Updated March 20, 2024]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026. (Back to sections: 1, 2, 3, 4, 5, 6)
2. Sargent B, Coulter C, Cannoy J, Kaplan SL. 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. Pediatr Phys Ther. 2024;36(4):370-421. (Back to sections: 1, 2, 3)
3. Kaplan SL, Coulter C, Sargent B. Physical Therapy Management of Congenital Muscular Torticollis: A 2018 Evidence-Based Clinical Practice Guideline From the APTA Academy of Pediatric Physical Therapy. Pediatr Phys Ther. 2018;30(4):240-290. (Back to sections: 1, 2, 3, 4, 5, 6, 7, 8, 9)
4. Petronic I, Brdar R, Cirovic D, Nikolic D, Lukac M, Janic D, et al. Congenital muscular torticollis in children: distribution, treatment duration, and outcome. Eur J Phys Rehabil Med. 2010;46(2):153-7. (Back to section: 1)
5. Cheng JC, Wong MW, Tang SP, Chen TM, Shum SL, Wong EM. Clinical determinants of the outcome of manual stretching in the treatment of congenital muscular torticollis in infants. A prospective study of 821 cases. J Bone Joint Surg Am. 2001;83(5):679-87. (Back to sections: 1, 2, 3, 4, 5)
6. Chen MM, Chang HC, Hsieh CF, Yen MF, Chen TH. Predictive model for congenital muscular torticollis: analysis of 1,021 infants using ultrasound. Arch Phys Med Rehabil. 2005;86(11):2199-203. (Back to section: 1)
7. Cheng JC, Au AW. Infantile torticollis: a review of 624 cases. J Pediatr Orthop. 1994;14(6):802-8. (Back to sections: 1, 2, 3)
8. Antares JB, Jones MA, Chak NTN, Chi Y, Li H, Li M, et al. Efficacy of non-surgical, non-pharmacological treatments for congenital muscular torticollis: a systematic review and meta-analysis. BMC Musculoskelet Disord. 2025;26(1):178. (Back to section: 1)
9. Kuo AA, Tritasavit S, Graham JM. Congenital muscular torticollis and positional plagiocephaly. Pediatr Rev. 2014;35(2):79-87; quiz 87. (Back to sections: 1, 2, 3)
10. Rogers GF, Oh AK, Mulliken JB. The role of congenital muscular torticollis in the development of deformational plagiocephaly. Plast Reconstr Surg. 2009;123(2):643-652. (Back to section: 1)
11. Choose PT. Guide | Physical Therapy Guide to Torticollis. 2022.
12. French National Health Authority. Preventing plagiocephaly without increasing the risk of sudden infant death.