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Torticollis is a postural abnormality of the neck leading to head tilt, flexion, and rotation. It can occur in people of all ages, from the newborn to adults. Classically, torticollis is categorized as congenital or acquired. Congenital muscular torticollis (CMT) is the most common form.

A newer classification proposed in 2012 uses non-paroxysmal (nondynamic) and paroxysmal (dynamic) torticollis as the two main categories.1


  • Non-paroxysmal or nondynamic torticollis1
    • CMT
    • Osseous torticollis including Arnold Chiari malformation, Klippel-Feil Syndrome and hemivertebrae
    • Central and peripheral nervous system torticollis
    • Ocular torticollis
    • Non-muscular, soft tissue torticollis including unilateral congenital sternocleidomastoid (SCM) absence
  • Paroxysmal or dynamic torticollis1
    • Benign paroxysmal torticollis
    • Spasmodic (cervical dystonia)
    • Sandifer syndrome induced torticollis secondary to gastroesophageal reflux
    • Drug-induced torticollis
    • Increased intracranial pressure-induced torticollis
    • Torticollis secondary to conversion disorder

Epidemiology including risk factors and primary prevention

  • CMT
    • Incidence: 0.3% to 2%.1
    • Predilections: Right, male (3:2), first-born, breech, and singleton delivery2
    • Risk factors include intrauterine malposition and complicated labor and delivery.


The patho-anatomy and pathophysiology behind torticollis is dependent on the primary etiology. In CMT, there is unilateral shortening of the sternocleidomastoid muscle.35 In some cases, shortening is due to a well-circumscribed “tumor” in the inferior one-third of the affected SCM due to a hematoma or a fibroma. As the tumor shrinks, the sternocleidomastoid (SCM) shortens, tilting the head toward and rotating the chin away from the affected SCM.

In general, disruption of arterial or neural supply to the SCM or trapezius can result in torticollis.1 For example, during an acute infection, muscle spasms or referred pain can lead to abnormal head positioning.

Another common cause of torticollis is from atlantoaxial rotary subluxation (AARS). Retropharyngeal edema is thought to cause laxity of the atlantoaxial ligaments. Laxity of these ligaments allows for subluxation of the facets of C1 and C2 causing abnormal tilt and rotation of the head.

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

  • Age of presentation1
    • CMT: By 6 weeks of age.
    • Older age of onset suggests other acquired conditions.
  • 50-70% of SCM tumors resolve spontaneously by one year old with minimal deficits.2
  • Resolution rates by 12 months old with conservative management (manual stretching, home exercise and positioning program) range from 70-97%.3
  • Early identification and treatment is associated with better outcomes and shorter treatment times.4
  • 9 to 21% with CMT require surgery, especially if there is concomitant osseous abnormalities or if CMT persists past 1 year of age.3
  • Long-term development of craniofacial and postural deformities in children with untreated or inadequately treated CMT have been described.5,

Specific secondary or associated conditions and complications

  • Craniofacial defects: 80% of cases, improves if treated early.6
  • Scoliosis: Commonly associated with genetic syndromes with bony abnormalities (Klippel-Feil and Larsen). Late-onset, asymptomatic thoracic scoliosis (8-13 degrees) in CMT also described.
  • Hip dysplasia: 2 to 20% incidence versus 2% in general population.1
  • Motor developmental delay and disorders of attention, coordination, language and affect: In a cohort of 38 children ages 7 and 8 years with history of CMT, 14 (37.8%) were diagnosed with ADHD, 1 with autism spectrum disorder, 5 (15.5%) with definite motor problems (defined as scores < 5th percentile on Movement Assessment Battery for Children or the Bruininks-Oseretsky Test).7 Alberta Infant Motor Scores were found to be lower in infants with CMT (n=82) versus healthy controls (n=40) at 2 and 6 months. Reason remains unclear, but authors speculate impaired midline posture results in asymmetrical development of sensory frame of reference for perception and action.8 In another study of 54 children with CMT with an average age of 8.5 months, the Peabody developmental motor scales-second edition was used to evaluate subjects motor development. Results showed motor developmental delay in 37% of children with CMT, affecting gross motor to a greater degree than fine motor.9

Essentials of Assessment


To help identify the etiology of the torticollis, obtain information in the following areas

  • Age of onset.
  • History of onset: Acute or insidious, trauma, fever, vomiting, neurologic deficits, exposure to medications.
  • Laterality of involvement
    • CMT – Right more common, head tilted toward and chin rotated away from affected SCM.
    • AARS- Head tilted away from and chin rotated toward affected SCM.
  • Aggravating activities
    • Supine positioning: Sandifer syndrome.
    • Neck extension: Juvenile idiopathic arthritis and AARS.
  • Associated Symptoms
    • Posterior fossa tumor: Increased intracranial pressure signs (vomiting, progressive headache, diplopia), balance/coordination problems.
    • Brachial plexus palsy: Unilateral arm weakness, pain and/or numbness, +/- unilateral ptosis.
    • Infection: Neck tenderness, fever, irritability, dysphagia, drooling, odynophagia, and respiratory distress.
    • Sandifer syndrome: Regurgitation, vomiting, hematemesis, anorexia, failure to thrive, asthma, chronic cough and/or hoarseness.
  • Time spent in prone while awake.
  • Prenatal and birth history.
  • Feeding history.
  • Developmental history.
  • Family history on past interventions and response will aid treatment planning.

Physical examination

  • Inspection: Head/neck posture, pharynx, plagiocephaly, facial dysmorphism, scoliosis, metatarsus adductus, and clubfoot can be associated with CMT.
  • Palpation: Tenderness or spasms of paracervical and trapezius muscles or spinous processes, thickening or mass of the SCM or trapezius, vertebral deformity, lymph nodes.
  • Cervical range of motion (ROM): Average passive range of motion in infants is 110° (100° to 120°) rotation and 70° lateral flexion (65° to 75°).10
  • Hip exam: Asymmetry in gluteal folds, ROM, Barlow, Ortolani, Galeazzi maneuvers.
  • Postural assessment: Compensatory scoliosis with attempts at head righting
  • Neurologic: Visual and auditory fixation and tracking, fundi for papilledema, cranial nerves, sensory testing, tone, and reflexes.
  • Functional strength testing: Consider symmetry and compensatory movements.

Functional assessment

  • Age-appropriate motor skills (rolling, hand dexterity and dominance).
  • Muscle Function Scale (MFS): scale of infant’s head righting response using the lateral neck flexors. Infant initially held in a vertical position, then lowered to horizontal position with head position (both sides) sustained for > 5 seconds. Scored 0 to 6 on each side, with higher numbers indicating better muscle function and therefore a better righting response. 
    • Head held below horizontal line.
    • Head held on horizontal line.
    • Head held slightly over horizontal line.
    • Head held high over horizontal line but <45°. Head held high over horizontal line and >45°.
    • Head held very high.

Mean MFS for children <1 year old:10

AgeMFS meanMFS range
2 months1.00-2
4 months2.61-4
6 months3.02-4
10 months3.43-4

Laboratory studies

  • Differential blood count +/- rapid streptococcal test if infection suspected.
  • Karyotype testing for trisomy 21, if indicated based on history of dysmorphism.
  • Genetic testing (sequence, deletion/duplication analysis) to check for GDF 6 or 3 mutations in Klippel-Feil syndrome, as needed based on history and exam.


Newborn and Infants

  • In CMT, ultrasound (US) of SCM is the study of choice to evaluate muscle fibrosis and monitor for resolution with intervention.11The following grading scale can be used.13
    • Grade 1: Increased SCM thickness
    • Grade 2: Well-demarcated heteroechoic region
    • Grade 3: Diffuse hyperechoic fibrous mass
  • Cervical spine radiographs (anteroposterior and lateral views): C1-C2 subluxation or congenital bony abnormalities but low yield (< 1%).1
  • Routine MRI in CMT is not recommended.
  • If hip exam normal, routine hip US in CMT is not recommended.14
  • No clear diagnostic guidelines are available for Sandifer syndrome. Barium swallow test may be considered for suspected cases.

Older Children and Adolescents

  • With trauma, cervical radiographs (anteroposterior and lateral views) are the first line. Add open-mouth odontoid view if AARS is suspected. Dynamic CT is useful in assessing C1-C2 rotation in different positions of neck rotation. If cervical CT is positive, cervical MRI/MRA is obtained to check for spinal cord, ligamentous, and vascular injuries.15
  • Without trauma, CT of the neck is obtained. If CT negative, brain and cervical spine MRI is obtained to evaluate for central nervous system (CNS) tumor, lesion, or infection such as diskitis.15

Supplemental assessment tools

  • Arthrodial protractor: Cervical lateral flexion and rotation.10
  • Plagiocephaly anthropometrics
    • Cranial vault asymmetry: Difference between diagonal (frontozygomaticus to opposite eurion) caliper measures; normal < 3 mm, mild/moderate ≤ 12 mm, moderate/severe >12 mm.16
    • Cranial vault asymmetry index: Difference in cranial diagonal diameter/longer cranial diagonal x 100; significant if >3.5%.

Early predictions of outcomes


  • Early treatment: if < 4 months of age; the average length of treatment was only 3.2 months and none required surgery.17
  • Initial deficit in rotation >15°, birth difficulties, presence of SCM tumor (especially if on the right) were associated with longer treatment duration.6
  • Severity of SCM fibrosis on US correlate with treatment duration and resolution.16,18
  • MFS scores and age of initiation of treatment had significant influence on treatment time in 33 infants. ROM deficits, plagiocephaly and gender had no effect.19
  • Deformation of the cervical spine may start as early as 8 months and increases with age and severity of fibrosis when untreated.20

Sandifer Syndrome

  • Responds to anti-reflux medications, upper body elevation when sleeping.

Benign Paroxysmal Torticollis

  • Usually self-limited (resolves by 3 years).
  • May be associated with migraine later in course21


Ask parents about

  • Sleeping position
  • Feeding set-up
  • Crib positioning
  • Car seat location

Social role and social support system

Physicians should inquire about home and social situations that could impact counseling and treatment outcomes. The number of members in the household, their level of understanding, typical daily routine of the caregiver/child, and the type of care setting (home versus day care) that is available should be considered.

Rehabilitation Management and Treatments

Available or current treatment guidelines

Currently, no standard guidelines exist for the treatment of torticollis. Treatment is largely based on best practice recommendations. Christensen and van Vlimmeren proposed conservative treatment algorithms for CMT.19,22 In 2018, the Academy of Pediatric Physical Therapy published an updated evidence based clinical practice guideline to address education for prevention, referral, screening, examination, prognosis and treatment.23

At different disease stages

CMT in < 1 year of age

  • Physical therapy and parental education
    • Early (< 4 months old) initiation of physical therapy is best. Passive stretching exercise protocols varied, with hold times ranging from 10 to 30 seconds and repetitions ranging from 3 to 40.6,13,17,24 One study showed that stretching for ten reps of 10 to 15 seconds for 10 sessions per day (100 stretches per day) was more effective at improving head tilt and cervical passive range of motion than at 5 sessions daily (50 stretches daily) over an 8-week period.25
    • By 6 to 8 months of age, infants may not tolerate passive stretching. Facilitation of active movements of the unaffected SCM, utilizing righting reactions, may be a good alternative.3
    • Massage and myofascial release.3
    • Kinesiology taping.12
    • Therapy frequencies ranges from 5 times/week to monthly.6,13,17,24
    • Handling, positioning, and exercises at home.1,19,22,24
    • Ultrasound diathermy with microcurrent therapy may decrease SCM thickness and improve therapeutic exercise efficiency and cervical range of motion.32
  • Orthoses
    • Tubular orthosis for torticollis (TOT) collar: Adjunct for >4.5 months old, >6° head tilt; worn during waking hours.22,25 TOT collar is approved for use in torticollis by the Food and Drug Administration (FDA).26
    • Custom cranial orthosis for plagiocephaly.
  • Botulinum toxin chemodenervation
    • Botulinum toxin Type A injections to SCM or upper trapezius may be considered for those who failed with exercises and TOT collar use.
      • Oleszek et al used 100 units in 0.5mL dilution, weight and age-based dosing.27
    • A 2020 meta-analysis found an 84% effective rate of botulinum toxin for CMT with surgical conversion rate of 9% and adverse reaction rate of 1%, most commonly injection site irritation and transient dysphagia.28
    • Another study published in 2023 found a 61% effective rate of botulinum toxin for refractory CMT with just under a 3% surgical conversion rate. Success was measured by whether the child could actively achieve 45° of lateral cervical flexion and 80° of cervical rotation post injection.34

CMT in >/=1 year old

  • Surgical indications
    • ≥ 6 months of conservative management.
    • Residual deficits in cervical rotation and lateral flexion >15°.
    • Tight band/tumor.
  • Surgical procedures
    • Distal unipolar lengthening works well for most.3
    • Bipolar/tripolar lengthening (distal and proximal).37
    • Z lengthening.
    • Radical resection.

Other causes1

  • Atlantoaxial rotary subluxation
    • Acute (< 1 week) and less severe – Soft cervical collar, rest, analgesics +/- diazepam or muscle relaxants.
    • Severe – Cervical traction, surgery.
  • Retropharyngeal abscess: Antibiotics (2nd or 3rd generation cephalosporins), NSAIDs, surgery if no improvement within 24 hours.
  • Primary cervical dystonia: Oral anticholinergics (i.e., trihexyphenidyl), clonazepam and other benzodiazepines, baclofen, botulinum toxin injections, deep brain stimulation for intractable cases.
  • Sandifer syndrome: Anti-reflux medication (proton pump inhibitors), head elevation during sleep, surgical fundoplication.
  •  Drug induced torticollis: Treat initially with diphenhydramine.

*No randomized clinical trials (RCT) with long-term follow-up found in the literature.

Coordination of care

CMT is ideally managed on an outpatient basis with coordination of care between the treating therapist and pediatric physiatrist. If trial of conservative management fails, discussion with a plastic surgeon or otolaryngologist regarding potential surgical intervention is recommended.

Patient & family education

  • Proper stretching techniques.
  • Positioning and handling skills incorporated into daily routine:
    • Feeding: Food or bottle presented to side of affected SCM to facilitate neck rotation toward that side.
    • Positioning: should be placed in a crib in such a way that he is forced to rotate his head to affected SCM and tilt toward unaffected SCM in order to see an interesting object such as a toy mobile.
    • Encouraging play in prone and facilitating neck extension to allow bilateral SCM muscle stretching.
    • Turning head to non-favored side while sleeping in supine.
  • Proper donning of TOT collar.

Emerging/unique interventions

  • Muscle Function Scale
  • Cervical Range of Motion
  • Developmental Milestones

Cutting Edge/Emerging and Unique Concepts and Practice

  • Kinesiology taping is a potential adjunct to correct muscular imbalances. Immediate improvements in MFS scores with muscle relaxation taping technique versus facilitation technique has been described, although prospective studies or long-term follow-up have yet to be published.12
  • Preliminary studies show that kinesiology taping improves pain in patients with cervical dystonia.29
  • Potential application of 3D stereophotogrammetry to track changes in facial asymmetries.30
  • Two adult cases of CMT were treated with percutaneous myotomies and intramuscular cell-assisted fat grafting with improvement in head positioning and range of motion, one of which had sustained results at 18 months postoperatively.31

Gaps in the Evidence-Based Knowledge

  • Factors impacting length of treatment (gender, laterality of involvement and age).
  • Efficacy of kinesio taping.
  • Efficacy of cervical orthosis (TOT collar).
  • Optimal timeframe and dosing for botulinum toxin.
  • The exact relationship between congenital torticollis and neurodevelopment and the effects of treatment and timing of intervention of developmental outcomes.


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Original Version of the Topic

Paola Mendoza, MD, Lainie K. Holman, MD. Torticollis. 9/20/2013.

Previous Revision(s) of the Topic

Nancy Yeh, MD and Melissa Trovato, MD. Torticollis. 8/1/2017.

Anton Dietzen, MD, Melissa Trovato, MD. Torticollis in Children and Adolescents. 2/23/2021

Author Disclosure

Melissa K. Trovato, MD
Nothing to Disclose

Emily Hillaker, DO
Nothing to Disclose