More Research Necessary to Guide Orthotic Care of Torticollis

Torticollis, also known as the shortening of the
sternocleidomastoid muscle (SCM), is typically correctable with early diagnosis
and therapeutic intervention, but in severe cases, an orthosis that manages a
triaxial range of motion may be added to the treatment protocol, according to
Gerald Stark, MESM, CPO/L, FAAOP, of Fillauer Companies Inc., in Chattanooga,

Stark discussed his literature review of torticollis management at the
American Academy of Orthotists & Prosthetists Annual Meeting
and Scientific Symposium
, in Orlando, Fla., and called for more data that
would guide management of torticollis with orthoses.

Torticollis is a physical symptom found in all ages in which the head
tilts toward the affected side and the chin toward the opposite side.
Congenital muscular torticollis (CMT) presents shortly after birth in about one
in 300 births.

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“One of the surprising things is that torticollis is actually the
third most prevalent pediatric orthopedic diagnosis,” Stark told
O&P Business News. “I did not realize the prevalence was that
high when I first studied the subject.”

According to Stark, 53% to 75% of the patients with torticollis tilt
toward the right side. This could be caused by birth posture or the way in
which the baby was delivered. The diagnosis, which would include decreased
movement for certain lateral head shifts and rotations, normally occurs in the
first 2 to 3 months of life.

“An excellent overview of torticollis has been provided by Colleen
Coulter-O’Berry and Susan Freed, but there needs to be more literature
regarding management to guide orthotic componentry and design,” Stark

Correction of torticollis

In the congenital presentation, 90% to 95% of torticollis cases are
correctable with stretching and orthotic care.

“Quite often, torticollis is related to other malformations of the
head. There is also a need for cranial remolding — not in all cases —
but often times there is,” Stark said. “Sometimes clinicians combine
torticollis management with a cranial remolding helmet.”

A cranial remolding orthosis or helmet may be used to manage
deformational plagiocephaly, also known as an asymmetric distortion of the
skull, which is often associated with torticollis, according to Stark.
Practitioners can create the orthosis using computer-aided design and
manufacturing. According to Stark, there is an 80% to 90% greater prevalence of
adult plagiocephaly if the torticollis is not corrected.

“It depends on severity, but primarily stretching is usually
effective and this was correlated by a Chinese study of over 1,000
children,” Stark said.

In that study by Cheng, 1,086 patients showed that mulitphasic
stretching was 91.6% effective. Only 5% to 10% of congenital patients need
surgery after 18 months. In fact, the parents can manage the stretching
themselves for deficits of 10° or less. Stark recommended avoiding cervical
flexion in bouncy seats, car seats or forward-facing baby carriers.

“Low-impact exercise to increase stability and gentle manipulation
of the neck should work,” Stark said. “Some advocated application of
heat and massages. Botox has even been used, but that is potentially dangerous
because you are injecting Botox in a sensitive area in the neck. Obviously,
that would be difficult for orthotists to advocate.”

Underlying cases require different treatments

Although current treatment plans have a relatively good success rate,
there are many underlying causes for torticollis with different solutions.
There are a number of pathologies that present as pediatric torticollis. The
literature divides congenital torticollis into three diagnostic areas: SCM
swelling, tightness with no swelling or postural changes with no swelling.
According to Stark, a correct clinical evaluation must be made to successfully
resolve torticollis.

Torticollis is deceptive in that at the outset it seems like a simple
issue of repositioning the head, Stark said. But there are a variety of
nonmuscular causes, and practitioners need to be aware of that effect among
pediatric patients. According to Stark, 18% of all torticollis presentations
may be due to nonmuscular, osseous infections or neurologic causes.

“The diagnosis may present like torticollis due to ocular
torticollis, which is cranial nerve palsy, or it could be where you have a
malformation in the cerebellum,” Stark said. “The neurologic issue
can be quite involved even though the presentation looks similar.”

The diagnosis can become complicated in some cases. Stark said that
adult torticollis is often more difficult to understand than CMT. — by
Anthony Calabro

For more information

  • Cheng JCY, Tang SP, Chen TK, et al. The clinical presentation and
    outcome of treatment of congenital muscular torticollis in infants — a
    study of 1,086 cases. J Pediatr Surg. 2000;35:1091-1096.
  • Freed S, Coulter-O’Berry C. Identification and treatment of
    congenital muscular torticollis in infants. J Prosthet Orthot.
  • Stark G. Clinical overview of torticollis. Presented at the
    American Academy of Orthotists and Prosthetists 27th Annual Meeting and
    Scientific Symposium. March 16-19, 2011. Orlando, Fla.
  • Disclosure: Stark has no direct financial interest in any
    products or companies mentioned in this article.


The vast majority of patients resolve with a stretching program by 6
months to 1 year. Many patients do not use any orthosis at all. It is
recommended to position the child in a crib so that they need to turn their
head to the affected side in order to see the activity in the room.

Torticollis can be caused by more serious congenital deformities of the
cervical spine, so if it does not resolve well or there are other congenital
deformities present in the child, X-rays or other imaging such as CT scan or
MRI may be needed. There is also an association with developmental hip
dysplasia, so the child’s hips should be carefully examined by their
pediatrician. If the case does not resolve adequately, a simple surgical
procedure to release the contracted sternocleidomastoid tendon is usually

‘Congenital’ means it is present at birth or at least
recognized soon afterwards. Torticollis presenting in later childhood is
different and usually due to atlantoaxial rotatory subluxation. It often
follows a viral infection and usually resolves with a cervical collar and
nonsteroidal anti-inflammatory drugs. Occasionally, traction is required if it
does not resolve quickly.

Torticollis arising in children after 1 to 2 years of age may also be a
sign of other more serious conditions and should be evaluated by an orthopedic
surgeon if it does not resolve expeditiously.

— Wally Krengel, MD
Chief, Spine Program,

Department of Orthopedics and Sports Medicine
Seattle Children’s

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