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Summary Table

Category	Details
Risk Factors	Breech presentation, difficult/traumatic delivery, first-born child, birth trauma, oligohydramnios, intrauterine crowding (large birth weight), associated with congenital hip dysplasia and metatarsus adductus
Etiology	Fibrosis and shortening of the sternocleidomastoid (SCM) muscle, likely due to ischemic injury or compartment syndrome of the SCM during birth
Patient Presentation	Infant (usually noticed at 2 to 4 weeks of age) with persistent head tilt to one side and chin rotation to the opposite side; parents report the baby "always looks one way"
Classic Physical Exam	Head tilted toward the affected SCM, chin rotated to the contralateral side, palpable firm non-tender mass ("pseudotumor") within the SCM body, limited passive range of motion of the neck, possible positional plagiocephaly (flattening of the ipsilateral occiput)
Key Diagnostic Results	Clinical diagnosis; ultrasound of the SCM shows fibrotic thickening or a mass within the muscle; cervical spine radiographs are obtained to rule out bony anomalies (e.g., Klippel-Feil syndrome); no routine labs needed
Management	First-line: conservative therapy with passive stretching exercises, repositioning, and physical therapy (effective in >90% of cases if started early); surgical release (SCM tenotomy or bipolar release) reserved for cases refractory to 6 to 12 months of conservative therapy
Keywords	"Head tilt," "chin rotation to the opposite side," "neck mass in a newborn," "SCM mass," "limited neck ROM in infant," "positional plagiocephaly," "breech delivery"

1. Pathophysiology

Congenital muscular torticollis (CMT) is the most common cause of torticollis in the pediatric population and the third most common congenital musculoskeletal anomaly. The underlying mechanism involves fibrosis and contracture of the sternocleidomastoid muscle on the affected side. The prevailing theory is that during a difficult or prolonged delivery (particularly breech), the SCM undergoes ischemic injury or a form of compartment syndrome. This leads to edema, followed by fibroblast proliferation and eventual replacement of normal muscle fibers with dense fibrous tissue.

The SCM has two heads of origin: one from the sternum and one from the clavicle. It inserts on the mastoid process of the temporal bone. When the muscle contracts unilaterally, it produces ipsilateral lateral flexion (tilting the ear toward the shoulder on the same side) and contralateral rotation (turning the chin toward the opposite shoulder). When the affected SCM becomes shortened and fibrotic, it pulls the head into a fixed position of tilt toward the affected side and chin rotation away from the affected side. This is the hallmark presentation that test-writers rely on.

The palpable mass within the SCM, sometimes called a "sternocleidomastoid pseudotumor of infancy," typically appears at 2 to 4 weeks of life. It represents the area of maximal fibrosis and is firm, non-tender, and mobile within the muscle belly. This mass usually regresses spontaneously over several months, but if the underlying contracture is not addressed, the positional deformity persists.

A secondary consequence of the persistent head position is positional plagiocephaly, where the ipsilateral occiput becomes flattened because the infant consistently rests on the same side of the head. Test-writers may describe this skull asymmetry as an additional clue. There is also a well-established association between CMT and developmental dysplasia of the hip (DDH), both of which share intrauterine crowding as a common risk factor. A hip examination (and often a hip ultrasound) should be performed in any infant diagnosed with CMT.

2. Classification and Clinical Manifestation

Type	Clinical Features	Prognosis
Postural torticollis	Head tilt present but no SCM tightness on palpation, no palpable mass, full passive range of motion achievable; mildest form	Excellent; resolves quickly with repositioning alone
Muscular torticollis	Head tilt with palpable SCM tightness and limited passive range of motion, but no discrete mass within the muscle	Good; responds well to structured physical therapy over weeks to months
SCM pseudotumor (sternomastoid tumor)	Head tilt with a firm, palpable, non-tender mass within the SCM; most limited range of motion; most severe form of CMT	Requires prolonged physical therapy; higher likelihood of needing surgical intervention if refractory

Acquired Torticollis

Category	Examples	Key Distinguishing Feature
Infectious / Inflammatory	Retropharyngeal abscess, Grisel syndrome (atlantoaxial subluxation after upper respiratory infection), cervical lymphadenitis	Acute onset with fever, sore throat, or recent URI; child is usually older (not a neonate)
Neurologic	Posterior fossa tumor, Chiari malformation, syringomyelia, spasmodic torticollis (cervical dystonia)	Progressive symptoms, neurologic deficits (nystagmus, ataxia, cranial nerve palsies), papilledema
Osseous / Structural	Klippel-Feil syndrome, atlantoaxial rotatory subluxation, cervical hemivertebra	Bony anomalies on cervical spine radiograph; limited motion in all directions; may have low posterior hairline, short neck, or restricted neck movement since birth
Ocular	Cranial nerve IV (trochlear) palsy	Child tilts head to compensate for diplopia; the tilt resolves when one eye is covered
Sandifer syndrome	Associated with GERD in infants	Episodic arching and abnormal neck posturing that occurs during or after feeds

The distinction between congenital and acquired torticollis is a favorite testing point. Acquired torticollis in a child older than the neonatal period, particularly with neurologic signs, warrants urgent imaging to exclude a posterior fossa lesion.

3. Diagnostic Workup

Test	Role	Expected Findings
Clinical examination	Best initial step and often sufficient for diagnosis	Head tilt toward affected SCM, chin rotation to opposite side, palpable SCM mass or tightness, limited passive ROM
Ultrasound of the SCM	Confirmatory imaging of choice for CMT	Thickened, echogenic (fibrotic) SCM with or without a discrete hypoechoic or heterogeneous mass
Cervical spine radiograph (AP and lateral)	To exclude bony anomalies	Should be normal in CMT; abnormal findings suggest Klippel-Feil (fused cervical vertebrae) or other congenital vertebral anomaly
Hip ultrasound	Screening for associated DDH (performed in all infants with CMT)	May show shallow acetabulum or hip instability
MRI of the brain and cervical spine	Reserved for atypical presentations: no palpable SCM abnormality, neurologic deficits, progressive torticollis, or onset beyond infancy	Evaluates for posterior fossa tumor, Chiari malformation, spinal cord pathology

Congenital muscular torticollis is fundamentally a clinical diagnosis. The test-writer expects you to recognize the classic triad: head tilt, contralateral chin rotation, and a palpable SCM mass in a young infant with a history of difficult delivery. No lab work is needed.

When imaging is indicated, ultrasound of the SCM is the best initial imaging modality. It is non-invasive, avoids radiation, and directly visualizes the fibrotic changes within the muscle. This is the confirmatory test for CMT.

Cervical spine radiographs should be obtained when there is clinical suspicion of a bony etiology, particularly if the torticollis is not associated with a palpable SCM abnormality, if passive range of motion is restricted in all planes (suggesting a structural block rather than a unilateral muscular contracture), or if there are features suggestive of Klippel-Feil syndrome (low posterior hairline, short neck, limited neck motion).

MRI of the brain and cervical spine is the critical "next step" when the presentation is atypical. A child presenting with new-onset torticollis beyond infancy, without SCM pathology, with neurologic signs such as ataxia, nystagmus, vomiting, or cranial nerve deficits, must be evaluated with MRI to rule out a posterior fossa tumor. This is a high-yield testing point: the exam tests whether you recognize that acquired torticollis in a child can be a presenting sign of a brain tumor.

4. Management and Treatment

Clinical Scenario	Management	Details
Mild CMT (postural type, age < 3 months)	Repositioning and parental stretching	Encourage the infant to look toward the restricted side using visual stimuli; supervised tummy time to strengthen neck extensors; reposition during sleep
Moderate to severe CMT (muscular type or pseudotumor type)	Formal physical therapy with passive stretching	Gentle passive lateral flexion away from the affected side and rotation toward the affected side; typically 2 to 3 sessions per week; home exercise program taught to parents
CMT refractory to 6 to 12 months of physical therapy	Surgical SCM release	Options include unipolar (distal) release or bipolar (both origin and insertion) release; followed by postoperative physical therapy and possible use of a cervical collar
Associated plagiocephaly	Repositioning; cranial molding helmet if persistent beyond 4 to 6 months	Helmet therapy is most effective when initiated between 4 and 12 months of age
Acquired torticollis with neurologic signs	Urgent MRI and neurosurgical consultation	Treatment directed at underlying cause (e.g., tumor resection, abscess drainage)

The cornerstone of management for CMT is early initiation of physical therapy. When stretching is started before 3 months of age, resolution rates exceed 90%. The stretching program involves gentle passive movements: laterally flexing the neck away from the affected SCM (stretching the tight muscle) and rotating the chin toward the affected side. Parents are taught these maneuvers and perform them multiple times daily at home.

Repositioning strategies are equally important and serve two purposes: they encourage active range of motion toward the restricted side and prevent worsening of positional plagiocephaly. Placing toys, lights, and the parent's face on the side the infant does not prefer to look toward promotes active turning. Supervised tummy time strengthens cervical extensors and reduces prolonged pressure on the flattened occiput.

If the torticollis persists despite 6 to 12 months of dedicated physical therapy, or if the child is older than 1 year at presentation with a fixed contracture, surgical release of the SCM is indicated. The procedure involves sectioning the fibrous bands at the distal insertion (unipolar release) or at both the origin and insertion (bipolar release). Postoperatively, physical therapy is resumed, and some surgeons prescribe a tubular orthosis for torticollis (TOT) collar to maintain the corrected position during healing.

For plagiocephaly that does not improve with repositioning, a cranial molding helmet may be considered. Helmet therapy works by applying gentle external pressure to the prominent areas of the skull while allowing growth in the flattened regions. It is most effective when started between 4 and 12 months, as cranial growth velocity is highest during this period.

5. Differential Diagnosis and Distractors

Differential Diagnosis	Why It Is Similar	Key Discriminator
Klippel-Feil syndrome	Presents with limited neck motion and abnormal head posture from birth, similar age group	Low posterior hairline, short neck, fused cervical vertebrae on radiograph; no SCM mass; motion restricted in all directions, not just lateral flexion/rotation
Posterior fossa tumor	Can cause head tilt in a child	Older child (not a neonate), progressive neurologic symptoms (ataxia, vomiting, papilledema, cranial nerve palsies), no SCM mass; MRI shows intracranial mass
CN IV (trochlear nerve) palsy	Produces a compensatory head tilt that can mimic torticollis	Head tilt resolves when one eye is covered (eliminates diplopia); no SCM mass; full passive neck ROM; positive Bielschowsky test
Sandifer syndrome	Abnormal neck posturing in an infant	Episodes are intermittent and temporally related to feeding; infant has signs of GERD (spitting up, irritability during feeds); no fixed contracture or SCM mass
Atlantoaxial rotatory subluxation	Acute torticollis in a child, often after URI or minor trauma	Older child (not a neonate), acute onset, "cock-robin" position (head tilted and rotated to the same side), history of preceding infection or trauma; CT shows rotatory displacement of C1 on C2
Retropharyngeal abscess	Acute torticollis with neck stiffness in a child	Fever, sore throat, drooling, muffled voice, bulging posterior pharyngeal wall; lateral neck radiograph shows prevertebral soft tissue widening
Cervical lymphadenitis	Neck mass with torticollis in a young child	Tender, warm, erythematous lymph node (not within the SCM muscle belly); signs of infection; fever

6. Traps and High-Yield Pearls

The single most tested trap with torticollis is the failure to distinguish congenital muscular torticollis from acquired causes that signal dangerous pathology. When the vignette describes a neonate or young infant with a birth history of breech presentation or difficult delivery, a palpable SCM mass, and the classic tilt-rotation pattern, the answer is CMT and the management is physical therapy. Students go wrong when they overcomplicate this straightforward presentation by ordering advanced imaging.

The reverse trap is equally important: when the vignette describes torticollis in an older child (beyond infancy), particularly with progressive symptoms, neurologic findings, or without a palpable SCM abnormality, the test-writer is asking you to recognize that this is not benign CMT. The "next best step" in that scenario is MRI of the brain and cervical spine, and the diagnosis they are testing is often a posterior fossa tumor.

Other commonly tested associations: always screen for developmental dysplasia of the hip in any infant with CMT (the examiner may test this as "what else should you evaluate"). Remember that the head tilts toward the affected (shortened) SCM and the chin rotates away from it. Students who confuse the direction of tilt versus rotation will misidentify the affected side. Finally, understand that the SCM pseudotumor is a benign fibrotic mass, not a neoplasm, and it does not require biopsy. A vignette describing a "neck mass in a newborn" is designed to test whether you can confidently identify this as CMT rather than pursuing an oncologic workup.

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