The Complete Guide to Torticollis in Babies
- Sabrina Thorpe
- May 27
- 12 min read
Torticollis is a condition that affects a large number of babies with some studies estimating up to 1 in 6 babies are affected by it. Simply put, torticollis is a condition in which a baby’s neck appears to be “twisted” or “tilted.” Parents of babies with torticollis will often notice that their baby has a head position preference, is developing flat spots on their skull, have feeding difficulties, will seem stiff, and often will struggle with tummy time.
For babies with torticollis, the earlier that treatment is started, the better off they are. Because torticollis has a number of associated conditions that can develop alongside of it, recognizing and treating it early prevents a number of problems from developing and needing prolonged intervention. While treatment can still be successful when started later, it should be expected that it will take longer to see a resolution of symptoms. When treated early, most babies make excellent progress and will see a resolution of their torticollis symptoms rapidly.
What is torticollis?
The name “torticollis” comes from the root words of tort, meaning twisted, and collis, meaning neck. Individuals with torticollis have a “twisted neck.”
If you were to look up torticollis in a medical textbook, you would likely find that the cause of torticollis is most commonly attributed to the sternocleidomastoid muscle (aka SCM). This muscle attaches just behind the ear and to the innermost portion of the collar bone. It turns the head in the opposite direction and tips the ear to the shoulder. When you turn and look to the side, the large muscle that pops out like a thick rope at the front of your neck is your SCM. You have one on either side of your neck, and they need to be balanced in strength and mobility between the two sides and with the rest of the neck muscles to keep the head upright and your eyes level with the horizon.
In babies, the diagnosis of Congenital Muscular Torticollis (CMT) will often be applied. This diagnosis implies that it is a congenital condition- something that a baby is simply born with. However, this diagnosis doesn’t look any deeper into the reasons why the torticollis develops, which we will get into further into this article.
It is also worth mentioning another cause of infant torticollis, and that is SCM tumors. These tumors are incredibly rare, but they can happen. They will manifest as a lump on the SCM muscle and will cause the muscle to operate dysfunctionally, causing a baby’s head to turn and tilt. These require surgical intervention to correct.
Signs and Symptoms of Torticollis in Babies
Babies with torticollis can present with any combination of these signs and symptoms:
Preference for the head being to one side
Persistent head tilt
Difficulty nursing on one side
Inability to move the head and neck symmetrically to both sides
Flat spot on the head
Difficulty with tummy time
Trunk arching and stiffness
Side body curve
Delayed rolling
Always rolling out of tummy time to their back on the same side
Asymmetrical movement of the arms and legs
Always sleeping with their head turned the same direction
Asymmetrical ATNR reflex
Ineffective rooting reflex on one side
It’s important to also acknowledge that mild torticollis can be easy to miss. Not every neck twist or tilt is dramatic, not every flat spot is immediately obvious (especially if a baby has a lot of hair). When parents are with their babies all day, it can be tough to notice small changes that are occurring, and when the tilt has been there from day one it can be difficult to recognize that the tilt is even there.
What Causes Torticollis?
There are a number of factors that contribute to the development of torticollis.
When a baby is born with a head tilt and it is present from day one it can be the result of something related to the pregnancy. This could be:
Altered in utero position
First pregnancies
Cramped positioning
Twins
None of these things are necessarily anything that moms can do anything about. Making sure that you are receiving regular care with a pelvic floor physical therapist to promote space through your pelvis and abdomen may be able to help with maintaining enough space for babies in utero and prevent cramped positioning, but this doesn’t automatically mean that baby won’t have a head tilt.
Head tilts present from day one can also be from factors related to the birth itself. These include:
Long labor
Instrument assisted deliveries (vacuum or forceps)
Fast delivery
Asynclitic presentation
Shoulder dystocia
When these situations arise during labor, we will see the neck muscles respond with tension. The rest of the baby's body can also respond with fascial tension, which can result in a presentation of a tilt.
Head tilts that develop after delivery and over time can be related to the development of plagiocephaly. Plagiocephaly is where there is flattening that develops on one side of an infant’s head. Sometimes this flattening can happen from in utero positioning. However, more often it is a result of persistent pressure to the same spot on the skull after baby has been born. It can be difficult to determine which came first- the torticollis or the plagiocephaly. These two conditions often go hand in hand and it is very rare to see one without the presence of the other.
Can Torticollis Affect More Than the Neck?
Short answer: yes.
Long answer: While the term torticollis refers to the neck as discussed previously, infant torticollis is a whole body condition. It is simply most easily noticed and recognized at the neck. Torticollis can affect:
Feeding
Latching and swallowing
Reflux
Hip dysplasia
Body tension
Sleep
Tummy time
Milestone progression
Asymmetrical motor skills
Balance and coordination issues later in life
Torticollis can affect more than the neck and can be caused by more than just the neck muscles. Clinically, I will often find babies with tension through their abdomen, cranial bones, jaws, and hips, which when released and addressed will allow the neck to straighten out- all without ever having directly treated the neck.
How is Torticollis Diagnosed?
Hopefully, pediatricians are catching torticollis at well baby checks and offering parents basic advice on how to manage it. Pediatricians are qualified to give basic positioning advice to help manage torticollis and they are able to screen for rare SCM tumors as discussed above. However, when a torticollis has been identified, the proper professional to refer to is a pediatric physical therapist. If you have a pediatric PCP who dismisses your concerns about torticollis, doesn’t offer any advice on how to manage it, and tells you that your baby “will just grow out of it” without making a referral to a physical therapist, it is imperative that you seek another opinion. In the state of Wisconsin, we are fortunate enough to have direct access for physical therapists, so you can also bypass a dismissive PCP to get your baby evaluated and treated.
In a physical therapy appointment there are a number of things the physical therapist will look at. Depending on the baby in front of us and how they are presenting, we will look at:
Neck range of motion. This tells us where baby is lacking motion and where there is tension in the neck, if any.
Neck strength. This tells us more information about muscle imbalances that may be contributing to the torticollis.
Physical assessment of your baby’s posture in just their diaper. We can see areas of tension based on skin rolls and folds, especially if they are persistent.
Arm and leg motion. We assess if the limbs move in a symmetrical manner, if there is tension, or if there is weakness.
Reflexes. If there are any reflexes that are over or under active, this gives us information about what may be driving the torticollis.
Tummy time. PTs love tummy time for babies, and for good reason! It gives us an excellent picture of how a baby is functioning and using their neck and spinal muscles as a unit and where there are imbalances.
Hip dysplasia screening. There is a high correlation between torticollis and hip dysplasia, so catching this is important for infants and can give us insight into tension in the lower body that can be affecting up the chain.
Jaw and cranial bone tension. This is something that requires specialized training to assess and treat, but it can be a missing piece in the torticollis puzzle. Because the neck muscles attach to the skull, tension here can result in a head tilt.
Head shape. We may take pictures of the shape of baby's head, or take measurements with a craniometer to determine if there is a significant degree of flattening happening.
Chest and abdominal tension. This is another assessment piece that takes specialized training to assess and treat. However, it has been my clinical experience that when a baby is presenting with torticollis and a host of other constitutional symptoms (i.e reflux, constipation, fussiness, feeding difficulties), looking at tension through the rib cage and abdomen is huge is resolving these co-conditions and the torticollis simultaneously.
How Physical Therapy Helps Torticollis
We’ve discussed what you can expect during a physical therapy exam to help diagnose and get to the root of a baby’s head tilt, but what does treatment actually look like?
Treatment is primarily based on the findings of our exam. Most commonly treatment includes:
Stretching
Gentle manual therapy
Strengthening exercises
Positioning
Parent handling techniques
Tummy time (with some modifications)
Side lying play
Motor development support
Environmental changes
Parent education
While bringing your baby to the physical therapist is important, it is also crucial to understand that the work done in physical therapy sessions is most effective when supported by consistent follow up at home. The more consistent families are with a home program, the faster their baby will see improvement.
This is also what makes early intervention so crucial. Babies are extremely pliable and shapeable when they are newborns. It takes less time and effort the earlier it is addressed and the earlier that good family habits are formed. It’s been my clinical experience that once a baby can hold their own head up independently (3-4mo old), treating torticollis becomes markedly more challenging. Baby has had months to develop a habit at that point, and it takes a longer time and more effort to break a movement pattern habit the longer it is present. When babies are brought in within the first 6-8 weeks of life at the first signs of torticollis, it can usually be resolved in less than 4 weeks. If a baby doesn’t start treatment until 4 months of age, it is more likely to be a multi-month process to correct.
What Parents Can Do At Home
There are a number of easy ways that parents can support their babies with torticollis at home. These can be applied at the first signs of torticollis, even if you haven’t been assessed by a medical professional yet:
Tummy time on your chest. Provide baby with a face to look at that is not tilting (sympathy tilting your head to match theirs can contribute to a perpetual tilt, so make sure you are providing baby with a good example). Baby should make an effort to match their eyes with yours.
Sidelying play. Place baby on their side and place toys that are visually stimulating in their line of sight to keep them engaged. You can sit on the floor with baby and use your leg to keep them on their side, or you can use a small rolled towel or receiving blanket behind their mid-back and hips to keep them on their side. Always supervise if you are going to use a blanket prop.
Alternate which end of the bassinet or crib they are sleeping on. Babies will often turn towards their parents in their sleep, so switching sides can encourage them to turn the other way and stay there for longer periods through the night.
Tracking play with visually stimulating toys. Newborns love black/white/red toys, things that are highly contrasting due to their poor vision at this stage. You can encourage them to lock their gaze on a toy and slowly move it back and forth across their face. They will start with moving just their eyes and gradually start to move their head to follow the toy as well as they master vision and neck movement. This can also be done in a tummy time position once baby can hold their head up in prone.
Place interesting things on the side baby doesn’t look to as often. This could look like setting them up in a bouncer seat and positioning it such that an older sibling or a pet is on the side of that baby doesn't look to as often. You can also place car seat toys to the side they don’t look to as often. Making slight modifications to their environment to encourage actively rotating can help strengthen and lengthen the neck muscles naturally, without having to force anything.
Change how you carry your baby. This can look like alternating arms more often and also carrying your baby tummy down (my personal favorite). Carrying baby in different ways challenges their body to use different muscles to respond to your movement, look at their environment, and if they fall asleep in your arms their head can be in different positions as well.
Babywearing can be incredibly helpful. Too much time in containers (swings, bouncer seats, car seats, bassinets, cribs, etc) can cause pressure to the head and create head flattening. This flattening then becomes a vicious cycle with torticollis because baby can’t move off of the flat spot as easily, causing the neck to tighten which causes more pressure to the spot... And round and round we go. Not all families are comfortable with putting baby on the ground on their tummy and allowing them to have free reign there, and in some homes it wouldn’t be safe to do so because of pets, older siblings, and other factors. Babywearing can be a good middle ground where baby is off the back of their head; they are getting input from their parent that is causing them to have to use their head, neck, and trunk muscles in response to movement; and they are able to freely turn their head to look around and up at their parent.
When Should You Seek Help for Torticollis?
Ideally, as soon as you notice a head tilt, you should be doing something to address the torticollis. You can start with the list in the previous section, and this can often be enough for families. However, there are times when you should definitely be seeking out a professional:
You’ve done the things on the list above consistently for 2 weeks and haven’t seen any change.
Your baby has significant head shape changes in addition to the tilt and positional preference.
They physically cannot move their head out of the position it is in or turn past their midline point, even with your gentle help.
The torticollis is accompanied by feeding challenges
The torticollis is accompanied by reflux, fussiness, or inconsolability
Baby is generally very stiff and resists tasks like diaper changes, clothing changes, or being put into a car seat
Baby is struggling to tolerate any tummy time.
Remember, earlier treatment is often easier and faster. It is never wrong to get an evaluation with a pediatric physical therapist.
What Happens if Torticollis is Left Untreated?
While the downstream effects of untreated torticollis may not be immediately obvious, here are several things that can result from untreated torticollis:
Worsening asymmetry that leads to neck pain, TMJ and jaw dysfunction, and in severe cases, scoliosis.
Flat spots on the skull that require helmet intervention. If even further untreated by helmets, this can affect the function of the brain and nervous system, particularly systems associated with vision, balance, and sensation, as these areas are often subjected to flattening. It is also important to note that simple safety equipment such as bike helmets are not designed to fit significantly asymmetrical skulls which places them at greater risk for injury as they grow older.
Movement compensations that cause altered bone growth, joint wear and tear, and place the body at greater risk for injury.
Delayed motor skills which can affect socialization with peers, self confidence, and overall feelings of security in one’s body.
Poor balance and coordination. The vestibular system (aka balance system, located in the ear) of a head that is persistently tilted cannot be activated properly to tell a person where their head and body are in space, how they are moving, and in what direction they are moving.
There is this very common misconception that torticollis and head shape changes are simply cosmetic issues. This couldn’t be farther from the truth. If any medical provider is saying this to you, it is recommended that you seek a second opinion.
Pulling It All Together
Torticollis is a very common infant complaint and one of the main reasons infants end up in physical therapy. Having an understanding of what torticollis is and how to address it are the first steps to helping your baby. Early intervention is key to managing torticollis, though this doesn’t mean that later treatment is doomed. It is simply important to understand it may take longer to treat. It is why at Foundation PT we are so passionate about parents advocating for early intervention for their babies. If you are local to Waukesha, WI, we would love to you help you and your baby find the help you need for torticollis. You do not need to have a physician referral or permission to have your baby seen at our clinic. We trust your eyes and your gut if you believe your baby needs help.
FAQ
Does torticollis go away on its own?
Typically, no. There are some cases where newborns will spend a couple days appearing to be favoring one side or the other, and then will change things up. However, once we see a pattern of a baby always looking the same direction or they become very distressed when physically placed looking the other way that we can safely say that this problem isn’t going to go away without some outside help.
Does torticollis affect crawling or walking?
Yes. If a torticollis persists to the age where a baby is learning to crawl or walk, it is likely that baby also has fully body muscle imbalances that are going to make learning these skills challenging.
Can tummy time fix torticollis?
Torticollis requires a fully body assessment and treatment plan. Tummy time is an important part of treatment for torticollis, but in most cases it will not fix a torticollis as an isolated intervention.
Dr. Sabrina Thorpe is a Doctor of Physical Therapy with a decade of clinic experience. She specializes in treating pregnant and postpartum women and their infants at Foundation Physical Therapy in Waukesha, WI.
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