# Torticollis Physiotherapy > Torticollis Physiotherapy: congenital muscular torticollis presentation, SCM stretching protocol, positioning, plagiocephaly links and referral thresholds. - Canonical URL: https://prepelephant.com/topics/allied/physiotherapy/torticollis-physiotherapy - Exam / course: Allied Health · Subject: Physiotherapy - Publisher: PrepElephant (https://prepelephant.com) — Prepared and reviewed by the PrepElephant Academic Review Team - First published: 2026-10-02 - Last updated: 2026-10-02 - How to cite: "Torticollis Physiotherapy", PrepElephant, https://prepelephant.com/topics/allied/physiotherapy/torticollis-physiotherapy ## Direct answer Head tilted to the right, chin rotated to the left — in an infant that posture is congenital muscular torticollis until proven otherwise: shortening (often with a palpable sternocleidomastoid "tumour") of the right muscle tilts the head toward the affected side and rotates it to the opposite side. Treatment is a structured home stretching programme — lateral flexion away from the affected side, rotation toward it, held about 10 seconds, repeated at every feed and nappy change — combined with anti-gravity positioning, environmental attraction to the restricted direction, and tummy time for the accompanying positional plagiocephaly. The large majority of infants treated in the first six months resolve without surgery; persistence beyond a year, or a hip click on the same baby, changes the plan, because developmental dysplasia of the hip travels with torticollis often enough to mandate hip screening. ## What you must remember - **The posture rule:** tilt toward the affected sternocleidomastoid, rotation away from it — say it in that order in every exam answer, and reverse it for the stretch. - **Stretch prescription:** lateral flexion to the opposite side plus rotation to the same side, gentle sustained stretch roughly 10 seconds, repeated 3-5 times per session at every feed, every nappy change — 6 to 8 sessions daily is the usual teaching. - **Palpable mass:** a sternomastoid tumour (fibrous mass within the muscle) appears in the first weeks, peaks then regresses over months; its presence does not doom conservative treatment. - **Association with DDH:** congenital muscular torticollis co-occurs with developmental dysplasia of the hip and with metatarsus adductus — the "packaging disorders" of intrauterine crowding — so hip examination or ultrasonography is standard. - **Plagiocephaly management:** alternate head position hourly, tummy time while awake and supervised (building to 30-60 minutes daily), reposition the cot so light and toys pull the head toward the tight side. - **Prognosis clock:** stretching begun under 6 months succeeds in the great majority (studies report above 90% resolution with early, adherent programmes); after 12 months of failed conservative care, surgical release is considered. - **Differential in the older child or adult:** acquired torticollis — atlantoaxial rotatory subluxation, cervical lymphadenitis (Grisel syndrome), ocular torticollis, sandifer syndrome, drug-induced acute dystonia — demands a different workup than a painless infant posture. ## Working through a real infant, step by step Take a 10-week-old sent from a well-baby clinic with a right sternomastoid tumour and a flattened right occiput. Session one is teaching, not stretching: the mother watches the therapist take the chin toward the right shoulder (rotation to the affected side) and the right ear toward the left shoulder (lateral flexion away), holding about 10 seconds without bouncing. The home programme is anchored to routine — every feed and every bath — because parents sustain exercises welded to habits, not ones issued as homework sheets. Positioning completes the plan: feeds arranged to pull gaze rightward, mobiles moved to the right of the cot, prone play on the mother's chest progressing to the floor, and the skull flattened side kept off the mattress by alternating head turns. Review at four-week intervals tracks rotation range with an arc measure and head shape clinically; by six to nine months most such infants hold the head straight and the tumour has softened. If rotation remains restricted past the first birthday despite a faithful programme, referral for surgical tenotomy is the honest next sentence — presented as a failure of the muscle, never of the mother. ## How the exam frames it — Indian angles included Theory papers ask for the clinical features and physiotherapy management of congenital muscular torticollis as a ten-mark long answer, expecting the posture rule, the stretch described directionally, positioning, plagiocephaly care and the DDH association in that order; the five-mark version is usually "stretching techniques for SCM" alone. Rashtriya Bal Swasthya Karyakram (RBSK) screening at birth and Anganwadi checks increasingly pick these infants up early in India, so mentioning referral timing (ideally before three months) reads well. The viva trap is direction: stretching the tight side into lateral flexion toward it is the exact opposite of correction, and forgetting the hip screen is the second error. One rule prevents both: the chin looks away from the lump, the stretch sends the chin to the lump's side. ## Frequently asked questions ### Which way does the head tilt in congenital muscular torticollis? The head tilts toward the affected sternocleidomastoid and rotates to the opposite side, so a right SCM lesion tilts right and turns the chin left. ### What stretches are prescribed for a tight sternocleidomastoid? Lateral neck flexion away from the affected side combined with rotation toward it, held roughly 10 seconds and repeated 3-5 times at each feed and nappy change. ### Why must the hips be examined in an infant with torticollis? Congenital muscular torticollis belongs to the intrauterine crowding or packaging disorders and associates with developmental dysplasia of the hip, so clinical hip screening or ultrasonography is standard. ### When is surgery considered for torticollis? Surgical release is considered when deformity and restricted rotation persist beyond about 12 months despite a properly conducted stretching programme. ### How is positional plagiocephaly managed alongside the stretch? Alternate head positions hourly, reposition the environment to attract gaze toward the tight side, and build supervised tummy time toward 30-60 minutes daily so the flattened occiput is unloaded.