Congenital muscular torticollis: assessment by goniometry and management
Assessment of congenital muscular torticollis in infants: sternocleidomastoid examination, cervical goniometry (lateral flexion and rotation), severity grading (APTA 2024 CPG), the relationship with plagiocephaly and management.
Congenital muscular torticollis (CMT) is one of the most common causes of restricted neck movement in infants and is strongly associated with positional plagiocephaly. The assessment, which includes examining the sternocleidomastoid (SCM) and measuring cervical range of motion, helps grade severity, guide management and follow progress objectively.
What congenital muscular torticollis is
CMT is a postural condition usually identified in the first months of life, characterized by tilting of the head to one side and rotation to the opposite side. It may be associated with changes in the sternocleidomastoid (SCM), such as muscle tightness or a palpable mass.
Restricted cervical mobility can encourage a persistent positional preference, increasing the exposure of a given region of the skull to pressure and contributing to cranial asymmetry. This is why assessing cervical mobility is important when positional plagiocephaly is suspected or present.
Assessment: SCM examination and goniometry
Muscle examination
The SCM examination should identify positional preference, muscle tightness or a palpable mass, as well as other relevant findings.
These findings, combined with the patient's age and the cervical rotation deficit, contribute to the clinical classification and to grading the severity of CMT.
Cervical goniometry
Measure passive cervical lateral flexion and rotation to both sides and calculate the deficits between them. When applicable, also assess active range of motion and the infant's ability to move the neck symmetrically.
In the APTA 2024 CPG severity grading, the grade is defined by the difference in passive cervical rotation between sides, combined with the age group and the presence of an SCM mass. Lateral flexion is measured and documented, but it does not enter the grade calculation directly.
Severity classification
Mamini follows the severity classification of the APTA clinical practice guideline (2024), which uses eight grades and considers age at assessment, the presence of an SCM mass and the difference in passive cervical rotation between sides.
Grade | Classification | Criteria |
|---|---|---|
1 | Early Mild | 0 to 6 months, postural preference only or passive rotation difference of less than 15° |
2 | Early Moderate | 0 to 6 months, passive rotation difference of 15° to 30° |
3 | Early Severe | 0 to 6 months, passive rotation difference greater than 30° or SCM mass |
4 | Later Mild | 7 to 9 months, postural preference only or passive rotation difference of less than 15° |
5 | Later Moderate | 10 to 12 months, postural preference only or passive rotation difference of less than 15° |
6 | Later Severe | 7 to 9 months, passive rotation difference greater than 15°, or 10 to 12 months with a difference of 15° to 30° |
7 | Later Extreme | 7 to 9 months with SCM mass, or 10 to 12 months with a rotation difference greater than 30° or SCM mass |
8 | Very Late | Over 12 months, with any CMT-related asymmetry |
The classification helps document severity, communicate with the family and follow progress. Severity should always be interpreted together with the other assessment findings.
The relationship with plagiocephaly
CMT and positional plagiocephaly are frequently associated. Restricted cervical mobility can encourage a positional preference and contribute to cranial flattening. This is why assessing cervical mobility is important when there is associated cranial asymmetry.
When both conditions are present, management should address both cervical mobility and the factors contributing to cranial asymmetry.
Management
The core of physical therapy treatment includes gaining cervical range of motion, encouraging active and symmetrical movement, postural control, environmental adaptations, caregiver education and tummy time while awake and supervised.
Manual techniques may be used as a complementary resource within the physical therapy approach, according to the individual assessment.
Early intervention is associated with better outcomes and, in general, shorter treatment periods. Follow-up should consider the progression of cervical range of motion, movement symmetry and motor development.
Referral for medical evaluation or further investigation should be considered in the presence of a large mass, lack of response to well-conducted treatment, significant facial asymmetry or suspicion of a non-muscular cause of torticollis.
How Mamini does it
In Mamini, goniometry records cervical lateral flexion and rotation angles, calculates the deficits between sides and uses this data to support the clinical classification and the severity grade according to the APTA guideline.
Results are stored in the patient's history, making it possible to follow how the measurements change across sessions and to document the response to treatment objectively.
You follow the progression of cervical range of motion session by session, with standardized records and traceable clinical references, without keeping a separate spreadsheet.
References
Sargent B, Coulter C, Cannoy J, Kaplan SL. Physical Therapy Management of Congenital Muscular Torticollis: A 2024 Evidence-Based Clinical Practice Guideline From the American Physical Therapy Association Academy of Pediatric Physical Therapy. Pediatric Physical Therapy. 2024;36(4):370-421. DOI: 10.1097/PEP.0000000000001114
Frequently asked questions
Which measurement defines the severity of torticollis?
The difference in passive cervical rotation between sides, combined with age at assessment and the presence of an SCM mass, according to the APTA (2024) severity classification. Lateral flexion should also be measured and documented, although it does not directly determine the grade.
Why assess torticollis together with plagiocephaly?
Because restricted cervical mobility can encourage a persistent positional preference and contribute to cranial asymmetry. Assessing cervical range of motion makes it possible to identify and follow this functional component during treatment.
Does manual therapy help with torticollis?
Manual techniques may be used as a complementary resource to physical therapy in selected cases, according to the clinical assessment. The response to treatment should be followed with objective measurements, including the progression of cervical range of motion.
When should I refer?
Referral for medical evaluation or further investigation should be considered in the presence of a large mass, lack of response to well-conducted treatment, significant facial asymmetry or suspicion of a non-muscular cause of torticollis.