Muscle Stretching Techniques for Congenital Muscular Torticollis: Review of the Literature and Practical Applications

Review Article

Austin J Musculoskelet Disord. 2019; 6(1): 1053.

Muscle Stretching Techniques for Congenital Muscular Torticollis: Review of the Literature and Practical Applications

Pommerol P1, Jeandel C2 and Captier G*2,3

¹Centre PAPL Formation, 24 Rue Sully 69006 Lyon, France

²Service de Chirurgie Orthopédique et Plastique Pédiatrique, Hôpital Lapeyronie, CHU de Montpellier, Université de Montpellier, Montpellier, France

³EA2415, Aide À La Décision Médicale Personnalisée, Université Montpellier, Montpellier, France

*Corresponding author: Guillaume Captier, Hôpital Lapeyronie, 371 Av. du Doyen Gaston Giraud, 34090 Montpellier, France

Received: July 31, 2019; Accepted: September 09, 2019 Published: September 16, 2019


Background: Congenital muscular torticollis is a risk factor for positional skull deformities. Sternocleidomastoid muscle stretching is at the basis of the treatment by physiotherapy for the myogenic forms.

Objective: To describe the techniques, frequency, and optimal duration of this conservative treatment as well as its efficacy.

Methods: Systematic review of clinical studies on infants younger than 18 months of age with congenital muscular torticollis published from 1990 to 2018. Comparative and cohort studies with follow-up and description of the used stretching technique were selected. Studies on the treatment of postural torticollis were excluded.

Results: Among the 508 studies identified by bibliographic search, ten met the inclusion criteria. They showed a large variation in stretching frequency, duration, and intensity. In 50% of cases, stretching was performed by two operators. The frequency of three times per week for infants younger than 6 weeks of age was the most common. The addition of stretching exercises at home by the parents was recommended. Treatment was more effective when started before 3 months of age, and the efficacy was assessed on the basis of the recovery of the head passive range of motion during lateral flexion and rotation.

Conclusions: Muscle stretching is the reference treatment for non-postural congenital muscular torticollis and allows its complete resolution, if started early. The parameters that influence the treatment success are the parents’ adhesion and the addition of a programme of home exercises/postural education.

Keywords: Infant; Congenital Muscular Torticollis; Stretching


CMT: Congenital Muscular Torticollis; PT: Postural Torticollis; MT: Myogenic Torticollis; SCM: Sterno Cleidomastoid Muscle


Congenital Muscular Torticollis (CMT) is characterized by a lateral flexion of the neck with rotation of the chin in the opposite direction. This musculoskeletal condition appears in the infant’s first weeks of life. It is a risk factor of postural skull deformities the incidence of which has increased after the recommendation of putting babies to sleep on their back to prevent sudden infant death [1,2]. Three clinical forms have been described: Postural Torticollis (PT) and two forms of Myogenic Torticollis (MT) caused by tightness of the Sternocleidomastoid (SCM) muscle or the presence of a fibrotic mass in the SCM muscle [3-5]. MT is characterized by a permanent limitation of the head passive range of motion, differently from PT. Manual muscle-stretching exercise is the reference treatment for MT. Different studies [4,6,7] have shown that muscle stretching allows limiting endomysial collagen fibril deposition and fibroblast migration around individual muscle fibers [8]. The treatment intensity is determined in function of the infant’s age, the type of muscle lesion, and the initial deficit of passive rotation [4]. The MT type is one of the significant predictive factors of the final result of conservative treatment [4,9,10]. Compared with MT with a lump or olive-like mass, MT due to muscle shortening are identified much later when the problems in lateral flexion and rotation become evident [11]. The main objective of this study was to review retrospective and prospective, comparative or not, clinical studies on muscle stretching for MT to determine the best modality (technique, frequency, and total number of sessions). The secondary objectives were to assess the efficacy of the physical treatment and to determine when to start, duration, and when/how to stop.


Literature search

Studies on CMT were identified by searching the following databases in 2018: Banque de Données en Santé Publique (BDSP; French Public Health Database) from 2005 to March 2018, CISMeF from 1998 to March 2018, Cochrane Library from 2002 to July 2018, EM Consulte from 1980 to July 2018, PEDro without limits and up to September 2018, MEDLINE via PubMed from 1994 to September 2018, and Google Scholar without limits and up to September 2018. This search was completed by a manual search using ResearchGate.

The key words used to interrogate these databases were: Torticollis in Infants, Torticollis Muscular Congenital with Inversion of the Words’ Order, Muscular Torticollis, Congenital Torticollis in Infants Stretching and Torticollis, Stretching and Torticollis Congenital Muscular Congenital Muscular Torticollis, and Physical Therapy and Torticollis Muscular Congenital. The word fibromatosis colli was not used because fibromatosis colli with CMT may regress spontaneously or show an almost inexistent torticollis [12].

Inclusion and exclusion criteria

Articles were selected on the basis of the following inclusion criteria: i) study on muscle stretching in infants with MT younger than 18 months at treatment initiation; ii) comparative or cohort study with follow-up; and iii) studies including a description of the muscle stretching technique.

Exclusion criteria were: i) incomplete description of the stretching protocol; ii) study that did not allow identifying the CMT types; iii) treatments concerning only PT; and iv) CMT associated with a neurological pathology.

Study selection

The literature and manual search returned 508 records that underwent four additional selection steps (Figure 1): i) selection based on the article title and key words (n=380 articles retained); ii) selection based on the inclusion criteria after reading the article summary (n= 48 articles retained); iii) these articles were fully read by two authors (PP and GC) (n=20 articles retained); and iv) ten articles were excluded based on the exclusion criteria, or due to lack of pertinence or contradictory data in the main text. The ten excluded articles included: Lee, 2015: study on two groups (treatment started before and after 6 weeks) of infants younger than 6 months using the conservative treatment protocol described by Emery [11] that included muscle stretching, massage and therapeutic ultrasound (important bias) and compared the effects of manual stretching and postural control intervention in infants with CMT (off topic); Haugen et al. 2011: study on a manual therapy without stretching; Ohman et al. 2011: off topic; Kwon and Park 2014, and Kim et al. 2009 [13]: studies on micro-current therapy; Giray et al. 2017, Ohman 2012: studies that included also kinesiology taping; Keklicek and Uygur 2018: study on soft tissue mobilization; Schertz et al. 2008 and 2012: follow-up of patients with torticollis, but poorly described treatment. The scientific pertinence of the selected articles (n=10) was assessed using the PEDro scale, a specific physiotherapy scale graded from 1 to 10 [14], and according to the levels of evidence proposed by French Higher health authority, where level I corresponds to the highest evidence level and level IV to the lowest.

Citation: Pommerol P, Jeandel C and Captier G. Muscle Stretching Techniques for Congenital Muscular Torticollis: Review of the Literature and Practical Applications. Austin J Musculoskelet Disord. 2019; 6(1): 1053.