Torticollis: How to diagnose.

If you are wondering if your infant has torticollis, the main cause of head flattening, it is pretty easy to assess yourself. For an infant without head control, simply place them on their back and stimulate them to look to either side. If there is a significant difference in head rotation, or if they turn to one side but cannot maintain position there (go back to the other side consistently), that is very suggestive. For older infants, stabilize the torso and stimulate them to turn in either direction. If there is a difference in head rotation one side vs. the other, it is suggestive. In the images below, notice that this child turns much farther to one side than the other. In fact, the head turning to the right side (the greater rotation) is also abnormal. Most normal infants cannot rotate their heads this far and this is indicative of the weaker sternocleidomastoid (SCM) muscle in torticollis. Recall that congenital muscular torticollis is a muscle IMBALANCE consisting of a tight SCM on one side, and a weaker/atrophied SCM on the other. The tight SCM often resolves in the first several months of life as motor and head control improves. However, the weak SCM muscle will take much longer to develop strength and tone. While a tight SCM muscle can create a head tilt, so can the weak one ever after the tight SCM muscle has stretched out. Why? Because when a child sits up and the neck muscles are forced to support the weight of the head, a weak SCM muscle allows the head to tilt over to the other side. This can manifest as an intermittent head tilt in some older kids, often when they are tired or preoccupied, and is often confused by therapists and other clinicians as persistence of SCM tightness. This can lead to rounds of unnecessary BOTOX injections and even surgery. The BEST test for SCM tightness is head rotation. If one can rotate to the "tight' side 75-80 degrees from midline, the SCM on that side is NOT tight. Any head tilting then is related to either the weak SCM muscle, which will gradually develop tone over time (PT strengthening exercises help accelerate) or some other issue. By the way, placing a child with a weak SCM muscle into a TOT collar to support the head makes no sense whatsoever. It is completely illogical to brace a weak muscle- it needs to be worked to build strength and tone.