Torticollis: Tight Muscles and Flat Heads

Torticollis

Torticollis can sound intimidating. It’s a long word for something that is actually incredibly common in babies. We’re always working to make the intimidating feel more manageable, and so we want to dig a little into the condition, explain what it really means, and share a few tips to solve the issue and alleviate the consequences.

Torticollis is the tightness of one particular muscle (sternocleidomastoid, or SCM muscle) on one side of a baby’s neck. With this condition, the SCM muscle is tighter on one side of the neck than the other, which results in ipsilateral head tilting and contralateral rotation. With the tightness of the SCM muscle on the right, a baby’s right ear will tilt down toward the right shoulder, with the head rotating up and to the left. We identify this by noticing a strong preference for looking toward only one side, the inability to turn her head smoothly from one side to the other, and looking at or reaching only for toys or objects on a particular side or with a particular arm. 

Flat Head Syndrome: Plagiocephaly and Brachycephaly

This strong positional preference can result in a flat side on the baby’s head, known as plagiocephaly. Left untreated, plagiocephaly can further lead to cranial asymmetries, such as asymmetrical ears, eyes, and facial bones. This positional preference causes an imbalance of muscles on the left and right sides of the body, which can also contribute to developmental delays. Tight muscles and positional preferences can also lead to injuries of other muscles and nerves. 

Brachycephaly, on the other hand, is when a flat spot is formed on the back of the baby’s head, causing the baby’s head shape to change. This can also lead to cranial or skull shape deformities and facial bone asymmetries. Since 1994, with the introduction of the “back is best” campaign around infant sleep, there has been a dramatic decrease in infant sleep deaths, specifically SIDS, or Sudden Infant Death Syndrome. We strongly believe “back is best” and know it saves lives. In fact, in physical therapy, we have our own saying: “supine to sleep and prone to play!” This means, on the back to sleep and on the tummy to play! Also, in the physical therapy world, we understand that laying on their backs to sleep can cause a flat spot to form on the back of babies’ heads. This is a fact that we are cognizant of, so we work hard to emphasize how important it is to play in tummy time and in side-lying.

Just as with everything, there are ranges of mild, moderate, or severe flat spots or flat head syndrome measurements. Our bones in our skull begin to fuse around two years of age, so age plays a major role in how much we can adapt and change a baby’s head shape before we turn to outside solutions. If we are unable to change the baby’s head shape with stretches and position changes, a cranial-shaping helmet is an easy, gentle, passive solution to flat head syndrome. 

Correction and Prevention

Before we turn to a helmet, there are other steps we try. Here are some things you can do prior to that stage to help correct torticollis and prevent plagiocephaly or brachycephaly:

Symmetrical Positioning:

Beginning when your baby is a newborn, be sure to alternate between holding your baby on the right and left, feeding facing the right and left, and placing objects on either side to encourage head rotation to the right and left equally.

Supervised Tummy Time:

Encourage head rotation to both sides by having exciting toys or soft books spread out evenly in front of him, having him reach equally with right and left arms. Be sure you’re switching which side you’re approaching him or playing with him from.

If you’re looking for tips on better tummy time sessions, check out our advice on improving the experience, choosing the best toys, and finding the best play mat.

Playing in Side-Lying Positions:

This extremely effective practice is often forgotten in conversations about symmetrical development. Playing on our sides promotes midline orientation, encourages bringing our hands together, and requires different core strength than when on our tummies. If your baby has torticollis or a preference for one side, playing on her side will help reduce the risk of plagiocephaly, or flat head syndrome, and can physically prevent her from turning toward her preferred side. For instance, if she loves to look toward the right, lay her on her right side to encourage her to look and play in the middle or to the left. 

Football-Carry:

This method for holding your baby can help encourage looking to his not-preferred side.  If he has a preference for tilting his right ear to right shoulder, hold him facing outward from you, with his body on a slight diagonal and his head in your right arm. This will facilitate his engrained “righting reflex,” or his desire to tilt his head to look at the world straight on.

Baby Wearing:

If your body feels good doing it and your baby loves it, baby-wearing can help to reduce the time spent lying on the back of her head, reducing the risk of plagiocephaly. Be cognizant of which way your baby’s head is turned, especially if she is so comfy that she is dozing off. It’s best to make sure she is turning her head equally in both directions.

Stretches and Massage for the Tight SCM Muscle:

These stretches and massages should ONLY be performed if you’ve been given direct instruction from your local physical therapist or physician.

You may gently massage this muscle, just as you would rub your own shoulder and calves if they were tight. In addition, if your baby loves to look left, try to encourage looking right with a toy, and when they’ve reached as far as they can go themselves, you may gently place a hand on their left shoulder, keeping that shoulder from popping up, and have him hold that end range for 3-10 seconds. If you repeat this gently and enough times, the end range will begin to shift more and more and he will be able to rotate further. 

Adjust the Items in Your House:

If your baby loves looking left, place her in her crib so that when you go to get her, you’re approaching her on her side. If she has a sibling in the backseat of your car with her or she loves to look out the window, place the car seat so her entertainment is on the right side too! The same goes for the changing table, bouncer, high chair, or other items you may have at home.

Encourage Looking Down:

Lastly, when your baby is doing so well you can barely notice his preferences to one side, that’s when we can’t forget about the “up” part of “up and to the side.”

Babies with torticollis have preferred looking up and to the side for so long, they need to practice looking down! This is best practiced through chin tucks, or neck flexion. When lying slightly propped, such as on a Boppy pillow, place an object low at chest level, to encourage that double-chin to appear as your baby looks down. Or, when sitting on your couch with your feet up, knees bent, place your baby lying up your legs, facing you. This will promote a strong midline orientation and encourage him to tuck his chin and flex his neck to see you! If your baby is old enough and showing signs of an emerging chin-tuck, you can practice pulling-to-sit with your hands holding her hands. Hold her hands with her arms close to her body and watch for that chin tuck.

Do not try to pull her to sit if she is under six months old or if a weak or serious head-lag persists.