Background: The natural history of congenital
muscular torticollis and the outcome of different treatment modalities
have been poorly investigated, and the results of treatment have
Methods: The main objective of this prospective
study was to evaluate the outcomes of 821 consecutive patients with
congenital muscular torticollis who were first seen when they were
less than one year old, were treated with a standardized program
of manual stretching, and were followed for a mean of 4.5 years.
Before treatment, the patients were classified into one of three
clinical groups: (1) palpable sternomastoid tumor, (2) muscular
torticollis (thickening and tightness of the sternocleidomastoid muscle),
and (3) postural torticollis (torticollis but no tightness or tumor).
Results: Of the 821 patients, 452 (55%)
had a sternomastoid tumor; 276 (34%), muscular torticollis;
and ninety-three (11%), postural torticollis. Multivariate
analysis of the outcomes showed that (1) the duration of treatment
was significantly associated with the clinical group (p < 0.0001),
a passive rotation deficit of the neck (p < 0.0001), involvement
of the right side (p < 0.0001), difficulties with the birth
(p < 0.009), and age at presentation (p < 0.0001);
(2) the overall final assessment score was associated with the rotation
deficit (p = 0.02), age at presentation (p = 0.014),
and duration of treatment (p < 0.0001); and (3) subsequent
surgical treatment was required by 8% (thirty-four) of
the 452 patients in the sternomastoid tumor group compared with 3% (eight)
of the 276 patients in the muscular torticollis group and 0% (none)
of the ninety-three patients in the postural torticollis group.
Conclusions: This large prospective study demonstrated
that controlled manual stretching is safe and effective in the treatment
of congenital muscular torticollis when a patient is seen before
the age of one year. The most important factors that predict the
outcome of manual stretching are the clinical group, the initial
deficit in rotation of the neck, and the age of the patient at presentation.
Surgical treatment is indicated when a patient has undergone at
least six months of controlled manual stretching and has residual
head tilt, deficits of passive rotation and lateral bending of the
neck of >15°, a tight muscular band or tumor, and a poor
outcome according to our special assessment chart.