Abstract
Background. Congenital muscular torticollis (CMT) is the third most common congenital anomaly among infants and is defined as the unilateral shortening of the sternocleidomastoid muscle. This anomaly leads to a lateral flexion to the affected side and contralateral cervical rotation. Current conservative management techniques have shown to have promising outcomes and decrease the risks of developmental delays and other musculoskeletal dysfunctions. Case Description This case report describes a female infant who was diagnosed with CMT and gross motor delay due to left sided head tilt and not meeting appropriate developmental milestones. Clinical Impressions. Conservative treatment was performed for five months and fifteen days with no improvements in range of motion. The physical therapist referred back to the primary care physician (PCP) due to lack of progress in cervical range of motion that was not consistent with CMT. At six months and one day, the PCP performed imaging with abnormal findings, leading to a diagnosis of Klippel-Feil Syndrome. Discussion. Physical therapy was discontinued immediately due to the new diagnosis, and that the physical therapy re-assessment demonstrated age appropriate gross motor skills. This case report illustrates the importance of ongoing assessment and interprofessional collaboration for successful identification and treatment of individuals who are originally diagnosed with CMT, but may have other conditions with similar signs and symptoms that are common with CMT.