Congenital muscular torticollis (CMT)

Congenital muscular torticollis (CMT) is a condition affecting the sternocleidomastoid (SCM) muscle of the neck.
The majority of cases of CMT are due to muscualr causes, although it can be secondary to a non-muscular condition. The infant's head tends to "twist" to one side due to shortening of the SCM muscle, typically from trauma and fibrosis formation.
Congenital= present at birth. Muscular= involving musculature of the neck. Torticollis= twisted neck.1


It is difficult to pinpoint an exact cause or reason why some infants are born with torticollis. Damage to the SCM can occur due to any of the following reasons and the result is a fibrosis and shortening which causes the neck to tilt to the damaged side and often rotate away.2 Possible causes of CMT of a non-muscular nature will be further discussed in differential diagnosis.
  • traumatic birth in which they underwent a vacuum procedure, were breech, etc.
  • Positioning of the child in the uterus (intrauterine crowding)
  • Ischemia of the affected side of the neck/upper body. Ischemia to the SCM may be caused by the previously mentioned intrauterine positioning or traumatic delivery. If the muscle is damaged due to ischemia, it is likely that the ipsilateral brachial plexius will also be damaged, resulting not only in CMT, but also in weak upper body strength, which will require additional interventions.2

The prevalence of CMT has been reported to be about 2%. Researchers have reported an increase in incidence ever since the introduction of the "back to sleep" campaign in which parents are encouraged to have their infant sleep on their back to prevent sudden infant death syndrome. A common subtype of CMT, positional preference, has a prevalence rate of 8.2%.4

CMT Subtypes2

  1. Sternomastoid tumor (SMT)
  2. Muscular torticollis (MT)
  3. Postural torticollis (POST)
  4. Postnatal muscular toricollis:
    1. Environmental-induced torticollis
    2. Plagiocephaly-induced torticollis
    3. Positional preference-induced torticollis

Physical Therapy Examination

Typically, it is the primary care physician who identifies CMT and refers the infant on to a physical therapist. Diagnosis of CMT ranges anywhere from 24 days to 3 months and is usually picked up during a routine visit to the doctors office within the baby's first months of life.2 A parent may have concerns and notice their child tends to keep their head to one side, lacks the ability to track objects across midline, or, in some cases has a palpable "lump" on their neck which is the case with the sternomastoid tumor subtype. A conservative home care stretching program may be established and monitored for a few months (a case in which the child is lacking <10 degrees of rotation between sides), or, if the condition is more severe, a referral to physical therapy will be made immediately, preferably within the first 2-3 months of the child's life.2 It has been stated that ‍‍‍‍‍‍69% of children who are treated within the first year of their life have a "good" outcome by 12 months of age.‍‍‍‍‍‍2 A scale to determine severity and predicted outcomes was created by Cheng, et. al. and is posted at the end of this section. Once the condition and the severity is established, the physical therapist will assess and treat the infant.

Subjective questions to ask parent or caregiver:
  • Evaluate prenatal and birth history:‍‍‍‍‍‍‍
    • Vaginal or C-section
    • Vacuum or forceps used?
    • Birth order (if multiple birth)
    • Birth weight/length
  • Feeding problems
  • Medications
  • Previous physical therapy interventions
  • Present concerns regarding the torticollis and head shape
  • Ask about baby's preferred sleeping position and if they have a head rotation preference (if so, to which side when sleeping)
  • Inquire about surface type that the baby normally sleeps on
Objective measures to assess for:
  • Restrictions in joint range of motion and muscle length with particular attention paid to:
    • Ipsilateral neck rotation
    • Contralateral lateral neck flexion
    • Contralateral asymmetric flexion and extension
    • Muscle and soft tissue extensibility
    • Skin creases about the neck
  • Active and Passive neck ROM
    • ‍‍‍‍‍‍Assessed in prone with the head and neck free of the supporting surface
      • This allows for a supporting surface and to keep the infant’s airways clear if the child lacks the strength or ROM to extend his/her head
      • In addition to prone, resting head position can also be measured or observed in supine or a seated position when applicable. Clinicians often choose to assess infants by beginning in supine then progressing towards prone and finally sitting when they are taking measurements.‍‍‍‍‍3
external image 1604S018t2.gif
‍‍ chart from Cheng et al, modified with permission from American Academy of Orthotists and Prosthetists.‍‍‍‍‍‍

Another aspect of the physical therapy exam to consider are non muscular causes of the muscle shortening. As with all orthopedic conditions, it is important to be aware of differential diagnoses. It has been stated that 1 in 5 infants diagnosed with CMT are of a non muscular origin. The following are several non-muscular conditions that may present in similar fashion as CMT and should be ruled out.
  • ‍‍‍‍‍‍Klippel-Feil syndrome
    • congenital fusing of at least 2 cervical vertebra5
  • brachial plexus injury
  • occular impairments
  • benign paroxysmal torticollis
  • arnold-chiari malformation‍‍‍‍‍‍

Congenital Muscular Torticollis and Developmental Dysplasia of the Hip

There is a well known association between CMT and Developmental Dysplasia of the Hip (DDH). Kim et al. reports a 14.9% correlation between the two conditions. However, it is not necessary to use ultrasound for screening/diagnosing DDH in all infants who present with CMT. Most cases of CMT and DDH had spontaneous resolution of the hip condition within 2 months of it being identified in the US screen. ‍‍‍‍‍‍Thorough hip examinations, including special tests such as the Barlow and Ortolani‍‍‍‍‍‍ should be completed on infants with CMT due to high prevalence rates, but US should only be used in specific cases.6


The typical findings/limitations of a baby with torticollis include:
  • ‍‍‍‍‍‍decreased ipsilateral rotation of the neck
  • decreased contralateral sidebend of the neck
  • contralateral asymmetric flexion/extension of the neck‍‍‍‍‍‍

Due to the attachment of the SCM and close proximity to the spine and skull, the shortened muscle and prolonged position of the head can lead to further deformities of the face and skull. Possible facial asymmetries include:
  • ‍‍‍‍‍‍cranial base deformity
  • craniofacial skeletal structure deformity
  • chin point and tip of nose unaligned
  • asymmetrical eyes
  • scoliosis toward the affected side (double spinal curve possible when child begins to sit and compensates for misaligned head position)
  • Inferior/posterior ipsilateral ear‍‍‍‍‍‍

Aside from the potential facial and muscular abnormalities, limitations of typical activities can also be a problem in an infant with CMT. According to Campbell's Physical Therapy for Children, some of the more noteworthy physical limitations are:
  • overcompensation of torso muscles
  • unable to keep head at midline while in a seated position
  • Difficulty weight bearing through the arm on the affected side
  • reaching across midline from the affected side
  • limitations with dual hand tasks such as clapping
  • visual and vestibular deficits leading to balance problems

Schertz et al did a study to determine if developmental delays persisted into adolescence, when the child born with CMT was 7-9 years old. Some of his findings include:
  • 5 children still had signs of mild torticollis
  • 9 out of 32 children were below normal and 2 were very low average on the Movement Assessment Battery for Children.
  • 7 out of 28 children were below normal and 1 was very low average on the Bruininks-Oseretsky Test of Motor Proficiency.
  • 14 of the children diagnosed with ADHD
  • overall, 19% of children in the study showed signs of motor delay
  • Children born with torticollis are at risk of developmental coordination disorder and ADHD

Other studies have shown that babies born with CMT typically have resolved to normal motor function by one year, and that risk of motor delay in infants may be more so related to lack of prone positioning (tummy time) while awake than with CMT.4,11



Positional plagiocephaly is a disorder in which the back or one side of an infant's head is flattened. It's most often the result of babies spending too much of time lying on their backs or by being in a position where their head is resting against a flat surface such as in cribs, strollers, swings, and playpens.7

Babies' skulls are soft and are made up of several skull plates. These movable plates have space between them, called sutures, that allow the head to be flexible so that the brain can grow. If the head is left in the same position for long periods of time, the plates move in a way that leaves a flat spot. Preterm babies are more likely to get flats spots on their heads because their heads are softer than those of full-term babies.
The most common causes of positional plagiocephaly include:
  • Too little time spent upright—sometimes called "cuddle" time
  • Too little "Tummy Time" when the baby is awake and supervised8
  • Too much time in car seats, carriers, and bouncy seats9

Chicken or The Egg??
Many infants are born with torticollis which is likely related to fetal positioning in the during late pregnancy and the infant consequently develops plagiocephaly after birth. On the flip side, the majority of infants with plagiocephaly have some limitation of active neck ROM that develops into a preference to turn the head to one side and not to the other which leads to torticollis.

Premature babies are more prone to positional plagiocephaly because their skulls are softer than full-term babies, and they spend a great deal of time on their backs without being moved or picked up because of their medical needs and extreme fragility after birth, which usually requires a stay in the neonatal intensive care unit (NICU).
Children who are left untreated may suffer from one or more of the following associated problems:10‍‍‍
  • Open mouth posture
  • Tongue may be pulled to one side or the other
  • Suck/swallow may be affected
  • Shortening of other neck or trunk muscles can occur
  • Facial asymmetry can occur
  • Feeding issues may occur
  • Fisting of hands, decreased strength, unequal weight bearing for crawling/walking, child may be perceived as clumsy

‍‍‍‍‍‍Physical Therapy Interventions‍‍‍‍‍‍

  • Conservative, non-operative treatment
    • passive, pain-free manual stretching to end range
    • creative activities to keep the head and trunk in midline
    • Gentle Massage
    • myofascial release
  • AAROM, strengthening, postural control exercises
  • Instructions to parents/caregivers on how to carry and position infants to promote elongation of involved SCM and to promote active contraction of the contralateral SCM
  • The type of conservative plan given will depend on the child's age, their tolerance to the stretches, the severity of the torticollis and the willingness/availability of the caregiver.2

Contraindications for passive neck ROM:3
  • Bony abnormalities
  • Fracture
  • Down syndrome
  • Myelomeningocele
  • Compromised circulatory or respiratory system
  • Malignancy
  • Osteomyelitis
  • Tuberculosis
  • Ruptured or lax ligaments
  • Infection
  • Shunt
  • Arnold-Chiari malformation (brain malformation when there is downward displacement of the cerebellar tonsils through the foramen magnum)

Orthotic devices

Cranial Helmets:
Cranial Helmet.jpg

What are they?
  • The cranial helmet is used to remold the head into a symmetrical shape as the baby grows. It allows the flattened areas to round out and prevents the bulging areas from bulging more. The helmet does not put pressure on the baby’s head, but rather guides the growth to specific areas to improve the head shape. It is very important to start treatment early since the growth of the head slows down after age of 12 months. Usually the earliest an infant can start wearing a helmet is at 5 months. Infants younger than that typically do not have the appropriate strength in the neck and head muscles to control the movements of the head. It is also important for the baby to be screened for other conditions that may have caused the uneven head growth.12
Why use them?
  • Infants who are fitted plastic helmets have been successfully used to remold the deformed heads. Each helmet is designed to fit snugly against the prominent aspects of the infants' cranium and to be fitting where the head is shallow. As the brain grows, the head is molded to fit the helmet and thus acquires a more usual shape. The treatment has been safe and effective. When torticollis is persistent after the initiation of treatment, rubber straps can be fixed to the outside of the helmet and attached to the side rails of the crib. While the infant sleeps, the straps can be tightened to stretch the shortened SCM muscle.13
The referral process:
  • Orthotic therapy with the cranial remolding helmet is started with a referral from the baby's pediatrician or a cranial facial physician. It is likely that the physician has recommended repositioning therapy prior to recommending the orthotic therapy. If the repositioning therapy does not correct the problem then orthotic therapy is often recommended.
The re-shaping process:
  • A mold or cast impression of the child's head is made in order to create a custom fabricated helmet that will help reshape the head. The child will continue to come in for readjustment over the next six months to one year. The bones remold to the helmet shape, and you will be able to see subtle changes in the child's head shape.14

Torticollis Collars:15
Torticollis Collar.jpgtorticollis-collar-06.jpgtorticollis-collar-02.jpg
What are they?
  • A loop of soft PVC tubing is braced by two short nylon tubes. Varying sizes of tubes are packaged with the collar. These tubes are positioned anterior and posterior to the crest of the trapezius. The PVC tubing is fastened with a connecting strap. A spare Velcro Strap is included. The Torticollis Collar is non-toxic and washable.
Why use them?
  • The Torticollis Collar use is added to the conservative treatment of infants with congenital muscular torticollis if they are 4 months of age or older and show a consistent head tilt of 5 degrees or more. The infant must have adequate ROM and lateral head righting reaction (head control and strength) to lift his or her head away from the side of the brace.
Torticollis Collar for the Fitter:
  • a simple to fit brace
  • easy adjustment using interchangeable tubes
  • longer tubes can be inserted to accommodate improved alignment
  • all parts for the Torticollis Collar are available as replacements
Torticollis Collar for the Wearer and/or Caregiver:
  • a cool, comfortable Torticollis Collar
  • easy to put on and remove
  • low profile; unobtrusive appearance
  • easy to keep clean (soap and water)
  • amount of support set to wearer needs15

Sports Injuries in Children

More and more children are participating in sports activities. This has obvious benefits as it helps to increase a child’s physical activity levels helping them to meet the requirements set by the Surgeon General as well as combat the staggering rates of childhood obesity. However, along with increased participation is an increase in sports related injuries. Half of all injuries seen in young athletes are due to overuse, which may continue to be a problem as trends for children to specialize in a particular sport lead to year round activity with limited rest periods to recover and minimal cross training.3

Incidence of Injury3

Sports with High Injury Rates for Gender
  • Ice hockey
  • Rugby
  • Soccer
  • Cross country running
  • Basketball
  • Gymnastics
  • Cross country running
It may be important to note that boys tend to have increased injury rates as they age. This could be due to the fact that as they age they build more muscle mass and can generate more power. Perhaps the alterations in body mass affect motor control and make one more susceptible to injury.
Most often injuries occur to the lower extremity, particularly the knee and ankle. However, rates of injuries are different for different sports such as baseball tends to have more upper extremity injuries.
What is concerning is that the rate of overuse injuries is on the rise. At one time injuries like this were considered to be rare, but now make up about 50% of reported injuries seen in kids mostly in part to kids specializing in sports at a younger age, increased training time, and lack of coaching. This estimate is probably low as many times these types of injuries are self-managed.3
Sports Causing Head/Neck/Back Injuries and/or Fatalities
  • Horseback riding
  • Hang gliding
  • Gymnastics
  • Trampoline
  • Alpine skiing
  • Diving
  • Football – most due to tackling
  • Ice hockey – most due to body checking
  • Baseball – hits from bat or ball contact to the chest/head/neck/throat

Injury Risk Management

  • Preparticipation examination - PPE (Physical) – determines general health and fitness level, detects risk factors and contraindications to physical activities, identifies sports that are safe to participate in, educates student. Required in most states.
  • Conditioning and training
  • Proper supervision
  • Protection of the body
  • Environmental control

Performing the PPE

  • History
    • short forms written in lay terms are the best
    • Must be signed by legal guardian
    • Looking for present conditions, past injuries, and family health history
  • Physical Exam3
    • Evaluates areas of concern noted in the history
    • Blood pressure for children should be predicted using gender and height percentile.
        • Upper limits include:
        • <6 years old - 110/75 mmHg
        • 6-10 years old – 120/80 mmHg
        • 11-14 years old - 125/85 mmHg
        • 15-18 years old – 135/90 mmHg
    • Ausculation of heart and lung sounds
    • Vision should be correctable to 20/200. Note pupil dilation symmetry
    • Abdominal palpation looking for tenderness or swollen organs
    • Presence of infectious skin diseases
    • Posture, spinal curvature, pelvic level, leg length, genu varus/valgus, pes planus, patellar positioning, muscle atrophy. Gait assessment with and without shoes. ROM, MMT, instability tests if previous injury or signs of instability.
  • Body Composition
    • BMI compared to standard growth charts. Underweight if below the 5th percentile, at risk for becoming overweight if between 85th and 95th percentile, and overweight if over the 95th percentile.
  • Specific Field Tests
    • Determines strengths and weaknesses, identifies any deficits caused by previous injuries, and assess potential to succeed in the sport in question.16,17
  • Other
    • PPE can also be used to screen for: substance abuse, eating disorders, depression, attention, mood, and unsafe sexual behaviors.18,19
Kansas PPE
Missouri PPE

Training Program3

  • Energy Training
    • Provides a strong aerobic base
    • Focus during the off-season
    • Low-intensity, long duration
    • Sport specific
    • Varies from low to moderate intensity
    • Include anaerobic training 2x/wk (intervals, pace training, fartleks)
  • Resistance Training
  • Speed
  • Nutrition
Resistance Training in Youth20,21
  • You cannot gain strength during preadolescence due to low levels of androgens
  • Now known that strength gains can be made in children as young as 5.
  • Absolute strength gains will be greater in older children due to higher levels of androgens.
  • Weightlifting will close growth plates and stunt growth
  • Resistance training can improve bone density,particularly when adequate nutritional needs are being met
  • No detrimental effects to the growth of the long bones
  • Kids won’t like weightlifting
  • Unlike cardiovascular training that requires long duration, resistance training combines short bursts of exercise with frequent rest periods, which closely resembles natural play activities.
  • Lifting hard will make my kid better at sports
  • Conflicting results on whether strength training actually helps with sport performance
  • Resistance training can help decrease risk of sport-related injury
  • Few young athletes actually participate in comprehensive strengthening programs, so this is an area that needs further development
  • Kid’s shouldn’t max out
  • Documented that 1RM is safe to perform with a child, if the child has previously been taught proper lifting techniques and is supervised while performing test in order to avoid injury.
  • However, field tests may be more appropriate than 1RM due to time constraints, not familiar with child’s technique, etc.

Research is unsure of the exact mechanisms behind the strength gains seen in children – normal growth and development, improved neural mechanisms*, hypertrophy, hormones. Yet, training effects do occur beyond normal growth and development as detraining effects can be seen after the termination of a strength training program, and losses occurred despite participation in other activities (Faigenbaum et al.). Keep in mind though that a child’s ability to gain muscle strength does appear to correlate with age and maturational status (Behringer et al.) so know what Tanner Stage of development they are in.20,21

So When and How Do I Start Training Kids?20,21
  • No specific age, kids should be emotionally and mentally mature enough to follow coaching instructions and endure the stresses of training.
  • Need to be supervised by coaches and staff that are knowledgeable of training in children
  • Start with 5-10 minute dynamic warm-up
  • Begin with lighter loads and focus on technique
  • 1-3 set of 6-15 reps both upper and lower body strength exercises
  • Include abdominal and lower back strengthening exercises
  • Promote symmetrical muscular development around joints
  • 1-3 sets 3-6 reps both upper and lower body power exercises
  • Increase resistance slowly 5-10%
  • Cool down with less intense calisthenics and static stretching
  • 2-3 times per week on nonconsecutive days
  • Keep a log to track individual progress

Recommendations for progression during resistance training for STRENGTH21

Muscle Action
Eccentric & Concentric
Eccentric & Concentric
Eccentric & Concentric
Exercise Choice
Single Joint and Multi-Joint
Single Joint and Multi-Joint
Single Joint and Multi-Joint
50-70% 1 RM
60-80% 1 RM
70-85% 1 RM
1-2 sets, 10-15 reps
2-3 sets, 8-12 reps
3+ sets, 6-10 reps
Rest Intervals
1 min
1-2 mins
2-3 mins
2-3 days/wk
2-3 days/wk
3-4 days/wk

Recommendations for progression during resistance training for POWER21

Muscle Action
Eccentric & Concentric
Eccentric & Concentric
Eccentric & Concentric
Exercise Choice
30-60% 1 RM velocity
30-60% 1 RM velocity
60-70% 1RM strength
30-60% 1 RM velocity
70-80% 1 RM strength
1-2 sets, 3-6 reps
2-3 sets, 3-6 reps
3+ sets, 1-6 reps
Rest Intervals
1 min
1-2 mins
2-3 mins
2 days/wk
2-3 days/wk
2-3 days/wk
  • Speed
    • Children are born with inherited muscle fiber types (slow twitch vs fast twitch).
    • Rather than training for speed, children athletes should focus on quickening reaction times as well as flexibility and strength.
  • Nutrition
Nutritional requirements are different for adults than children. Body fat can be measured in children using skinfold assessments. Also, younger children tend to have higher caloric needs than older children and varies with activty level. To calculate caloric needs:
    • Ideal weight (lbs) x10 = basal calorie requirements
    • Basal calories x3 for sedentary
    • Basal Calories x5 for moderately active
    • Basal Calories x10 for vigorous activity
    • Add 10 to 14 kcal/min for boys and 9-12 kcal/min for girls for additional sports activities3
  • eating-yogurt1.jpg

Child athletes should eat 50% carbs, 15% protein, and 30% fat (with no more than 10% being saturated fat). Generally a healthy diet is sufficient and parents should be cautious in using supplements. Also, parents of athletes should be aware that young children cannot store glycogen for muscle storage and the result is generaly water retention and muscle stiffness.

Dietary habits should change throughout training. During the offseason athletes should focus on weight maintenance and preseason should focus on achieving optimal weight and maintaining good nutrition.
  • Before event: youth should eat an easily digestible meal 2-3 hours before competition. The meal should be low in fat, salt, protein and bulk.
    • Also, children require 16 ounces of water to replenish for each pound of weight lost during competition. Youths involved in distance running should consume 400-500 ml water prior to event.
    • Kids should also consume water every 30-45 minutes during activity. Sports drinks have been demonstrated to reduce dehydration simply becuase of children's preference.
    • Cool fluids enter the system more easily.3

Signs of dehydration:
  • Irritability
  • headache
  • nausea
  • weakness
  • cramps
  • abdominal distress

Overweight children will benefit from a reduction in 1000 kcal per day which can result in a 2 lb loss each week.3

Michelle Obama's Obesity Initiative

Photo from:

Supervision and well being
Realize that many of childrens coaches are volunteers and may have limited training in appropriate warm up techniques before athletic competition. "The American Academy of Pediatrics has stated that coaches should encourage preparticipation screenings every two years, enforce the use of a warm-up procedures and enforce rules concerning safety." The Academy also suggests attending a certification program which includes, "Teaching techniques, basic sport skills, fitness, first aid, sportsmanship, enhancement of self-image, and motivational skills."3

Parents reaction to football injury

Children should also be fitted with appropriate equipment for the particular sport, such as eye protection. In wrestling, the use of headgear has been shown to reduce the number of head and neck injuries. Oral injuries should also be a concern and atheltes should wear mouth guards when appropriate to the sport. "Helmets should always be approved by the National Operating Committee on Standards for Athletic Equipment and the American National Safety Institiute."
The environment should be monitored for safe play.
  • Kids require greater fluid replenishment than adults
  • Kids cannot endure exercise in extreme temperatures as adults can due to a greater surface area per body weight.3
Factors leading to injury:3
  1. training errors (overtraining)
  2. muscle imbalances
  3. anatomical malalignment
  4. inappropriate footwear
  5. playing surface
  6. disease state
  7. growth


‍‍‍‍‍‍Pronation in children may be observed after the child starts a new sport and begins to have lower extremity pain.Link to a podiatrist website with information on treatment for overpronation in children.23

McLeod et al. discusses:24
  • Ways to prevent overuse injuries which have been recommended by the ACSM, WHO, Internataional Federation of Sports Medicine, American Academy of Pediatrics and International Olympic Commitee
  • Signs of an overuse injury
  • Important components of annual physical
  • Factors that predispose an athlete to injury.
  • Includes a throwing chart for coaches to keep track of each player's pitches

Overtraining as a result of:
  • Specialization in sports at a younger age
  • Failure to properly prepare for the competitive season
  • Not taking breaks in the off season
    • Repetitive movments have been shown to result in imbalances between muscles and tendons which can lead to problems. Even cautious children may develop injuries becuase of anatomical malalignment issues.
    • Common malalignement issues include:
      • leg length discrepency, femoral anteverion, and ankle pronation among others.
    • Properly fitted shoes can help with some alignment issues and children experienceing pain should consider changing footwear. Playing sports on differentt terrain may cause injuries especially when the child is not wearing appropriate shoes.3

Current disease states must be considered in child athletes. This may include notifying coachs of old injuries or medical history.
Common childhood conditions include:3
  • Legg Calve Perthes
  • Juvenile Rheumatoid Arthritis
  • Osgood Schlatter's
  • Sever's Disease
  • Osteochondritis Dissecans
  • Little Leaguer's Elbow

Why are these diagnosis seen in children?3
  • Children's cartilage has low resistance to repetitive loading
  • Articular cartilage is suseptible to shearing
  • Longitudinal growth begins at the bones and later in the soft structures, causing muscles to tighten
  • Bone changes composition from a cartilagenous material to a firmer bone
  • The epiphysis is especially suseptible to damage at this time and trauma at the growth plate may inhibit proper growth

Musculoskeletal Injuries

  • Three main methods for classification of concussion severity
    • American Academy of Neurology: Severity graded based on signs and symptoms present at time of injury
    • Cantu Evidence Based: Severity graded based on presence and persistence of symptoms post-injury
    • International Conference on Concussion: Severity graded on rate of recovery; not presenting symptoms
  • Initial Assessment
    • Initial assessment occurs at time of injury --> important to take an in depth history as well as assessment of present signs and symptoms
    • Graded Symptom Checklist

  • Return to Sport Following Concussion
Return to activity.png

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F90 Premier Headguard -->

Common Musculoskeletal Injuries
  • Traction Burners3,25
    • A common musculoskeletal injury particularly is adolescents
    • Defined as an injury to the brachial plexus --> typically seen with to collision sports
    • Repeated Injury can be cause muscular weakness which can be prevented or treated with strengthening exercises
    • It is suggested that return to play should be determined by physician physician (full neck range of motion, strength, and sensation)


  • Lumbar Spondylolysis/Spondylolisthesis
    • Repeated hyperextension/hyperflexion of the lumbar spine particularly with specific sport activities (football blocking, pole vaulting, soccer, gymnastics and wrestling)
    • Adolescent athletes can be managed with the use of a back brace until healing occurs
    • Conservative Treatment of Lumbar Spondylosis in Young Soccer Players26
      • Retrospective Review of 34 soccer players diagnosed with spondylolysis and a minimum 2 year follow up
      • All received conservative treatment during cessation of sport activity
      • Subjects with pain a rest or daily living activities were also treated with thoracolumbar orthotic
      • Rehabilitation Protocol Focused on: strengthening of abdominal muscles, hamstring stretches, core stability exercises and pain free trunk rotation range of motion
      • At 2 year follow-up: 82% had excellent results, 12% good results, 3% fair and 3% poor results

  • Little League Shoulder3,27
    • Common injury seen in adolescents specifically baseball pitchers and catchers
    • Defined as a fracture of the proximal humeral growth plate due to rotational forces from excessive throwing
    • Primary complaint if proximal shoulder pain with throwing and "aching" of shoulder for days after
    • Treatment includes cessation of throwing until growth plate heals along with strengthening of parascapular and core musculature
    • Prevention includes strengthening exercises as well as following recommended guidelines for age-specific pitch counts

  • Disorders of Patellar Mechanism3,28
    • One of the most common causes of knee pain in young athletes in patellofemoral pain syndrome
    • Blunt force trauma, repetitive microtrauma and growth spurts can all be causes for patellofemoral joint pain
    • Abnormal patella tracking can cause excessive friction and forces on the cartilage behind the patella
    • Often seen in kids that are involved in sports requiring a lot of running and jumping (track, volleyball and basketball)
    • Pain is seen with running, squatting and climbing stairs
    • Rehabilitation usually involves balance of knee/hip strength, stretching and correction of gait biomechanics

Rehabilitation and Return to Play

The rehabilitation protocols and techniques of adults are often applied to children and adolescents. While this is often what occurs in clinical practice, there are certain aspects that need to be considered in the child or adolescent patient:3
  • Age-appropriate modifications
  • Specifically related to relevant anatomy
  • Surgical procedures/modifications performed (if applicable)
  • Protection and preservation of future bone growth
  • Unique psychological factors
There are also barriers and facilitators, which need to be considered when assessing an individual's return to play following an injury:29
  • Personal factors:
    • Age
    • Physical strength
    • Psychological readiness of child
  • Environmental factors:
    • Health services provided
    • Sport-related factors
    • Parental attitude--According to clinicians surveyed by Mazer et al.,29 parental attitude (either aggressive or overly cautious) had the most consistent effect on their decision for whether or not to recommend a child to return to activity.
Even though clinicians seem to be aware these aspects need to be considered during treatment, this is not necessarily what occurs in clinical practice due to a lack of consistent and randomized research. A review by Cohen and Sala,30 found that there is a significant lack of "well-designed studies with sufficient numbers of patients to address the issues relevant to the management of the injured young athlete." Furthermore, in most cases the rehabilitation programs used in studies were not described to a high enough level to allow the programs to be properly replicated.30

Acute & Intermediate Phases of Rehabilitation
Rehabilitation programs for children and adolescents begin with first aid immediately after an injury occurs on the field of the sporting event. Once a child has started rehabilitation, patient and family education regarding the necessity of protecting the injury is very important. During this phase, the patient's goals also need to be addressed.3 Unfortunately, there is very little information regarding these phases of rehabilitation for musculoskeletal injuries; however, based on a PubMed search, there are numerous studies outlining the rehabilitation for traumatic brain injuries.

Advanced Stages of Rehabilitation
The long-term goal of rehabilitation is to safely return to activity/sport/play, while minimizing the risk for subsequent injury. This is best achieved through a comprehensive training program. This should include basic strength and balance training, and it is equally important (if not more important) to retrain biomechanics techniques. Through this training, the risk for injury will be reduced. The transition to returning to activity needs to be gradual and safe, and should be based on clinical milestones the child meets.3

Return to Activity
The timing of a child returning to activity should be based on objective measures obtained from a functional evaluation. This includes measuring muscle strength using a dynamometer, patient-reported outcome tools, and performance-based functional assessments. Examples of performance-based functional tests include jumping, hopping, or cutting. For physical objective measures, the recommended criteria for return to activity are that the performance of the involved tissue be at least 85-90% of the contralateral tissue.3

The Young Athlete with a Physical Disability

Risk of Injury
All young athletes are at risk for injury, due to the nature of the activities being performed. This risk can be exacerbated in an athlete who already has a pre-existing disability.3 Acute soft-tissue injuries are the most commonly reported injuries.31,32 These include sprains/strains, skin abrasions, and soft tissue contusions.32

Preparticipation Examination (PPE)
As stated above, a PPE is important, regardless of whether or not an athlete has a physical disability. PPEs are important to screen for medical conditions or injuries that could put an athlete at risk, such as cardiac problems.33 The PPE for an athlete with a physical disability should be very similar to that of an athlete without disability because it serves the same purpose. It is important to not focus on the young athlete's primary condition that is causing the physical disability. If this occurs, the examiner is at risk to neglect common medical issues.32 An example of a PPE for athlete's with physical disabilities is provided below:34
Another PPE example is the Sports-Medical Assessment Protocol, which has been assessed on athletes with disability. It includes an interview, a cardiorespiratory assessment, and a physical and functional examination.35 In individuals with disability, it is also important to assess posture and balance that is required for both safe and effective participation in activities. For instance, different activities require different levels of balance (wheelchair basketball vs. sitting volleyball).3,32

Training Programs
Physical activity and training programs are just as important in a pediatric population with disability, as they are for those without disability. These programs and activities have very similar physiological benefits as they do for able-bodied individuals, such as increased maximal oxygen uptake and increased muscle force.3 According to a review by Patel and Greydanus32, there are many activities an individual with a physical activity can participate in; an individual with a physical disability can actually participate in almost every activity an individual without a disability can (with some modifications). The review article has a very helpful and lengthy table to reference for available activities.

Adaptive Sports Resources

Case summary


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  2. Freed SS, Coulter-O'Berry C. Identification and treatment of congenital muscular torticollis in infants. JPO. 2004; 16(4S):18-23.
  3. Campbell SK, Palisano RJ, Orlin MN. Physical Therapy for Children. 4th ed. St. Louis, MO: Elsevier Saunders; 2012:292-312,453-497.
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