Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents for evaluation of persistent head tilt and limited cervical range of motion. Parents report preference for looking to one side, noted since [Age]. No history of trauma, fever, or neurological deficits. Feeding and developmental milestones are otherwise age-appropriate.
Clinical Examination Findings
Head is tilted toward the affected side with chin rotated toward the opposite shoulder. Palpable firm, non-tender mass noted within the sternocleidomastoid (SCM) muscle. Cervical rotation is restricted to [Degrees] on the affected side. No cranial nerve deficits; symmetric Moro reflex; no hip dysplasia noted on Barlow/Ortolani maneuvers.
Treatment Protocol
Initiate aggressive physical therapy focusing on passive stretching of the SCM muscle and active range of motion exercises. Implement positioning program: encourage prone play, side-lying on the affected side, and visual stimulation from the restricted side. Follow-up in [Timeframe] to monitor progress and assess for plagiocephaly.