Report of a Child with Severe Fibrosis and Problems after Surgery both as an Infant and at Preschool Age

A case report describing a child with severe left-sided congenital muscular torticollis (CMT). Physical therapy (PT) had no effect before surgery was performed. The first surgery was performed at 13 months of age and in the beginning post-surgery results were good. However, reoccurrence of fibrosis tissue occurred soon with a contracture in the sternocleidomastoid muscle (SCM), with a rather mild head tilt and elevated shoulder on the affected left side. Due to the COVID-19 pandemic, re-surgery was delayed for about two years. During that time the problems increased; the elevated shoulder got more prominent and a lump developed in the left-side upper trapezius muscle. Re-surgery was performed at pre-school age. Rehabilitation after re-surgery was challenging and took a long time. Early in treatment he achieved good passive range of motion (PROM) in the cervical spine but there were substantial problems with the elevated left shoulder and lump in the same shoulder, unusual problems at this young age.