Congenital muscular torticollis is traditionally treated by positioning techniques, neck collars and physical therapy. Refractory cases require surgical release. We reviewed 163 consecutive cases of infant positional molding over one year. Sixty-six of these patients had congenital muscular torticollis. Eight patients with congenital muscular torticollis were refractory to conservative management. Instead of surgical release, all eight patients underwent botulinum toxin type A injections to affected muscles (sternocleidomastoid, scaleneus, and trapezius). The number of units injected ranged from 60-82 units per patient; mean 68 units. Follow-up ranged from 2-12 months. Parents and physical therapist were surveyed. There were no complications. All patients demonstrated improvements with resting head position and active/passive range of motion. Parents and therapists reported patient comfort with therapy and quality of therapy improved in each case. None of the eight patients required surgical release. This experience with botulinum toxin type A in the treatment of severe recalcitrant congenital muscular torticollis serves as the foundation for a proposed treatment algorithm advocating the use of botulinum toxin type A in cases that fail to progress with conservative management and in less severe cases to improve therapy comfort, quality and compliance.