Chapter 3Chapter 3

Assessment of PostureAssessment of Posture

IntroductionIntroduction

Posture is the position of the body at a given Posture is the position of the body at a given point in timepoint in time

Correct posture can:Correct posture can:– improve performanceimprove performance– decrease abnormal stressesdecrease abnormal stresses– reduce the development of pathological reduce the development of pathological

conditionsconditions

IntroductionIntroduction

Faulty posture:Faulty posture:– Deviates from ideal postureDeviates from ideal posture– Requires an increased amount of muscular Requires an increased amount of muscular

activityactivity– Places an increased amount of stress on the Places an increased amount of stress on the

joints and surrounding tissuesjoints and surrounding tissues Restrictions in normal movement patterns Restrictions in normal movement patterns

may cause compensatory posturesmay cause compensatory postures– Overtime can result in muscle imbalances and Overtime can result in muscle imbalances and

soft tissue dysfunctionsoft tissue dysfunction

IntroductionIntroduction

Pain related to postural deviations is a Pain related to postural deviations is a common clinical occurrencecommon clinical occurrence– Many do not seek help until pain is experiencedMany do not seek help until pain is experienced

Postural assessment is used to determine if Postural assessment is used to determine if postural deviations are contributing factors postural deviations are contributing factors in patient’s pain or dysfunctionin patient’s pain or dysfunction

Posture must be evaluated in functional and Posture must be evaluated in functional and nonfunctional positionsnonfunctional positions

Clinical AnatomyClinical Anatomy

Musculoskeletal system is designed to Musculoskeletal system is designed to function in a mechanically and function in a mechanically and physiologically efficient manner to use the physiologically efficient manner to use the least possible amount of energyleast possible amount of energy

Postural deviations or skeletal malalignment Postural deviations or skeletal malalignment cause other joints in kinetic chain to undergo cause other joints in kinetic chain to undergo compensatory motions or postures to allow compensatory motions or postures to allow body to move as efficiently as possiblebody to move as efficiently as possible

The Kinetic ChainThe Kinetic Chain

Closed kinetic chainClosed kinetic chain– Weight-bearingWeight-bearing– Lower extremity Lower extremity – Distal segment meets resistance or is fixatedDistal segment meets resistance or is fixated– Interdependency of each joint = predictable changes in Interdependency of each joint = predictable changes in

position position – Figure 3-1A, page 53Figure 3-1A, page 53

Open kinetic chainOpen kinetic chain– Non-weight-bearingNon-weight-bearing– Upper extremityUpper extremity– Distal segment moves freely in spaceDistal segment moves freely in space

The Kinetic ChainThe Kinetic Chain

A dysfunction occurring in one area may A dysfunction occurring in one area may affect the proximal or distal associated joints affect the proximal or distal associated joints and soft tissue structuresand soft tissue structures– Causing a specific postural deviationCausing a specific postural deviation

The body compensates for these deviations The body compensates for these deviations to maintain as much efficiency as possible in to maintain as much efficiency as possible in movement and functionmovement and function

Table 3-1, page 54Table 3-1, page 54

Muscular FunctionMuscular Function

Muscles produce joint motion and provide Muscles produce joint motion and provide dynamic joint stabilitydynamic joint stability

Muscles must be of adequate length and Muscles must be of adequate length and function in a proper mannerfunction in a proper manner– If too short or too long If too short or too long

Adverse stress on jointsAdverse stress on joints Work inefficientlyWork inefficiently Create need for compensatory motionsCreate need for compensatory motions

Table 3-2, page 55Table 3-2, page 55

Muscular Length-Tension Muscular Length-Tension RelationshipsRelationships

Describes how a muscle is capable of Describes how a muscle is capable of producing different amounts of tension producing different amounts of tension (force), depending on its length(force), depending on its length

Active insufficiencyActive insufficiency– Muscle is shortened and maximum tension Muscle is shortened and maximum tension

cannot be producedcannot be produced Passive insufficiencyPassive insufficiency

– Muscle is lengthened and cannot generate Muscle is lengthened and cannot generate sufficient tension to be effectivesufficient tension to be effective

Figure 3-4, page 56Figure 3-4, page 56

Agonist and Antagonist Agonist and Antagonist RelationshipsRelationships

AgonistAgonist– Muscle that contracts to perform the primary movement Muscle that contracts to perform the primary movement

of a jointof a joint

AntagonistAntagonist– Performs opposite movement of agonist and must relax Performs opposite movement of agonist and must relax

to allow agonist’s motion to occurto allow agonist’s motion to occur– Reciprocal inhibitionReciprocal inhibition

Bicep/triceps exampleBicep/triceps example Co-contractionCo-contraction

– Used for dynamic stability of jointUsed for dynamic stability of joint

Muscular ImbalancesMuscular Imbalances

Impaired relationship between a muscle that Impaired relationship between a muscle that is overactivated, subsequently shortened is overactivated, subsequently shortened and tightened and another that is inhibited and tightened and another that is inhibited and weakenedand weakened– Table 3-3, page 57Table 3-3, page 57

Postural vs. phasic musclesPostural vs. phasic muscles– Table 3-4, page 57Table 3-4, page 57– Table 3-5, page 57Table 3-5, page 57

Soft Tissue ImbalancesSoft Tissue Imbalances

Joint’s capsule and surrounding ligaments Joint’s capsule and surrounding ligaments undergo adaptive changes from prolonged undergo adaptive changes from prolonged overstressing or understressing of structureoverstressing or understressing of structure

Faulty posture can alter the position of Faulty posture can alter the position of joints, causing an increase in stress on joints, causing an increase in stress on different portions of the joint capsule and different portions of the joint capsule and surrounding ligamentssurrounding ligaments

Clinical Evaluation of PostureClinical Evaluation of Posture

Not an exact scienceNot an exact science– Radiographs, photographs, computer analysisRadiographs, photographs, computer analysis– Clinical tools – plumb lines, goniometers, Clinical tools – plumb lines, goniometers,

flexible rulers, inclinometers (fig. 3-5, page 58)flexible rulers, inclinometers (fig. 3-5, page 58)

Subjective vs. objective methodsSubjective vs. objective methods– Normal, mild, moderate, severe postureNormal, mild, moderate, severe posture– Quantifiable measurements can assess Quantifiable measurements can assess

treatment plan treatment plan

Clinical Evaluation of PostureClinical Evaluation of Posture

Commonly assessed in various positionsCommonly assessed in various positions– Standing and sittingStanding and sitting– Sport-specific and ADLsSport-specific and ADLs

OrthopositionOrthoposition– Normal or properly aligned postureNormal or properly aligned posture– 4 movements to perform before assessment4 movements to perform before assessment

Page 58Page 58

HistoryHistory

To determine if a postural dysfunction is To determine if a postural dysfunction is contributing to the patient’s pathologycontributing to the patient’s pathology

Identify any routine repetitive motions Identify any routine repetitive motions IF injury is chronicIF injury is chronic

– Explore day to day tasks and postureExplore day to day tasks and posture

If injury is acuteIf injury is acute– Determine factors that may have predisposed Determine factors that may have predisposed

athlete to the injuryathlete to the injury

HistoryHistory

Mechanism of injuryMechanism of injury– Common responsesCommon responses

Insidious onsetInsidious onset Pain worsening as day progressesPain worsening as day progresses Posture-specific painPosture-specific pain Intermittent, vague , or generalized painIntermittent, vague , or generalized pain Starting as an ache and progressingStarting as an ache and progressing

Type, location, and severity of symptomsType, location, and severity of symptoms Side of dominanceSide of dominance Activities of daily livingActivities of daily living

– Table 3-7, pages 60-61Table 3-7, pages 60-61

HistoryHistory

Driving, sitting, and sleeping posturesDriving, sitting, and sleeping postures– Table 3-8, page 62Table 3-8, page 62

Specific postures causing discomfortSpecific postures causing discomfort Level and intensity of exerciseLevel and intensity of exercise Medical HistoryMedical History

InspectionInspection

ConsiderationsConsiderations– Area being used is private, comfortableArea being used is private, comfortable– Patient preparednessPatient preparedness– Do not inform patient you are assessing postureDo not inform patient you are assessing posture– Use systematic approachUse systematic approach

Start at feet and work superiorly or vice versaStart at feet and work superiorly or vice versa

– Compare bilaterally for symmetryCompare bilaterally for symmetry– Your eyes should be at level of region you are Your eyes should be at level of region you are

observingobserving

Overall ImpressionOverall Impression

Determine patient’s general body typeDetermine patient’s general body type– Ectomorph, mesomorph, endomorphEctomorph, mesomorph, endomorph– InheritedInherited– Can indicate a person’s natural abilities and Can indicate a person’s natural abilities and

disabilitiesdisabilities– Does not necessarily dictate how they may Does not necessarily dictate how they may

functionfunction– Box 3-1, page 64Box 3-1, page 64

Views of Postural InspectionViews of Postural Inspection

Inspect from lateral, anterior, posterior viewsInspect from lateral, anterior, posterior views Plumb linePlumb line

– Feet as permanent landmarkFeet as permanent landmark– Lateral viewLateral view

Slightly anterior to lateral malleolusSlightly anterior to lateral malleolus

– Anterior and posterior viewAnterior and posterior view Equidistant from both feetEquidistant from both feet

– Box 3-2, page 65Box 3-2, page 65

ViewsViews

Lateral viewLateral view– Table 3-9, page 63Table 3-9, page 63

Anterior viewAnterior view– Table 3-10, page 66Table 3-10, page 66

Posterior viewPosterior view– Table 3-11, page 67Table 3-11, page 67

Inspection of Leg Length Inspection of Leg Length DiscrepancyDiscrepancy

Three categoriesThree categories– Structural (true)Structural (true)– Functional (apparent)Functional (apparent)– CompensatoryCompensatory– Table 3-12, page 68Table 3-12, page 68

Block method (Box 3-3, page 69)Block method (Box 3-3, page 69) Figure 3-6, page 68Figure 3-6, page 68 Figure 3-7, page 70Figure 3-7, page 70 Figure 3-8, page 70Figure 3-8, page 70

PalpationPalpation

To determine specific positions (key To determine specific positions (key landmarks) not necessarily for point landmarks) not necessarily for point tendernesstenderness

Lateral aspectLateral aspect– Pelvic positionPelvic position

ASIS and PSIS, 9-10ASIS and PSIS, 9-1000

Box 3-4, page 71Box 3-4, page 71

PalpationPalpation

Anterior aspectAnterior aspect– Patellar positionPatellar position– Iliac crest heightsIliac crest heights

Figure 3-9, page 70Figure 3-9, page 70

– ASIS heightsASIS heights Figure 3-10, page 70Figure 3-10, page 70

– Lateral malleolus and fibula head heightsLateral malleolus and fibula head heights– Shoulder heightsShoulder heights

Figure 3-11, page 72Figure 3-11, page 72

PalpationPalpation

Posterior aspectPosterior aspect– Many of same landmarks used for anterior viewMany of same landmarks used for anterior view– PSIS positionPSIS position

Figure 3-12, page 72Figure 3-12, page 72

– Spinal alignmentSpinal alignment– Scapular positionScapular position

Box 3-5, page 73Box 3-5, page 73 Not important at this timeNot important at this time

Common Postural DeviationsCommon Postural Deviations

Not all postural deviations cause pathologyNot all postural deviations cause pathology Clinicians must identifyClinicians must identify

– Normal postureNormal posture– Asymptomatic deviationsAsymptomatic deviations– Deviations causing dysfunction and/or painDeviations causing dysfunction and/or pain

Potential muscle imbalances can cause Potential muscle imbalances can cause poor posture poor posture OROR be a result of poor posture be a result of poor posture

Deviations also caused by skeletal Deviations also caused by skeletal malalignment, anomalies, or combinationmalalignment, anomalies, or combination

Foot and AnkleFoot and Ankle

HyperpronationHyperpronation– Review chapter 4Review chapter 4– Figure 3-13, page 74Figure 3-13, page 74

SupinationSupination– Review chapter 4Review chapter 4

The KneeThe Knee

Genu RecurvatumGenu Recurvatum– Knee axis of motion is posterior to plumb lineKnee axis of motion is posterior to plumb line– Box 3-6, page 75Box 3-6, page 75

Genu ValgumGenu Valgum– Occurs due toOccurs due to

structural anomalies or muscular weaknesses at the hipstructural anomalies or muscular weaknesses at the hip Secondary to hyperpronation of the feetSecondary to hyperpronation of the feet

– Can lead to Can lead to Increased pronationIncreased pronation Internal tibial and femoral rotationInternal tibial and femoral rotation Medial patellar positioningMedial patellar positioning

The KneeThe Knee

Genu VarumGenu Varum– Occurs due toOccurs due to

Structural anomalies at the hipStructural anomalies at the hip Excessive supinationExcessive supination

– Can lead toCan lead to SupinationSupination External tibial and femoral rotationExternal tibial and femoral rotation Lateral patellar positioningLateral patellar positioning

Interrelationships Between RegionsInterrelationships Between Regions

Table 3-14, page 83Table 3-14, page 83 May be impossible to determine if posture is May be impossible to determine if posture is

the cause or the effectthe cause or the effect– Understand relationships and importance of Understand relationships and importance of

correcting the factors involvedcorrecting the factors involved

Most soft tissue dysfunctions that have a Most soft tissue dysfunctions that have a gradual, insidious onset have, at least, a gradual, insidious onset have, at least, a minimal postural componentminimal postural component

Documentation of Postural Documentation of Postural AssessmentAssessment

Table 3-15, page 85Table 3-15, page 85– As part of a SOAP noteAs part of a SOAP note

Figure 3-14, page 84Figure 3-14, page 84– Standard postural assessment formStandard postural assessment form

Guidelines for documenting postureGuidelines for documenting posture– Pages 83, 85Pages 83, 85