Chapter 3 Assessment of Posture

Introduction Posture is the position of the body at a given point in time Correct posture can: improve performance decrease abnormal stresses reduce the development of pathological conditions

Introduction Faulty posture: Deviates from ideal posture Requires an increased amount of muscular activity Places an increased amount of stress on the joints and surrounding tissues Restrictions in normal movement patterns may cause compensatory postures Overtime can result in muscle imbalances and soft tissue dysfunction

Introduction Pain related to postural deviations is a common clinical occurrence Many do not seek help until pain is experienced Postural assessment is used to determine if postural deviations are contributing factors in patient’s pain or dysfunction Posture must be evaluated in functional and nonfunctional positions

Clinical Anatomy Musculoskeletal system is designed to function in a mechanically and physiologically efficient manner to use the least possible amount of energy Postural deviations or skeletal malalignment cause other joints in kinetic chain to undergo compensatory motions or postures to allow body to move as efficiently as possible

The Kinetic Chain Closed kinetic chain Open kinetic chain Weight-bearing Lower extremity Distal segment meets resistance or is fixated Interdependency of each joint = predictable changes in position Figure 3-1A, page 53 Open kinetic chain Non-weight-bearing Upper extremity Distal segment moves freely in space

The Kinetic Chain A dysfunction occurring in one area may affect the proximal or distal associated joints and soft tissue structures Causing a specific postural deviation The body compensates for these deviations to maintain as much efficiency as possible in movement and function Table 3-1, page 54

Muscular Function Muscles produce joint motion and provide dynamic joint stability Muscles must be of adequate length and function in a proper manner If too short or too long Adverse stress on joints Work inefficiently Create need for compensatory motions Table 3-2, page 55

Muscular Length-Tension Relationships Describes how a muscle is capable of producing different amounts of tension (force), depending on its length Active insufficiency Muscle is shortened and maximum tension cannot be produced Passive insufficiency Muscle is lengthened and cannot generate sufficient tension to be effective Figure 3-4, page 56

Agonist and Antagonist Relationships Muscle that contracts to perform the primary movement of a joint Antagonist Performs opposite movement of agonist and must relax to allow agonist’s motion to occur Reciprocal inhibition Bicep/triceps example Co-contraction Used for dynamic stability of joint

Muscular Imbalances Impaired relationship between a muscle that is overactivated, subsequently shortened and tightened and another that is inhibited and weakened Table 3-3, page 57 Postural vs. phasic muscles Table 3-4, page 57 Table 3-5, page 57

Soft Tissue Imbalances Joint’s capsule and surrounding ligaments undergo adaptive changes from prolonged overstressing or understressing of structure Faulty posture can alter the position of joints, causing an increase in stress on different portions of the joint capsule and surrounding ligaments

Clinical Evaluation of Posture Not an exact science Radiographs, photographs, computer analysis Clinical tools – plumb lines, goniometers, flexible rulers, inclinometers (fig. 3-5, page 58) Subjective vs. objective methods Normal, mild, moderate, severe posture Quantifiable measurements can assess treatment plan

Clinical Evaluation of Posture Commonly assessed in various positions Standing and sitting Sport-specific and ADLs Orthoposition Normal or properly aligned posture 4 movements to perform before assessment Page 58

History To determine if a postural dysfunction is contributing to the patient’s pathology Identify any routine repetitive motions IF injury is chronic Explore day to day tasks and posture If injury is acute Determine factors that may have predisposed athlete to the injury

History Mechanism of injury Type, location, and severity of symptoms Common responses Insidious onset Pain worsening as day progresses Posture-specific pain Intermittent, vague , or generalized pain Starting as an ache and progressing Type, location, and severity of symptoms Side of dominance Activities of daily living Table 3-7, pages 60-61

History Driving, sitting, and sleeping postures Table 3-8, page 62 Specific postures causing discomfort Level and intensity of exercise Medical History

Inspection Considerations Area being used is private, comfortable Patient preparedness Do not inform patient you are assessing posture Use systematic approach Start at feet and work superiorly or vice versa Compare bilaterally for symmetry Your eyes should be at level of region you are observing

Overall Impression Determine patient’s general body type Ectomorph, mesomorph, endomorph Inherited Can indicate a person’s natural abilities and disabilities Does not necessarily dictate how they may function Box 3-1, page 64

Views of Postural Inspection Inspect from lateral, anterior, posterior views Plumb line Feet as permanent landmark Lateral view Slightly anterior to lateral malleolus Anterior and posterior view Equidistant from both feet Box 3-2, page 65

Views Lateral view Anterior view Posterior view Table 3-9, page 63

Inspection of Leg Length Discrepancy Three categories Structural (true) Functional (apparent) Compensatory Table 3-12, page 68 Block method (Box 3-3, page 69) Figure 3-6, page 68 Figure 3-7, page 70 Figure 3-8, page 70

Palpation To determine specific positions (key landmarks) not necessarily for point tenderness Lateral aspect Pelvic position ASIS and PSIS, 9-100 Box 3-4, page 71

Palpation Anterior aspect Patellar position Iliac crest heights Figure 3-9, page 70 ASIS heights Figure 3-10, page 70 Lateral malleolus and fibula head heights Shoulder heights Figure 3-11, page 72

Palpation Posterior aspect Many of same landmarks used for anterior view PSIS position Figure 3-12, page 72 Spinal alignment Scapular position Box 3-5, page 73 Not important at this time

Common Postural Deviations Not all postural deviations cause pathology Clinicians must identify Normal posture Asymptomatic deviations Deviations causing dysfunction and/or pain Potential muscle imbalances can cause poor posture OR be a result of poor posture Deviations also caused by skeletal malalignment, anomalies, or combination

Foot and Ankle Hyperpronation Supination Review chapter 4 Figure 3-13, page 74 Supination

The Knee Genu Recurvatum Genu Valgum Knee axis of motion is posterior to plumb line Box 3-6, page 75 Genu Valgum Occurs due to structural anomalies or muscular weaknesses at the hip Secondary to hyperpronation of the feet Can lead to Increased pronation Internal tibial and femoral rotation Medial patellar positioning

The Knee Genu Varum Occurs due to Can lead to Structural anomalies at the hip Excessive supination Can lead to Supination External tibial and femoral rotation Lateral patellar positioning

Interrelationships Between Regions Table 3-14, page 83 May be impossible to determine if posture is the cause or the effect Understand relationships and importance of correcting the factors involved Most soft tissue dysfunctions that have a gradual, insidious onset have, at least, a minimal postural component

Documentation of Postural Assessment Table 3-15, page 85 As part of a SOAP note Figure 3-14, page 84 Standard postural assessment form Guidelines for documenting posture Pages 83, 85