1. ACE Personal Trainer Manual 5th Edition
Chapter 7: Functional Assessments: Posture, Movement, Core, Balance, and Flexibility
Lesson 7.1

2. After completing this session, you will be able to:
Learning Objectives
After completing this session, you will be able to:
Explain the relationship between common postural deviations and the corresponding muscle imbalances that may occur
Differentiate between correctible and non-correctible factors for muscle imbalances and postural deviations
Utilize the right angle rule model and demonstrate the use of the plumb line to note postural asymmetries and gross deviations
List the five common deviations and analyze common observations, muscle imbalance relationships, and anatomical positioning for each
Evaluate and record client postural deviations using the postural-deviation worksheet
Chapter 7: Functional Assessments: Posture, Movement, Core, Balance, and Flexibility explains the importance of functional assessments and outlines how to perform each of them properly.
Common postural deviations:
Kyphosis-lordosis
Flat back
Sway back
Scoliosis
5 common deviations:
Ankle pronation/supination and the effect on tibial and femoral rotation
Hip adduction (“hip hiking”)
Pelvic tilting (anterior or posterior)
Shoulder position and the scapulothoracic joint
Head position

3. Postural assessments evaluate body-segment alignment.
MOVEMENT
Movement starts from a static base or alignment of the body segments (posture).
Postural assessments evaluate body-segment alignment.
Movement screens evaluate how posture impacts the ability to move.
While clients often express a desire to lose weight, tone or shape their bodies, or improve overall fitness levels, one primary objective of all training programs should be to improve functionality, which means that they should help clients enhance their ability to perform their activities of daily living (ADL).
One key facet of functionality involves movement efficiency, or the ability of an individual to generate appropriate levels of force and movement at desired joints, while controlling or stabilizing the entire kinetic chain against reactive forces and gravity-based forces.
Movement operates from a static base or alignment of the body segments, which is commonly referred to as posture. Since movement originates from this base, a postural assessment can be conducted to evaluate body-segment alignment in addition to movement screens that evaluate how posture, both good and bad, impacts the ability to move
Sequencing a client’s assessments involves consideration of protocol selection and timing of the assessments. The physiological assessments must be consistent with the client’s goals and desires, and with the discoveries made during the needs assessment.

4. Offers insight into: STATIC POSTURAL ASSESSMENT Muscle imbalances
Altered neural action
Potentially dysfunctional movement
Tight or shortened muscles
Static posture represents alignment of the body’s segments. Holding a proper postural position involves the actions of multiple postural muscles, generally the deeper muscles that contain greater concentrations of type I muscle fibers and function to hold static positions or low-grade isometric contractions for extended periods.
Good posture is a state of musculoskeletal alignment that allows muscles, joints, and nerves to function efficiently.
Poor posture is an indicator that movement may be dysfunctional.
Figure 7-1
Neutral spine alignment with slight anterior (lordotic) curves at the neck and low back and a posterior (kyphotic) curve in the thoracic region
Personal trainers should consider conducting a static postural assessment on clients as an initial assessment to gain valuable insights into:
Muscle imbalance at a joint and the working relationships of muscles around a joint
Altered neural action of the muscles moving and controlling the joint
Potentially dysfunctional movement
Tight or shortened muscles are often overactive and dominate movement at the joint, potentially disrupting healthy joint mechanics (the concept of neural hypertonicity is covered in Chapter 9)

5. POSTURAL DEVIATIONS

6. POSTURAL DEVIATIONS AND MUSCLE IMBALANCES

7. POSTURAL DEVIATIONS AND MUSCLE IMBALANCES

8. Comparison of normal posture versus scoliosis
POSTURAL DEVIATIONS AND MUSCLE IMBALANCES
Comparison of normal posture versus scoliosis
Notice the deviations that occur at the shoulders and the hips.
Scoliosis is largely a structural (skeletal) issue and is not something that can be corrected through addressing muscle imbalances in a training program. Trainers should communicate with a client’s healthcare provider about an appropriate strategy for designing an exercise program for a person with scoliosis.
Trainers must respect scope of practice when performing a postural assessment on clients, particularly in the presence of pain or injury. They must understand the need for referral to more qualified healthcare professionals when pain or underlying pathologies are present (e.g., scoliosis).

9. MOVEMENT EFFICIENCY PATTERN
Proper postural alignment promotes optimal neural activity of the muscles controlling a joint.
Proper postural alignment promotes optimal neural activity of the muscles controlling and moving the joint. When joints are correctly aligned, the length-tension relationships and force-coupling relationships function efficiently. This facilitates proper joint mechanics, allowing the body to generate and accept forces throughout the kinetic chain, and promotes joint stability and mobility and movement efficiency (refer to Chapter 9 for more information on the concept of mobility, stability, and movement efficiency).
Figure 7-3 illustrates the importance of muscle balance and its contribution to movement efficiency. Given how an individual’s static posture reflects potential
muscle imbalance, it stands to reason that trainers should consider conducting a static postural assessment on their clients as an initial assessment.

10. Non-correctible factors:
POSTURAL DEVIATIONS AND MUSCLE IMBALANCES
Correctible factors:
Repetitive movements
Awkward positions and movements
Side dominance
Lack of joint stability
Lack of joint mobility
Imbalanced strength-training programs
Non-correctible factors:
Congenital conditions
Some pathologies
Structural deviations
Certain types of trauma
Muscle imbalance and postural deviations can be attributed to many factors that are
both correctible and non-correctible, including the following:
Correctible factors
Repetitive movements (muscular pattern overload)
Awkward positions and movements (habitually poor posture)
Side dominance
Lack of joint stability
Lack of joint mobility
Imbalanced strength-training programs
Non-correctible factors
Congenital conditions (e.g., scoliosis)
Some pathologies (e.g., rheumatoid arthritis)
Structural deviations (e.g., tibial or femoral torsion, or femoral anteversion)
Certain types of trauma (e.g., surgery, injury, or amputation)

11. RIGHT-ANGLE RULE OF POSTURE ASSESSMENT
Given the propensity many individuals have toward poor posture, an initial focus of trainers should be to restore stability and mobility within the body and attempt to
“straighten the body before strengthening it.”
The trainer can start by looking at a client’s static posture following the right-angle rule of the body. This model demonstrates how the human body represents itself in vertical alignment across the major joints—the ankle (and subtalar joint), knee, hip, and shoulder, as well as the head. This model allows the observer to look at the individual in all three planes to note specific “static” asymmetries at the joints (e.g., front to back and left to right).
As illustrated in Figure 7-4, the right-angle model implies a state in the frontal plane wherein the two hemispheres are equally divided, and in the sagittal plane wherein the anterior and posterior surfaces appear in balance. The body is in good postural position when the body parts are symmetrically balanced around the body’s line of gravity, which is the intersection of the mid-frontal and mid-sagittal planes and is represented by a plumb line hanging from a fixed point overhead.
While this model helps trainers identify postural compensations and potential muscle imbalances, it is important to recognize that limitations exist in using this model.

12. Objective is to observe the client’s symmetry against a plumb line
STATIC POSTURE ASSESSMENT
Objective is to observe the client’s symmetry against a plumb line
Instruct the client to wear form-fitting, athletic-style clothing to expose as many joints and bony landmarks as possible.
Focus on the obvious, gross imbalances and avoid getting caught up in minor asymmetries.
Using a length of string and an inexpensive weight (e.g., a washer), trainers can create a plumb line that suspends from a ceiling or fixed point to a height 0.5 to 1 inch (1.3 to 2.5 cm) above the floor.
Individuals will consciously or subconsciously attempt to correct posture when they are aware they are being observed; instruct them to maintain a normal, relaxed posture.
When conducting these assessments, instruct the client to wear form-fitting, athletic-style clothing to expose as many joints and bony landmarks as possible, and have the client remove his or her shoes and socks. The use of adhesive dots placed upon the bony landmarks may help identify postural deviations.
Trainers should bear in mind that the body is rarely perfectly symmetrical and that overanalyzing asymmetries is time-consuming, potentially intimidating to clients, and may induce muscle fatigue in the client that can alter his or her posture even further. Therefore, when looking for gross deviations, the trainer should select an acceptable margin of asymmetry that he or she will allow and focus on larger, more obvious discrepancies. For example, start by focusing on gross deviations that differ by a quarter-inch (0.6 cm) or more between the compartments of the body.

13. CHRONOLOGICAL PLAN FOR CONDUCTING ASSESSMENTS
When conducting assessments of posture and movement, the following key components should be included (Figure 7-5).
Client history—written and verbal.
Collect information on musculoskeletal issues, congenital issues (e.g., scoliosis), trauma, injuries, pain and discomfort, the site of pain or discomfort, and what aggravates and relieves pain or discomfort (e.g., with discomfort in the upper back, the client may feel temporary relief by hunching forward and rounding the shoulders).
Collect lifestyle information, including occupation, side-dominance, and habitual patterns (information regarding these patterns may take time to gather).
Visual and manual observation
Identify observable postural deviations.
Verify muscle imbalance as determined by muscle-length testing.
Determine the impact on movement ability or efficiency by performing movement screens.
Facilitate movement to distinguish correctible from non-correctible compensations.

14. Toes should be aligned in the same direction as the feet.
DEVIATION 1: FOOT PRONATION/SUPINATION
Both feet should face forward in parallel or with slight (8 to 10 degrees) external rotation.
Toes should be aligned in the same direction as the feet.
Any excessive pronation (arch flattening) or supination (high arches) at the subtalar joint should be noted.
Apply What You Know
Stand with shoes off and place hands firmly on the fronts of the thighs.
Slowly move between pronation and supination; notice what happens to the orientation of the knees and thighs with each movement.
Additionally, notice how the calcaneus everts as the subtalar joint is pronated.

15. KINETIC CHAIN
Because the body is one continuous kinetic chain, the position of the subtalar joint affects the position of the tibia and femur. Barring structural differences in the skeletal system (e.g., tibial torsion or femoral anteversion), a pronated subtalar joint position typically forces internal rotation of the tibia and slightly less internal rotation of the femur.
Subtalar joint pronation forces rotation at the knee and places additional stresses on some knee ligaments and the integrity of the joint itself. Additionally, as pronation tends to move the calcaneus into eversion, this may actually lift the outside of the heel slightly off the ground (moving the ankle into plantarflexion). In turn, this may tighten the calf muscles and potentially limit ankle dorsiflexion, but the opposite is also true: A tight gastrocnemius and soleus complex (triceps surae) may force calcaneal eversion in an otherwise neutral subtalar joint position.
To illustrate, have students stand barefoot facing a wall with the feet 36 inches (0.9 m) away. Extend both arms in front of the body, placing the hands on the wall for support. Slowly lean forward, flexing the elbows and dorsiflexing the ankles while keeping both heels firmly pressed into the floor. Observe for any movement in the feet (e.g., appearance of the arch collapsing with calcaneal eversion). As a tight gastrocnemius and soleus complex (triceps surae) reach the limit of their extensibility, the body may need to evert the calcaneus to allow further movement. This scenario may occur repeatedly in gait immediately prior to the push-off phase if the gastrocnemius and soleus complex is tight, forcing calcaneal eversion and subtalar joint pronation.

16. DEVIATION 2: HIP ADDUCTION
A lateral tilt of the pelvis that elevates one hip higher than the other
Can be seen in people with leg-length discrepancies
Progressively lengthens and weakens the right hip abductors, which are unable to hold the hip level
posterior view
Hip adduction defines a lateral tilt of the pelvis that elevates one hip higher than the other, which may be evident in individuals who have a limb-length discrepancy.
If a person raises the right hip as illustrated here, the line of gravity following the spine tilts over toward the left, moving the right thigh closer to this line of gravity. Consequently, the right hip is identified as moving into adduction.
This position progressively lengthens and weakens the right hip abductors, which are unable to hold the hip level. Sleeping on one’s side can produce a similar effect, as the hip abductors of the upper hip fail to hold the hip level.

17. DEVIATION 3: PELVIC TILTING
Anterior tilting of the pelvis frequently occurs in individuals with tight hip flexors, which is generally associated with sedentary lifestyles where individuals spend
countless hours in seated (i.e., shortened hip flexor) positions (Figure 7-9).
With standing, this shortened hip flexor pulls the pelvis into an anterior tilt (i.e., the superior, anterior portion of the pelvis rotates downward and forward) (Figure 7-10).

18. DEVIATION 3: PELVIC TILTING
Figure 7-11: Anterior and posterior tilting of the pelvis—sagittal (side) view. An anterior pelvic tilt rotates the superior, anterior portion of the pelvis forward and downward, spilling water out of the front of the bucket, whereas a posterior tilt rotates the superior, posterior portion of the pelvis backward and downward, spilling water out of the back of the bucket.
Figure 7-12 illustrates the alignment of the anterior superior iliac spine (ASIS) and posterior superior iliac spine (PSIS) in neutral alignment, as well in anterior and posterior pelvic tilts. An anterior pelvic tilt will increase lordosis in the lumbar spine, whereas a posterior pelvic tilt will reduce the amount of lordosis in the lumbar spine.
Apply What You Know
Stand with hands placed on the hips and gently tilt your pelvis anteriorly, noticing the change in position and increase in muscle tension in the lumbar region.
Next, tilt your pelvis posteriorly and notice how the lumbar spine flattens and reduces tension in the lumbar extensors.
Tight or overdominant hip flexors are generally coupled with tight erector spinae muscles, producing an anterior pelvic tilt, while tight or overdominant rectus abdominis muscles are generally coupled with tight hamstrings, producing a posterior pelvic tilt. This coupling relationship between tight hip flexors and erector spinae is defined by Vladimir Janda as lower-cross syndrome. With foot pronation and accompanying internal femoral rotation, the pelvis may tilt anteriorly to better accommodate the head of the femur, demonstrating the point of an integrated kinetic chain whereby foot pronation can increase lumbar lordosis due to an anterior pelvic tilt.

19. DEVIATION 4: SHOULDER POSITION AND THE THORACIC SPINE
Limitations and compensations to movement at the shoulder occur frequently due to the complex nature of the shoulder girdle design and the varied movements performed at the shoulder. In Chapter 9, basic shoulder movements are discussed that outline the collaborative function of the scapulothoracic region (the scapulae and associated muscles attaching them to the thorax) and glenohumeral joint to produce shoulder movements.
Observation of the position of the scapulae in all three planes provides good insight into a client’s quality of movement at the shoulders. Figure 7-15 illustrates the “resting” position of the scapulae, which can vary considerably from person to person.
While the glenohumeral joint is highly mobile and perhaps a less stable joint, the scapulothoracic joint is designed to offer greater stability with less mobility.
However, it still contributes approximately 60 degrees of movement in raising the arms overhead, with the glenohumeral joint contributing the remaining 120 degrees. Further, the scapulothoracic joint promotes many important movements of the scapulae.
Collectively, they allow for a diverse range of movements in the shoulder complex.

20. Scapular Protraction and Winging
DEVIATION 4: SHOULDER POSITION AND THE THORACIC SPINE
Scapular Protraction and Winging
You can perform a quick observational assessment to identify scapular protraction and winging. While looking at the client from the posterior view, if the vertebral (medial) and/or inferior angle of the scapulae protrude outward, this indicates an inability of the scapular stabilizers (primarily the rhomboids and serratus anterior) to hold the scapulae in place.
Noticeable protrusion of the vertebral (medial) border outward is termed “scapular protraction” (Figure 7-16a), while protrusion of the inferior angle and vertebral (medial) border outward is termed “winged scapulae (Figure 7-16b).
Scapular protraction can also be identified from the anterior view. If the knuckles or the backs of the client’s hands are visible when the hands are positioned at the sides, this generally indicates internal (medial) rotation of the humerus and/or scapular protraction (Figure 7-17).

21. DEVIATION 4: SHOULDER POSITION AND THE THORACIC SPINE

22. DEVIATION 5: HEAD POSITION
With good posture, the earlobe should align approximately over the acromion process, but given the many awkward postures and repetitive motions of daily life,
a forward-head position is very common.
This altered position does not tilt the head downward, but simply shifts it forward so that the earlobe appears significantly forward of the acromioclavicular (AC) joint.
To observe the presence of this imbalance, use the sagittal view, aligning the plumb line with the AC joint, and observe its position relative to the ear.
A forward-head position represents tightness in the cervical extensors and lengthening of the cervical flexors. To demonstrate this point, place one thumb on your manubrium (top of the sternum) and the index finger of the same hand on the chin. Slowly slide the head forward and observe how the spacing between the
fingers increases, representing the change in muscle length.
An alternative option for observing forward-head position is via the alignment of the cheek bone and the collarbone. With good posture, they should almost be in vertical alignment with each other. To demonstrate this point, have a client place one finger on his or her collar bone (aligned under the cheek) and place another finger on the cheek bone (aligned under the eye). From the sagittal plane, the trainer can observe the vertical alignment of the two fingers.

23. POSTURAL ASSESSMENT CHECKLIST
When performing basic postural assessments, trainers can use the checklist provided in Figure 7-20 to guide themselves through their observations, and complete the worksheets provided in Figures 7-21 and 7-22 (available for free download at to mark any postural compensations they identify.

24. SUMMARY
Personal trainers should consider conducting a static postural assessment on clients as an initial assessment.
Muscle imbalance and postural deviations can be attributed to many factors that are both correctible and non-correctible.
Proper postural alignment promotes optimal neural activity of the muscles controlling and moving the joint.
When joints are correctly aligned, the length-tension relationships and force-coupling relationships function efficiently.