Postural Assessment
The ability to perform a postural evaluation accurately and thoroughly
requires many skills on the part of the individual. The examiner must be able
to separate the parts of the body from the whole and in turn assess the sum
of these parts, in reference to their interaction in the entire anatomical
structure. In correct posture, the gravity line passes through the axes of all
joints, with the body segments aligned vertically. The gravity line is
represented by a vertical line drawn through the body’s center of gravity,
located at the second sacral vertebra (S2). The gravity line is an everchanging reference line that responds to the constantly altering body position
during upright posture. Although the gravity line generally does not pass
through all joint axes of the human body, persons with excellent posture may
come close to fulfilling that criterion. Therefore, the closer a person’s
postural alignment lies to the center of all joint axes; the less gravitational
stress is placed on the soft tissue components of the supporting system.
Assessment:
The strength and length of muscles involved in joint motion must be
balanced. The balance is based on force couple (two or more translatory
forces that in combination produce rotation) principle among muscles
involved in the three cardinal planes of motion. When a force couple is out
of balance, the segment moves off its axis of rotation and there is faulty joint
motion. The head, trunk, shoulders and pelvic girdle serve as the
foundations, from which forces are directed to the limbs.
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Postural faults can be used as guidelines for identifying alterations in
muscle and ligament length. This may occur when one muscle groups
becomes tight and the antagonist elongated. Synergistic muscles around a
joint may be unbalanced as well as the agonists.
Minor alignment faults in posture limit motion and lead to tightness of
muscles and other soft tissues. Muscles that are elongated often develop
their maximal force in the stretched position and are weak in the normal
physiological position. Kendall calls this condition stretch weakness.
Alignment of body segments should be observed while the person is
standing still and during such movements as walking, to detect faulty
patterns of muscle activity and joint mobility. The better the quality of
movement and the better the alignment of gravitational forces through
joint’s axes, the better is the sequence of motion. When postural alignment
improves, imbalances are minimized.
Analysis:
A systematic approach to postural analysis involves viewing the
body’s anatomical alignment relative to a certain established reference line.
This reference (gravity) line serves to divide the body into equal front and
back halves and to bisect it laterally. In preparing to carry out postural
assessment, the examiner should be aware of factors that will enhance the
success and validity of the examination process. These factors are:
1. Postural assessment must be performed with the subject minimally
clothed, in order to ensure a clear view of the contours and anatomical
landmarks used for reference.
2. The examiner should instruct the subject to assume a comfortable and
relaxed posture.
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3. Subjects who use orthotic or assistive devices should be assessed with and
without them to determine their effectiveness in correcting posture.
4. The examiner should note relevant medical history and other information
that may account for certain postural abnormalities. Important information
includes:
- Any history that accounts for present postural abnormalities.
- A complete description of present symptoms.
- All previous treatments for the presenting postural complaints, including
orthopedic and neurological therapy.
- The upper limb dominance of the subject, which is often responsible for
symptomatic postural deviations.
Postural examination is most commonly performed by assessing the
body’s alignment in lateral, posterior and anterior views.
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1) Standing Posture
a) Lateral View
Lateral postural assessments should be performed from both sides to
detect and rotational abnormalities that might go undetected if observed
from only one lateral perspective. Ideally, the plumb line should pass
through the ear lobe and shoulder joint.
1. Head and neck:
Plumb line: The line falls through the ear lobe to the acromion process.
Common faults include:
* Forward head: The head lies anterior to the plumb line. It may be due to:
- Excessive cervical lordosis.
- Right cervical extensor, upper trapezius, and levator scapulae muscles.
- Elongated cervical flexor muscles.
* Flattened lordotic cervical curve: The plumb line lies anterior to the
vertebral bodies. It may be due to:
- Stretched posterior cervical ligaments and extensor muscles.
- Tight cervical flexor muscles.
* Excessive Lordotic curve: The gravity line lies posterior to the vertebral
bodies. It may be due to:
- Vertebral bodies and joints compressed posteriorly.
- Anterior longitudinal ligament stretched.
- Tightness of posterior ligaments and neck extensor muscles.
- Elongated levator scapulae muscles.
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2. Shoulder:
Plumb line: It falls through the acromion process. Common faults include:
* Forward shoulders: The acromion process lies anterior to the plumb line;
the scapulae are abducted. It may be due to:
- Tight pectoralis major and minor, serratus anterior and intercostal muscles.
- Excessive thoracic kyphosis and forward head.
- Weakness of thoracic extensor, middle trapezius and rhomboid muscles.
- Lengthened middle and lower trapezius muscles.
* Lumbar Lordosis: The lumbar region is flat as the subject raises arm
overhead. It may be due to:
- Tightness of the latissimus dorsi muscle and thoraco-lumbar fasciae.
3. Thoracic vertebrae:
Plumb line: The line bisects the chest symmetrically. Common faults
include:
* Kyphosis: Increased posterior convexity of the vertebrae. It may be due to:
- Compression of inter-vertebral disks anteriorly.
- Stretched thoracic extensors, middle and lower trapezius muscles and
posterior ligaments.
- Tightness of anterior longitudinal ligament, upper abdominal and anterior
chest muscles.
* Pectus excavatum (Funnel chest): Depression of the anterior thorax and
sternum. It may be due to:
- Tightness of upper abdominal, shoulder adductor, pectoralis minor and
intercostal muscles.
- Bony deformities of sternum and ribs.
- Stretched thoracic extensors, middle and lower trapezius muscles.
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* Barrel chest: Increased overall antero-posterior diameter of rib cage. It
may be due to:
- Respiratory difficulties.
- Stretched intercostals and anterior chest muscles.
- Tightness of scapular adductor muscles.
* Pectus cavinatum (Pigeon chest). The sternum projects anteriorly and
downward. It may be due to:
- Bony deformity of the ribs and sternum.
- Stretched upper abdominal muscles.
- Tightness of upper intercostal muscles.
4. Lumbar vertebrae:
Plumb Line: The line falls midway between the abdomen and back and
slightly anterior to the sacroiliac Joint. Common faults include:
* Lordosis: Hyperextension of lumbar vertebrae. It may be due to:
- Anterior pelvic tilt.
- Compressed vertebrae posteriorly.
- Stretched anterior longitudinal ligament and lower abdominal muscles.
- Tightness of posterior longitudinal ligaments, lower back extensor and hip
flexor muscles.
* Sway back: Flattening of the lumbar vertebrae (the pelvis is displaced
forward). It may be due to:
- Thoracic kyphosis.
- Posterior pelvic tilt.
- Stretched anterior hip ligaments-hips hyperextended.
- Compression of vertebrae posteriorly.
- Stretched posterior longitudinal ligaments, back extensors and hip flexors.
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* Flat back: Flattening of the lumbar vertebrae. It may be due to:
- Posterior pelvic tilt.
- Tightness of the hamstring muscles.
- Weakness of the hip flexor muscles.
- Stretched posterior longitudinal ligaments.
5. Pelvis and hip:
Plumb Line: The line falls slightly anterior to the sacroiliac joint and
posterior to the hip joint, through the greater trochanter, creating an
extension moment. Common faults include:
* Anterior pelvic tilt. The anterior superior iliac spines lie anterior to the
pubic symphysis. It may be due to:
- Increased lumbar Lordosis and thoracic Kyphosis.
- Compression of vertebrae posteriorly.
- Stretched abdominal muscles, sacro-tuberous, sacroiliac and sacro-spinous
ligaments.
- Tightness of hip flexors.
* Posterior pelvic tilt. The symphysis pubis lies anterior to the anterior
superior iliac spines. It may be due to:
- Sway back with thoracic kyphosis.
- Compression of vertebrae anteriorly.
- Stretched hip flexors, lower abdominal muscles and joint capsule.
- Tightness of hamstring muscles.
6. Knee:
Plumb line: The line passes slightly anterior to the midline of the knee,
creating an extension moment. Common faults include:
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* Genu recurvatum: Knee is hyperextended and the gravitational stresses lie
far forward of the joint axis. It may be due to:
- Tightness of quadriceps, gastrocnemius and soleus muscles.
- Stretched popliteus and hamstring muscles at the knee.
- Compression forces anteriorly.
- Shape of tibial plateau.
* Flexed knee: The plumb line falls posterior to the joint axis. It may be due
to:
- Tightness of and hamstring muscles at the knee.
- Stretched quadriceps and tight gastrocnemius muscles.
- Posterior compression forces.
- Bony and soft tissue limitations.
7. Ankle:
Plumb line: The line lies slightly anterior to the lateral malleolus, aligned
with tuberosity of 5th metatarsal. Common faults include:
* Forward posture: The plumb line is posterior to the body; body weight is
carried on the metatarsal heads of the feet. It may be due to:
- Ankles in dorsiflexion with forward inclination of the legs; posterior
musculature stretched.
- Tightness of dorsal musculature.
- Posterior muscles of the trunk remain contracted.
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b) Posterior view
In a posterior view examination, the examiner’s plumb line divides the
body into equal left and right halves.
1. Head and neck:
Plumb line: The midline bisects the head through the external occipital
protuberance; head is usually positioned squarely over the shoulders so that
eyes remain level. Common faults include:
* Head tilt: Subject’s head lies more to one side of the plumb line. It may be
due to:
- Tightness of lateral neck flexors on one side.
- Stretched lateral neck flexors contra-laterally.
- Compression of vertebrae ipsi-laterally.
* Head rotated: The plumb line is to the right or left of the midline. It may
be due to:
- Tightness of the sternocleidomastoid, upper trapezius, scalene and intrinsic
rotator muscles on one side.
- Elongated contralateral rotator muscles.
- Compression and rotation of the vertebrae.
2. Shoulder and scapula:
Plumb line: It falls midway between shoulders. Common faults include:
* Dropped shoulder: One shoulder is lower than the other. It may be due to:
- Hand dominance (dominant shoulder is lower).
- Lateral trunk muscles are short and hip is high and adducted.
- Tightness of the rhomboid and latissimus dorsi muscles.
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* Elevated shoulder: One shoulder is higher than the other. This may be due
to:
- Tightness in the upper trapezius and levator scapulae muscles on one side;
hypertrophy may be noticed on the dominant side.
- Elongated and weak lower trapezius and pectoralis minor.
- Scoliosis of the thoracic vertebrae.
* Shoulder medial rotation: The medial epicondyle of the humerus is
directed posteriorly. It may be due to:
- Joint limitation in lateral rotation.
- Tightness of the medial rotator muscles.
* Shoulder lateral rotation: Olecranon process faces posteriorly. It may be
due to:
- Joint limitation in medial rotation.
- Tightness of the lateral rotators.
* Adducted scapulae: The scapulae are too close to the midline of the
thoracic vertebrae. It may be due to:
- Shortened rhomboid muscles.
- Stretched pectoralis major and minor muscles.
* Abducted scapulae: The scapulae have moved away from the midline of
the thoracic vertebrae. It may be due to:
- Tightness of the serratus anterior muscle.
- Lengthened rhomboid and middle trapezius muscles.
* Winging of the scapulae: The medial borders of the scapulae lift off ribs. It
may be due to:
- Weakness of the serratus anterior.
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3. Trunk:
Plumb Line: The line bisects the spinous process of the thoracic and lumbar
vertebrae. Common faults include:
* Lateral deviation (Scoliosis): The spinous processes of the vertebrae are
lateral to the midline of the trunk.
- Intrinsic trunk muscles are shortened on one side.
- Contralateral intrinsic trunk muscles are lengthened.
- Compression of vertebrae on the concave side.
- Structural changes in rips or vertebrae.
- Leg-length discrepancy and obliquity.
- Internal organ disorders.
4. Pelvis and Hip:
Plumb line: The line bisects the gluteal cleft and the posterior superior iliac
spines are on the same horizontal plane; the iliac crests, gluteal folds and
greater trochanters are level. Common faults include:
* Lateral pelvic tilt: One side of the pelvis is higher than the other due to:
- Scoliosis with ipsilateral lumbar convexity.
- Leg-length discrepancies.
- Shortening of the contralateral quadrates lumborum.
- Tight ipsi-lateral hip abductor muscles on the same side and tight
contralateral hip adductor muscles.
- Weakness of the contralateral abductor muscles.
* Pelvic rotation: The plumb line falls to the right or left of the gluteal cleft.
It may be due to:
- Tightness of medial rotator and hip flexor muscles on the rotated side.
- Ipsilateral lumbar rotation.
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 Abducted hip: The greater trochanter is higher on the involved side. It
may be due to:
- Tightness of the hip abductor muscles.
- Tightness of contralateral hip adductor muscles.
- Weakness of contralateral adductors and ipsilateral abductors.
5. Knee:
Plumb Line: The plumb line lies, equidistant between the knees. Common
faults include:
 Genu varum: The distal segment (leg) deviates toward midline in relation
to the proximal segment (thigh); the knee joint lies lateral to the mechanical
axis of the lower limb. It may be due to:
- Tightness of medial rotator muscles at the hip with hyper-extended knees,
quadriceps and foot evertor muscles.
- Compression of medial joint structures.
- Femoral retroversion.
- Elongated lateral hip rotator muscles, popliteus and tibialis posterior.
 Genu Valgum: The mechanical axis for the lower limbs is displaced
laterally. It may be due to:
- Tightness of ilio-tibial band and the lateral knee joint structures.
- Femoral ante-version.
- Lengthened medial knee joint structures.
- Compression of lateral knee joint.
- Foot pronation.
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6. Ankle and Foot:
Plumb line: The line is equidistant from the malleoli, a line (Feiss’) is
drawn from the medial malleolus to the first metatarsal bone and the
tuberosity of the navicular bone lies on the line. Common faults include:
 Pes planus (Pronated): There is decreased medial longitudinal arch, the
Achilles tendon is convex medially and the tuberosity of the navicular bone
lies below the Feiss line. It may be due to:
- Shortened perennial muscles.
- Elongated posterior tibial muscle.
- Stretched plantar calcaneo-navicular (spring) ligament.
- Structural displacement of the talus, calcaneus and navicular bones.
 Pes Cavus (supinated): The medial longitudinal arch is high and the
navicular bone lies above Feiss’ line. It may be due to:
- Shortened posterior and anterior tibial muscles.
- Elongated peroneal and lateral ligaments.
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c) Anterior View
Relationships can be posturally assessed from the anterior view with
the plumb line bisecting the body into equal left and right halves.
1. Head and Neck:
Plume Line: The line bisects the head at the midline into equal halves.
Common faults include:
 Lateral Tilt: See section on posterior view.
 Rotation: See section on posterior view.
 Mandibular asymmetry: The upper and lower teeth are not aligned and
the mandible is deviated to one side. It may be due to:
- Tightness of the mastication muscles on one side.
- Stretched mastication muscles on the contralateral side.
- Mal-alignment of temporo-mandibular joints.
- Mal-alignment of teeth.
2. Shoulders:
Plumb Line: A vertical line bisects the sternum and xiphoid process. It may
be due to:
 Dropped ore elevated shoulder: See section on posterior view.
 Clavicle and joint asymmetry: It may be due to:
- Prominences secondary to joint trauma.
- Subluxation or dislocation of sterno-clavicular or acromio-clavicular joints.
- Clavicular fractures.
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3. Elbows:
A line bisects the upper limbs and forms an angle of 5° to 15° laterally
at the elbow with the elbow extended. This angle is normal and is referred to
as the carrying angle. Common faults include:
 Cubitus valgus: The forearm deviates laterally from the arm at angle
greater than 15° (female) and 10° (male). It may be due to:
- Elbow hyperextension.
- Distal displacement of trochlea in relation to capitulum of humerus.
- Stretched ulnar collateral ligament.
 Cubitus varus: The forearm deviates medially (adducts) from the arm, at
an angle of less than 15° for females and 10° for males. It may be due to:
- Fracture about the elbow joint.
- Inferior displacement of the humeral capitulum.
- Stretched radial collateral ligament.
4. Hip:
Plumb line: Common faults include:
 Lateral rotation: The patellae angle out. It may be due to:
- Tightness of the lateral rotators and gluteus maximus muscles.
- Weakness of the medial rotator muscles.
- Femoral retroversion.
- Internal tibial torsion (compensated).
 Medial rotation: The patellae face inward. It may be due to:
- Tightness of the ilio-tibial band and the medial rotator muscles.
- Weakness of the lateral rotator muscles.
- Femoral ante-version.
- External tibial torsion (compensated).
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5. Knee:
Plumb Line: The legs are equidistant from a vertical line through the body.
Common Faults include:
 External tibial torsion: Normally, the distal end of the tibia is rotated
laterally 25° from the proximal end. Excess of 25° rotation is an increase in
torsion and is referred to as lateral tibial torsion (toeing out). It may be due
to:
- Tightness of the tensor fasciae latae muscle or ilio-tibial band.
- Bony mal-alignment.
- Cruciate ligament tear.
- Femoral retroversion.
 Internal tibial torsion: The feet face directly forward or inward.
- Tightness of the medial hamstring and gracilis muscles.
- Structural deformities of the tibia (traumatic or developmental).
- Anterior cruciate ligament tear.
- Femoral ante-version.
- Foot pronation.
- Genu valgus.
6. Ankle and Foot:
Plumb line: Common Faults include:
 Hallux valgus: Lateral deviation of the first digit at the metatarsophalangeal joint. It may be due to:
- Excessive medial bone growth of the first metatarsal head.
- Joint dislocation.
- Tight adductor hallucis muscle.
- Stretched abductor hallucis muscle.
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 Claw toes: Hyperextension of the metatarso-phalangeal joint and flexion
of the proximal interphalangeal joints, associated with pes cavus. It may be
due to:
- Tightness of the long toe flexors.
- Shortness of the toe extensor muscles.
 Hammer toes: Hyperextension of the metatarsophalangeal joints and
distal interphalangeal joints and flexion of the proximal interphalangeal
joints. It may be due to:
- Shortness of the toe extensors.
- Lengthened lumbricals.
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2) Sitting Posture
Hip and Pelvis:
Observation: The pelvis assumes a posterior tilt with the posterior inferior
iliac spines in the same horizontal plane as the superior pubic ramus.
Common faults include:
 Posterior pelvic tilt: The superior pubic ramus is superior to the posterior
inferior iliac spines. It may be due to:
- Lumbar vertebrae flexed excessively.
- Tightness of the hamstring muscles.
- Elongated low back extensors.
 Anterior pelvic tilt: The superior pubic ramus lies inferior to the posterior
inferior iliac spine. It may be due to:
- Tightness of low back extensor muscles.
- Lengthened hip extensor muscles.
- Excessive lumbar lordosis.
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