Chapter 3

1. Chapter 3 Assessment of Posture

2. 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

3. 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

4. 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

5. 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

6. The Kinetic Chain • Closed 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

7. 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

8. 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

9. 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

10. Agonist and Antagonist Relationships • Agonist • 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. History • Mechanism of injury • 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

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

18. 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

19. 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

20. 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

21. Views • Lateral view • Table 3-9, page 63 • Anterior view • Table 3-10, page 66 • Posterior view • Table 3-11, page 67

22. 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

23. 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

24. 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

25. 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

26. 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

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

28. The Knee • Genu Recurvatum • 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

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

30. 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

31. 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