Posture Examination

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There is a lot of controversy about examination for posture regarding its validity and reliability. Many clinicians state that there is no such thing as poor or ideal posture. Some may however still choose to make comments about posture, or at least want to be aware of the terminology, or think that there is some limited value in the concept. Nevertheless it should usually be a routine part of the Musculoskeletal Examination.

Posture Assessment

The patient should be instructed to adopt their usual posture. Examine the anterior, lateral, posterior views of the patient.

In Standing

During normal quiet standing, the body aims for general equilibrium. The line of gravity typically passes through the body’s center of mass, which is located just anterior to the second sacral vertebra (S2). For stable standing, this line of gravity should ideally pass slightly posterior to the hip joint, anterior to the knee joint, and anterior to the lateral malleolus of the ankle. This alignment helps minimize muscular effort. If the body moves around this axis, it will induce movement unless counteracted by other forces. To maintain this quiet standing posture, specific structures are activated:

• At the hip, extension is passively opposed by the iliofemoral ligament (also known as the Y ligament of Bigelow). Active opposition is provided by the iliopsoas and rectus femoris muscles.
• At the knee, hyperextension is prevented passively by the posterior capsule and actively by the gastrocnemius muscle.
• At the ankle, dorsiflexion is actively resisted by the gastrocnemius-soleus complex.

In the sagittal plane, when assessing posture, observe that the line of gravity should pass through the earlobe, the shoulder joint (or slightly posterior), the hip joint (or slightly posterior as noted above), the greater trochanter of the femur, slightly anterior to the midline of the knee joint, and finally to the lateral malleolus (or slightly anterior) (See also sagittal balance of the spine)

In the coronal plane, the line of gravity should bisect the body into equal halves, with weight distributed evenly between the two feet. Also, assess for shoulder and pelvic symmetry, and the alignment of the hips, knees, and ankles. Look at the "hole" or space between the elbows and the trunk and assess if the area and shape are symmetrical on both sides. (see also coronal balance of the spine).

Assess for head alignment: The head should be centered both medial-laterally and anteroposteriorly. The external auditory meatus should align vertically with the shoulder.

Evaluate spinal curvatures. The line of gravity also passes through the points of inflection of the cervical, thoracic, lumbar, and sacral spinal curves. This alignment is crucial for minimizing excessive rotation around this axis, thereby decreasing muscular energy expenditure. During an examination, note whether these curves are under- or overdeveloped, or if they appear higher or lower (migrated) than typically expected. The normal spinal curves are:

• Cervical: Lordotic
• Thoracic: Kyphotic
• Lumbar: Lordotic
• Sacral: Kyphotic

The pelvis should be level, with an anterior tilt of approximately 0–15° measured from the anterior superior iliac spines (ASIS) to the posterior superior iliac spines (PSIS). Also, look for excessive hip or knee flexion, as these can affect pelvic tilt and, consequently, lumbar lordosis.

In Sitting

Assess if the ears are aligned with the shoulders, and that the shoulders are aligned with the hips. Look at the shoulders to see whether they are relaxed and if the elbows are close to the sides of the body. The angles of the elbows, hips, and knees should be around 90 degrees. The feet should be flat on the floor. The forearms should be parallel to the floor with straight wrists.

Tonic vs Phasic Muscles

Thinking through tonic vs phasic muscles and how they change with dysfunction can help in understanding postural abnormalities.

Tonic vs Phasic Muscles (V Janda)

Tonic Muscles Developmentally older Tension and shortening	Phasic Muscles Developmentally younger Weakness and wasting
Adductor pollicis Flexor digiti minimi Palmar interossei Palmaris longus FDS FDP FCU FCR Pronator Teres Pronator quadratus Short head biceps Brachioradialis Long head triceps Subscapularis Pectoralis major Pectoralis minor Teres Major Coracobrachialis Upper trapezius Iliocostalis, longissimus Iliopsoas Rectus femoris Adductor longus,,brevis, magnus Biceps femoris Soleus FHL FDL	Extensors and External rotators hips VMO and VL Abductors hip joint – Gluteus medius/minimus Gastrocnemei Peronei Abductor Pollicis Longus and Brevis Opponens pollicis Dorsal interossei Extensor digiti minimi ECRL/B ECU ED Anconeus, Lateral and medial head triceps Teres minor, Infraspinatus Supraspinatus Serratus anterior Deltoid Long head biceps Lower trapezius Rhomboids Abdominals Longus colli Lomgus capitis Rectus capitis anterior

"Syndromes"

The following syndromes all have limited reliability and validity. They all come with assumptions about which muscles are "weak" or "tight." Vladimir Janda was an important doctor who promulgated the idea of certain postural problems and their relationship to the activity of phasic and tonic muscles.

The upper (or shoulder) crossed syndrome

there is elevation and protraction of the shoulders, rotation and abduction (winging) of the scapula and forward head posture.

The lower (or pelvic) crossed syndrome

there is an anteriorly rotated pelvis, increased lumbar lordosis, and slight hip flexion.

The kyphosis-lordosis posture

this is basically the same as the upper and lower crossed syndromes.

Layer syndrome

there are alternate 'layers' of hypertrophic and hypertrophic muscles when viewed from behind. There is weakness of the lower stabilisers of the scapula, lumbosacral erector spinae, rectus abdominis, transversus abdominis, and gluteus maximus. There is hypertrophy of the cervical erector spinae, upper trapezius, levator scapulae, thoracolumbar erector spinae, and hamstrings.

Flat back posture

there is a slightly extended cervical spine, flexion of the upper thoracic spine, straight lower thoracic spine, absent lumbar lordosis, posterior pelvic tilt, hip extension, and slight plantarflexion of the ankle joint.

Sway back posture

there is a forward head posture, slightly extended cervical spine, increased flexion and posterior displacement of the upper trunk, flexion of the lumbar spine, posterior pelvic tilt, hyperextended hips, anterior pelvic displacement, hyperextended knees, and neutral ankles.

Handedness posture

for right handed individuals there is a lower right shoulder, adducted and depressed right scapula, thoracolumbar curve convex to the left, lateral pelvic tilt high on the right, right hip adduction with slight medial rotation, and left hip abduction with slight right foot pronation.

True Deformities

There are various true postural deformities.

Camptocormia

From Camptocormia.[edit]

Camptocormia also known as bent spine syndrome is a usually organic disorder characterised by marked flexion (greater than 45 degrees) of the thoracolumbar spine that increases during the day and completely disappears when supine.

Scoliosis

From Idiopathic Scoliosis.[edit]

Idiopathic Scoliosis is a three dimensional spinal deformity in frontal, sagittal, and axial planes. It is defined as a coronal spinal curvature of at least 10° with rotation of the vertebral bodies and has unknown aetiology.

Scheueremann's Disease

From Scheuermann's Disease.[edit]

Scheuermann's disease (SD) is a developmental disorder in adolescence that causes a rigid or relatively rigid hyperkyphosis of the thoracic, thoracolumbar, or rarely lumbar spine and has specific radiographic findings.

Pisa syndrome

Tilting of the trunk especially when sitting or standing. Seen mostly in Parkinson's disease.

Dropped head syndrome (antecollis)

Also seen in Parkinson's disease.