ASSESSMENT OF POSTURgdffftzzfffghugE.ppt

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1. BY:
Dr.R.Swathiiyer
MPT 1
st
year

2. •Introduction
•Types
•Deformities
•Assessments:anterior,lateral and posterior
view.
•Effect of ageing on posture.

3. INTRODUCTION
•Posture which is,Relativedisposition of the body at any one
moment.
•Composite of the positions of the different parts of the
body at the time.
•Ideal postural alignment is defined as a straight line that
passes through the ear lobe, the bodies of the cervical
vertebrae, the tip of the shoulder, midway through the
thorax, through the bodies of the
lumbar vertebrae, slightly posterior to the hip joint, slightly
anterior to the axis of the knee joint, and just
anterior to the lateral malleolus.

4. TYPES
a vertical line, directly
through the centerof
gravity of the body
must fall within the
base of support
the net torque about
each articulation of
the body must be zero
Static
posture
that which is
adopted while the
body is in action, or
in the anticipatory
phase just prior to
an action
Dynamic
posture

5. Cont….
•In human stance, the body weight is borne exclusively by the
two lower extremities.
•The human species’ base of support (BoS), defined by an area
bounded posteriorly by the tips of the heels and anteriorly by
a line joining the tips of the toes, is considerably smaller than
the quadrupedal BoS
•The human’s center of gravity ( CoG ) is the point where the
mass of the body is centered and will be referred to here as
the center of mass (CoM).

6. Cont….
•Postural control, which can be either static or dynamic, refers
to a person’s ability to maintain stability of the body and body
segments in response to forces that threaten to disturb the
body’s equilibrium
•Reactive (compensatory): responses occur as reactions to
external forces that displace the body’s CoM.
•Proactive (anticipatory): responses occur in anticipation of
internally generated destabilizing forces such as raising arms
to catch a ball or bending forward to tie shoes.

7. Cont….
•Anatomic Factors Affecting Correct Posture
•• Bony contours (e.g., hemivertebra)
•• Laxity of ligamentous structures
•• Fascial and musculotendinous tightness (e.g., tensor
•fasciae latae, pectorals, hip flexors)
•• Muscle tonus (e.g., gluteus maximus, abdominals, erector
•spinae)
•• Pelvic angle (normal is 30°)
•• Joint position and mobility
•• Neurogenic outflow and inflow

8. Cont….
•Causes of Poor Posture
•Postural (Positional) Factors
•Structural Factors

9. LORDOSIS
•Common Spinal Deformities
•Lordosis
•Lordosisis an excessive anterior curvature of
the spine.
•Pathologically, it is an exaggeration of the
normal curves found in the cervical and lumbar
spines.
•Causes of increased lordosisincludes (1)
postural deformity; (2) lax muscles, especially
the abdominal muscles in combination with
tight muscles, especially hip flexors or lumbar
extensors; (3) a heavy abdomen, resulting
from excess weight or pregnancy'

10. Cont….
(4) compensatory mechanisms that result from another
(5) hip flexioncontracture
(6) spondylolisthesis;
(7) congenital problems, such as bilateral congenital
dislocation of the hip
(8) failure of segmentation of the neural arch
of a facet joint segment
(9) fashion (e.g., wearing high-heeled shoes)There are
two types of exaggerated lordosis, pathological
lordosisand swayback deformity.

11. Trunk
•Sway-back
Forward head
Increased cervical
lordosis
Increased thoracic
kyphosis
Decreased lumbar
lordosis
Posterior pelvic tilt
Knees slightly
hyperextended
Ankles neutral
Short and Tight:
•Upper abdominals
•Intercostals
•Hamstrings
Lengthened and
Weak:
•Neck flexors
•Hip flexors
•Thoracic
extensors
•Lower abdominals

12. KYPHOSIS
•Kyphosis
•Kyphosis is excessive posterior curvature of the spine
•There are several causes of kyphosis, including tuberculosis, vertebral
compression fractures, Scheuermann's disease, ankylosing spondylitis,
senile osteoporosis,tumors, compensation in conjunction with lordosis,
and congenital anomalies
. Kypholordotic posture

13. Cont….
•There are four types of kyphosis:
1.Round back: has a long, rounded curve with
decreased pelvic inclination («30°) and
thoracolumbarkyphosis. The patient often
presents with the trunk flexed forward and a
decrease lumbar curve.
2.Hump back/gibbus: localized, sharp
posterior angulationin the thoracic spine
3.Flat back:Apatient has decreased pelvic
inclination to 20°and a mobile lumbar spine
4.Dowager’s hump:Thedeformity commonly is
caused by osteoporosis, in which the thoracic
vertebral bodies begin to degenerate and
wedge in an anterior direction, resulting in a
kyphosis

14. SCOLIOSIS
•Scoliosis is a lateral curvature of the spine
•This type of deformity is often the most visible spinal deformity,especially
in its severe forms. The most famous example of scoliosis is the
"hunchback of Notre Dame."
•In the cervical spine, a scoliosis is called torticollis.
•Nonstructural scoliosis may be caused by postural problems, hysteria,
nerve root irritation,inflammation, or compensation caused by leg length
discrepancy or contracture (in the lumbar spine).
•Structural scoliosis primarily involves bony deformity,which may be
congenital or acquired or excessive muscle weakness as seen in a long
term quadriplegic.

15. Cont….
•On Observation:
•Standing
•The examiner should first determine the patient's body
•type
•There are three body types: ectomorphic,mesomorphicand endomorphic.
•Following conditions to be noted observing from front:
1.The head is straight on the shoulders (in midline).
•The examiner should note whether the head is habitually tilted to one
side or rotated (e.g., torticollis)
•The cause of altered head position must be established.Foreg, it may be
the result of weak muscles, trauma, a hearing loss, temporomandibular
joint problems, or the wearing of bifocal glasses.

16. Cont….
2. The posture of the jaw is normal. In the resting position, normal jaw
posture is when the lips are gently pressed together, the teeth are slightly
apart and the tip of the tongue is behind the upper teeth in the roof of the
mouth. This position maintains the mandible in a good .It also enables
respiration through the nose and diaphragmatic breathing.
3. The tip of the nose is in linewith the manubriumsternum, xiphisternum,
and umbilicus.Ifthe umbilicus is used as a reference point, the examiner
should remember that the umbilicus is almost always slightly off center.

17. Cont….
4. The upper trapezius neck line is equal on both sides.The muscle bulk of
the trapezius muscles should be equal, and the slope of the muscles
should be approx equal. Because the dominant arm usually shows greater
laxity by being slightly lower, the slope on the dominant side may be
slightly greater.
5. The shoulders are level:In most cases, the dominant side is slightly lower.
6. The clavicles and acromioclavicular joints are level and equal. They should
be symmetric; any deviation should be noted. Deviations may be caused
by subluxations or dislocations of the acromioclavicular or sternoclavicular
joints, fractures, or clavicular rotation

18. Cont….
7. There is no protrusion, depression, or lateralization of the sternum, ribs,
or costocartilage. If there are changes, they should be noted.
8. The waist angles are equal, and the arms are equidistant from the waist.
If a scoliosis is present, one arm hangs closer to the body than the other
arm. The examiner should also note whether the arms are equally rotated
medially or laterally.
9. The carrying angles at each elbow are equal. Any deviation should be
noted. The normal carrying angle varies from 5°to 15°.

19. Cont….
10. The palms of both hands face the body in the relaxed standing position.
Any differences should be noted and may give an indication of rotation in
the upper limb.
11. The "high points" of the iliac crest are the same height on each side.
With a scoliosis, the patient may feel that one hip is "higher" than the
other. This apparent high pelvis results from the lateral shift of the trunk;
the pelvis is usually level.The same condition can cause the patient to feel
that one leg is shorter than the other.
12. The anterior superior iliac spines are level. If one ASIS is higher than the
other, there is a possibility that one leg is shorter than the other or that
the pelvis is rotated more or shifted up or down more on one side

20. Cont….
13. The pubic bones are level at the symphysis pubis.
14. The patellae of the knees point straight ahead.
•Sometimes the patellae face outward ("frog eyes" patellae)or inward
("squinting" patellae). The position of the patella may also be altered by
torsion of the femoral neck (anteversion-retroversion), femoral shaft,or
tibial shaft.
15. The knees are straight.
•The knees may be in genu varum or genu valgum. The examiner should
note whether the deformity results from the femur, tibia, or both.
16. The heads of the fibulae are level.

21. Cont….
•17. The medial and lateral malleoli of the ankles are level.
•18. Two arches are present in the feet and equal on the two sides. In this
position, only the medial longitudinal arch is visible. The examiner should
note any pes planus (flatfoot) or pronated foot, pes cavus ("hollow"foot)
or supinated foot, or other deformities.
•19. The feet angle out equally(this Fick angle is usually 5°to 18°. This
finding means that the tibias are normally slightly laterally rotated (lateral
tibial torsion). The presence of pigeon toes usually indicates medial
rotation of the tibias(medial tibial torsion), especially if the patella face
straight ahead. If the patella face inward (squinting patella)in the presence
of "pigeon toes" or outward,theproblem may be in the femur (abnormal
femoral torsion or hip retroversion/anteversion problems).

22. Cont….
20. There is no bowing of bone. Any bowing may indicate diseases such as
osteomalacia or osteoporosis.
•21. The bony and soft-tissue contours are equally symmetric on the two
halves of the body. Any indication of muscle wasting, muscle hypertrophy
on one side, or bony asymmetry should be noted.

23. Cont….
•Lateral View
•From the side, the examiner should note whether the following conditions
hold true:
1. The ear lobe is in line with the tip of the shoulder (acromion process) and
the "high point" of the iliac crest. This line is the lateral line of reference
dividing the body into front and back halves.
•If the chin pokes forward, an excessive lumbar lordosis may also be
present. This compensatory change is caused by the body's attempt to
maintain the center of gravity in the normal position.

24. Cont….
2. Each spinal segment has a normal curve. Large gluteus maximus muscles
or excessive fat may give the appearance of an exaggerated lordosis.
3. The shoulders are in proper alignment. If the shoulders droop forward
(i.e., the scapulae protract), "rounded shoulders" are indicated. This
improper alignment may be caused by habit or by tight pectoral muscles
or weak scapular stabilizers.
4. The chest, abdominal, and back muscles have proper tone. Weakness or
spasm of any of these muscles can lead to postural alterations.

25. Cont….
5. There are no chest deformities,such as pectus
carinatum (undue prominence of the sternum) or pectus
excavatum (undue depression of the sternum).
6. The pelvic angle is normal30°The posterior superior iliac spine should be
slightly higher than the anterior superior iliac spine.
7. The knees are straight, flexed, or in recurvatum
(hyperextended). Usually, in the normal standing position,the knees
areslightly flexed (0°to 5°). Hyperextension of the knees may cause an
increase in lordosis in the lumbar spine. Tight hamstrings or
gastrocnemius muscles can also cause knee flexion.

26. Cont….
Posterior View
•When viewing from behind the examiner should note whether the
following conditions hold true:
1.The shoulders are level, and the head is in midline.Thesefindings should
be compared with those from the anterior view.
2. The spines and inferior angles of the scapulae are level and the medial
borders of the scapulae are equidistant from the spine. If not, is there a
rotational or winging deformity of one of the scapulae?

27. Cont….
3. The spine is straight or curved laterally, indicating scoliosis. A plumbline
may be dropped from the spinous process of the 7
th
cervical vertebra
Normally, the line passes through the gluteal cleft. This line is the
posterior line of reference.
4. The ribs protrude or are symmetric on both sides.
5. The waist angles are level.
6. The arms are equidistant from the body and
equally rotated.

28. Cont….
7. The posterior superior iliac spines (PSISs) are level . If one is higher than
the other,one leg may be shorter or rotation of the pelvis may be present.
The examiner should note how the PSISs relate to the ASISs. 8. The gluteal
folds are level. Muscle weakness nerve root problems, or nerve palsy may
lead to asymmetry.
8.The gluteal folds are level.
9. The knee joints are level. If they are not, it may indicate that one leg is
shorter than the other.
10. Both of the Achilles tendons descend straight to the calcanei.

29. Cont….
11. The heels are straight or are angled in (rearfoot varus) or out (rearfoot
valgus).
12. Bowing of femur or tibia is present or absent.

30. Cont….
Forward Flexion
•From this position, using the anterior and posterior skyline views, the
examiner can note the following:
1.Whether there is any asymmetry of the rib cage (e.g., rib hump). If a
hump is.present, a level and tape measure may be used to obtain the
perpendicular distance between the hump and hollow.
2. Whether there is any asymmetry in the spinal musculature.
3. Whether a pathological kyphosisis present.

31. Cont….
4.Whether lumbar spine straightens or flexes as it normally should.
5. Whether there is any restriction to forward bending such as
spondylolisthesisor tight hamstrings.

32. Cont….
Sitting
With the patient seated on a stool so that the feet are on the ground and
the back is unsupported, the examiner looks at the patient's posture
Sitting without a back support causes the patient to support his or her
own posture and increases the amount of muscle activity needed to
maintain the posture.

33. Cont….
This observation is carried out, as in the standing position,from the front,
back, and side. If any anteroposterior or lateral deviations of the spine are
observed,the examiner should recall whether they were present when the
patient was examined while standing. It should be noted whether the
spinal curves increase or decrease when the patient is in the sitting
position and how the curves change with different sitting postures,From
the front, it can be noted whether the knees are the same distance from
the floor.
If they are not, this may indicate a shortened tibia. From the side, it can be
noted whether one knee protrudes farther than the other. If it does, this
may indicate a shortened femur on the other side.

34. Cont….
Supine Lying
With the patient in the supine lying position, the examiner
notes the position of the head and cervical spine as well as the shoulder
girdle. The chest area is observed for any protrusion (e.g., pectus
carinatum) or sunken areas (e.g., pectus excavatum).
•The abdominal musculature should be observed to see whether it is
strong or flabby, and the waist angles should be noted to see whether
they are equal. As in the standing position, the ASISs should be viewed to
see if they are level. Any extension in the lumbar spine should be noted.

35. Cont….
•In addition, it should be noted whether bending the knees helps to
decrease the lumbar curve; if it does, it may indicate tight hip flexors.
•The lower limbs should descend parallel from the pelvis.
•If they do not, or if they cannot be aligned parallel and at right angles to a
line joining the ASISs, it may indicate an abduction or adduction
contracture at the hip.
•If, in the history, the patient has complained of symptoms on arising from
supine lying or from going into the supine position, the examiner should
ask the patient to repeat these movements, provided they do not
exacerbate the symptoms.

36. GOOD POSTURE PART FAULTY POSTURE
In standing,thelongitudinal
arch has the shape of a half
dome.
FOOT Low longitudinal arch or
flat foot.
Barefootor in shoes
without heels,thefeet toe
out slightly
Low metatarsal
arch,usuallyindicated by
calluses under the ball of
the foot
In shoes with heels the feet
are parallel.
Weight borne on inner side
of the foot(pronation)
In walking with or without
heels,thefeet are parallel
and the weight is
transferred from heel along
the outer border to the ball
of the foot
Weight borne on the outer
border of the
foot(supination)
Toeing-out while
walking,orwhile standing
in shoes with heels
In sprinting the feet are
parallel or toe in
slightly.theweight is on the
balls of the feet and toes
because heels don’t come
in contact with ground

37. GOOD POSTURE PART FAULTY POSTURE
Toesshldbe
straight,i.e,neithercurled
downward nor bent
upward.theysldextend
forward in line with the
foot and not be squeezed
together or overlap.
TOES Toes bend up at the first
joint and down at middle
joints so that the weight
rests on the tips of the
toes.thisfault if often
associated with wearing
shoes that are too short
Big toe slants inward
toward the midline of the
foot.”Bunion”thisfault is
often associated with
wearing shoes thstaere
too narrow and pointed at
toes.

38. GOOD POSTURE PART FAULTY POSTURE
Legaare straightup and
down.kneecapsface
straight ahead when feet
are in good
positions.lookingat the
knees from the side,the
knees are straight,i.e
neither bent forward nor
locked backward.
KNEES AND LEGS Kneestouch when feet are
apart
Knees are apart when feet
touch
Knee curves slightly
backward
Knee bends slightly
forward i.eit is not as
straight as it should be.
Kneecapsface slightly
toward each other or
outwards

39. GOODPOSTURE PART FAULTYPOSTURE
Iideally,thebody weight is
borne evenly on both
feet,andthe hips are
level.oneside is not more
prominent than the other
as seen from front or
back,noris one hip more
forward or backward than
the other as seen from the
side.thespine does not
curve to the left or right-
handed indivisualsis not
uncommon.also,tendency
toward a slightly low right
shoulder and slightly high
rthip is frequently found in
rt-handed people vice
versa
HIPS,PELVIS AND SPINE
BACK VIEW
One hip is higher than the
other.sometimesit is not
really much higher but
appears so because a
sideways sway of body has
made it more prominent.

40. •Prone Lying
•With the patient lying prone, the examiner notes the position of the head,
neck, and shoulder girdle, as previously described. The head should be
positioned so that it is not rotated, side flexed, or extended.
•Any condition such as Sprengel's deformity or rib hump should be noted,
as should any spinal deviations. The examiner should determine whether
the PSISs are level and should ensure that the musculature of the
buttocks,posterior thighs, and calves is normal.
•As with supine lying, if assuming the position or recovering from the
position causes symptoms, the patient should be asked to repeat these
movements, as long as symptoms are not made worse.

41. ON EXAMINATION
•Leg Length Measurement:
•The patient lies supine with the pelvis set square or
"balanced" on the legs(i.e., the legs at an angle of 90°
to a line joining the ASISs).
•The legs should be 15 to 20 cm (6 to 8inches) apart
and parallel to each other.
•The examiner then places one end of the tape
measure against the distal aspect of the ASIS, holding
it firmly against the bone.
•The index finger of the other hand is placed
immediately distal to the medial or lateral malleolus
•A slight difference, up to 1.0 to 1.5 cm (0.4 to
0.6inch), is considered normal

42. •The examiner then applies overpressure to maintain flexion of all three parts of
the spine (cervical, thoracic, and lumbar), using the hand of the same arm to
maintain overpressure in the cervical spine. With the other hand, the examiner
then holds the patient's foot in maximum dorsiflexion.
•While the examiner holds these positions, the patient is asked to actively
straighten the knee as much as possible.
•The test is repeated with the other leg and then with both legs at the same time.
•if the patient is unable to fully extend the knee because of pain, the examiner
releases the overpressure to the cervical spine and the patient actively extends the
neck.
•If the knee extends farther, the symptoms decrease with neck extension,
or the positioning of the patient increases the patient's symptoms, then the test is
considered positive for increased tension in the neuromeningealtract

43. POSTURAL ANALYSIS
Muscles
function most
efficiently
Optimum
conditions for
internal organs
Good
posture
Increased strain
on supporting
structures
Less efficient
balance of the
body over its
base of support
Poor
posture

44. EFFECT OF POSTURE ON AGEING
•Age
Infants and Children
•Postural control in infants develops progressively during
•the first year of life, from control of the head to control of the body
in a sitting posture and then to control of the body in a standing
posture.
•Stability in a posture,orthe ability to fix and hold a posture in
relation to gravity, must be accomplished before the child is able to
move within a posture.
•The child learns to maintain a certain posture, usually through co-
contraction of antagonist and agonist muscles around a joint,
andthenis able to move in and out of the posture (sitting to
standing and standing to sitting)
•Once stability is established, the child proceeds to controlled
mobility and skill.

45. •The young adult group of students in their 20s had the least amount of
movement of the CoP; the individuals in the youngest and oldest groups
had the greatest amount of CoP motion.
Elderly
•Postural alignment in elderly people may show a more flexed posture than
in the young adult; however, many elderly individuals in their 70s and 80s
still demonstrate a close-to-optimal posture. Hardacker and colleagues
•found that cervical lordosis increased with increasing age
•Hammerberg and Wood123 in a study of the radiographic profiles of 50
elderly individuals 70to 85 years of age showed an average kyphosis angle
of 52, with a range of 29 to 79, and an anterior position

46. •The LoG passed, on average, 40 mm anterior to the posterosuperior
corner of S1. Gelb and colleagues53 in a study of 100 middle-aged and
older volunteers (average age of 57 years) noted that as age increased,
•The LoG was located more anteriorly with a loss of lumbar lordosis and an
increase in thoracic and thoracolumbar kyphosis. However, the mean
values of 34 for thoracic kyphosis and 64 for lumbar lordosis values fell
within normally accepted ranges for younger populations. No correlations
were found between age and kyphosis either in the thoracic region or at
the thoracolumbar junction. Only the loss of lumbar lordosis at the
proximal levels showed the strongest correlation with age.53 The flexed
posture observed in some elderly persons is probably due to a number of
factors, some of which may relate to aging processes

47. •The ROM at the knees, hips, ankles, and trunk may be restricted because
of muscle shortening and disuse atrophy. Furthermore, as voluntary
postural response times in elderly people appear to be longer than in
young people, elderly persons may elect to stand with a wide BoSto have
a margin of safety. Postural responses of older adults, aged 61 to 78 years,
to platform perturbations show differences in timing and amplitude and
include greater coactivationof antagonist and agonist muscles in
comparison with younger subjects, aged 19 to 38 years.
•Iverson and associates,125 who tested noninstitutionalizedmen 60 to 90
years of age on two types of balance tests that involved one-legged
stance, found that balance time and torque production decrease
significantly with age. In some of the tests, the authors found that torque
production was a significant predictor of balance time; that is, the greater
the torque production,thelonger the balance time. These authors also
found that men who exercised five to six times per week had greater
torque production than did men who exercised less frequently. This
finding suggests that high levels of fitness and activity may have beneficial
effects on the aging person’s ability to perform oneleggedbalancing activities
that are needed for activities of daily living such as walking.125

48. REFERENCES:
•Joint structure and function:cynthia C.Norkin
•Muscles testing and function:kendall
•orthopedic physical assessment:david magee