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.
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.
* 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.
* 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:
* 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.
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.
* 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.
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.
* 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.
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.
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. SHOULDER:
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.
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).
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 metatarso-phalangeal 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.
·
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.
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.
* Forward head: The head
lies anterior to the plumb line. It may be due to:
- Excessive
cervical lordosis.
* Excessive
Lordotic curve: The gravity line lies posterior to the vertebral
bodies. It may be due to:
* Forward
shoulders: The acromion process lies anterior to the plumb line; the
scapulae are abducted. It may be due to: 
* Lumbar
Lordosis: The lumbar region is flat as the subject raises arm
overhead. It may be due to:
* Kyphosis: Increased
posterior convexity of the vertebrae. It may be due to:
* Pectus excavatum
(Funnel chest): Depression of the anterior thorax and sternum. It may
be due to:
* Pectus cavinatum (Pigeon chest). The sternum projects anteriorly and
downward. It may be due to:
* Genu recurvatum:
Knee is hyperextended and the gravitational stresses lie far forward of
the joint axis. It may be due to:
Plumb line: It falls midway between shoulders.
Common faults include:
- Tightness
in the upper trapezius and levator scapulae muscles on one side; hypertrophy
may be noticed on the dominant side.
* Shoulder
medial rotation: The medial epicondyle of the humerus is directed
posteriorly. It may be due to:
* Adducted
scapulae: The scapulae are too close to the midline of the thoracic
vertebrae. It may be due to:
* Winging
of the scapulae: The medial borders of the scapulae lift off ribs. It
may be due to: 
* Lateral deviation
(Scoliosis): The spinous processes of the vertebrae are lateral to
the midline of the trunk.
·
Hallux valgus: Lateral deviation of the
first digit at the metatarso-phalangeal joint. It may be due to:
- Hammer toes: Hyperextension of the
metatarsophalangeal joints and distal interphalangeal joints and flexion of the
proximal interphalangeal joints. It may be due to:
