Primary reference: Muscles – Testing and Function with

Posture and Pain, Kendall et al, 2005

Developed by D Allison 2013

 Posture
• the position or attitude of the body
• the relative alignment of body parts
• the usual way in which the body is held

Postural Observation
• The process of evaluating the position of the body and limbs to determine
directly observable physical abnormalities

• Postural problems can be the result of a clinical problem

• Postural problems can be the cause of a clinical problem
• Postural problems showing no symptoms can produce mechanical stress
on the body which can cause or lead to injuries

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 What influences posture?
• Heredity • Occupation
• Height & weight • Sports, hobbies,
• Personality activities
• Emotions • Diet
• Gender • Culture
• Age (stage of development) • Injuries & diseases
• Habits • Clothing

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 Bad posture: Good posture:
• Decreased mechanical • Maximum mechanical
efficiency efficiency with minimal
• Decreased range of effort
motion • Full range of motion
• Increased muscle • Decreased muscle
tension activity
• Increased energy • Decreased muscle
requirements & fatigue tension
• Muscle imbalances • Improved nerve
• Chronic abnormal function and blood
loading on muscles, flow
bones and other soft • Decreased risk of injury
tissue • Aesthetically more
• Chronic overuse injuries attractive
• Poor appearance
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 Muscle imbalances
• Over-used muscles • Under-used muscles
become short become long
– “locked short” – “locked long”
– hypertonic – hypotonic
– Facilitated (the nervous system is over- – Inhibited (the nervous system is under-
stimulating the muscle) stimulating the muscle)
– Internal tension causing the muscle to – External tension causing the muscle to
feel tight feel taut
• Needs to be relaxed and stretched • Needs to be stimulated and strengthened
How? How?
– General massage – General massage
– Broadening strokes can break down – Broadening strokes can break down
adhesions and cross-fibre linkages to adhesions and cross-fibre linkages without
allow lengthening further lengthening
– Lengthening strokes: DG, rectilinear – NO Lengthening strokes: DG, rectilinear
frictions frictions
– Stretching – Strengthening
– Posture awareness and correction – Posture awareness and correction
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• There is no normal posture
• Ideal posture serves as a
reference point
• Ideal posture:
– Distributes gravitational
forces equally
– Contributes to balanced
muscle function
– Minimizes stress on
ligaments, articular surfaces
and fascia
– Minimizes risk of injury
– Maximizes efficiency in
activities of daily living
Ideal Posture
• Benefits:
– Prevents muscles aches and fatigue
– Correct alignment of bones and joints
– Reduces wear and tear on joint
surfaces
– Prevents muscle strain and overuse
– Reduces stress on spinal joints
– Maintains normal spinal curves
– Improves nerve, blood and lymph
function
– Improves organ function
– Improves health
– Improves self-confidence and
appearance
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 Ideal posture
Lateral view Posterior view

Kendall et al: Muscles Testing and Function with Posture and Pain 2005
 Ideal posture
• Ant (Post) view • Lateral view:
– Horizontal lines: – Vertical line:
• Eyes, ear lobes • Apex of skull
• Acromion process • Ear lobe
• (Inf angle scapulae) • Acromion process
• ASIS (PSIS) • Lumbar vertebral
• (Gluteal crease) bodies
• Patellae (popliteal crease) • Slightly post to centre
• Malleoli of hip joint
• Slightly ant to centre
– Mid-sagittal line: of knee joint
• Nasal septum • Slightly ant to lat
• (Occipital protuberance) malleolus
• Suprasternal notch
• Umbilicus
• (Spinous processes)
• Pubic symphysis
• (Gluteal cleft)

Developed by D Allison 2013

Common postural variations:
Posterior view

Ideal high shoulder high hip head tilt S-scoliosis

[ C-scoliosis ]

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Important Postural Muscles:
Posterior view

Erector Spinae
Intrinsic Spinal mm

Kendall et al: Muscles Testing and Function with Posture and Pain 2005
 Common postural variations:
Scoliosis
• C-scoliosis • S-scoliosis

Developed by D Allison 2013

 Scoliosis
• Functional scoliosis
• Temporary curvature that may be
related to an imbalance in the
muscles, a pelvic tilt, a high or low
shoulder or hip
• Straightens on flexion (Adam’s test) or
lateral flexion
• Can be corrected or reduced with
massage, manipulation, exercise
and/or bracing
• Stresses occur at the apex of a curve,
and at the change of convexity in a
curve
• Structural scoliosis
• Relatively fixed curvature which
does not straighten on flexion
(Adam’s test) or lateral flexion
• Often associated with vertebral
and rib deformities and poor
functioning of organs
• Requires surgery
• Massage could be used to
alleviate pain and discomfort
• Adam’s test:
Developed by D Allison 2013
Structural abnormalities

Developed by D Allison 2013

 Handedness Patterns
Each of the above figures illustrates a typical pattern of posture as related to
handedness. Handedness patterns related to posture may form at an early age. The
slight deviation of the spine toward the side opposite the higher hip may appear as
early as age 8 or 10 years. There tends to be a compensatory low shoulder on the
side of the higher hip. In most cases, the low shoulder is less significant than the
high hip. Usually shoulder correction tends to follow correction of lateral pelvic tilt,
but the reverse does not necessarily occur.

Figure A shows a pattern typical of right-handed people.

- right shoulder is lower than the left
- pelvis is deviated slightly toward the right
- right hip appears slightly higher than the left
- usually there is a slight deviation of the spine toward
the left
- left foot is more pronated than the right
- right Gluteus medius is usually weaker than the left
Figure B shows the opposite pattern, which is typical of
left-handed individuals. (Usually, however, the low
shoulder is not quite as marked as in this subject.)
RIGHT HANDED LEFT HANDED

Developed by D Allison 2013 Kendall et al: Muscles Testing and Function with Posture and Pain 2005
 Muscle tightness patterns in
Scoliosis
• C-scoliosis convex left
• Short: (darker shading)
– R L ES, QL (trunk lat flex)
– L glut med/min (hip abd)
– L TFL/ITB
– R Add (hip add)
– L fib(per) long/brev
– R tib post, fhl, fdl

• Long: (lighter shading)

– Contralateral mm to above

– Mm pattern forms a zigzag

Kendall et al: Muscles Testing and Function with Posture and Pain 2005

Developed by D Allison 2013

 Common postural variations:
Posterior view
• High shoulder • High hip

Developed by D Allison 2013

 Common postural variations:
Posterior view
• C-Scoliosis: • S-Scoliosis:
– One shoulder high – Same shoulder & hip high
– One hip high
– Opposite shoulder & hip high ** Draw in the appropriate spinal C and
S curves below

Developed by D Allison 2013

 Treatment: scoliosis
Concavity – lengthen muscles – DG, rectilinear frictions
Convexity – do NOT lengthen – broadening, cross fibre frictions

? ?
Concave side Convex side
? ?

33yo 50yo 55yo

Progression without treatment
Developed by D Allison 2013
Common postural variations:
Posterior view
• Head position
– Tilt
– Rotation

Developed by D Allison 2013

Legs & feet

Developed by D Allison 2013

Developed by D Allison 2013
Important Postural Muscles:
Lateral view

Back Extensors Abdominals

Erector Spinae Rectus Abdominus
Quadratus Lumborum External Obliques
Hip Extensors Hip Flexors
Gluteus Maximus Iliopsoas
Hamstrings Rectus Femoris
Tensor Fascia Lata

IDEAL POSTURE
Developed by D Allison 2013
 Common postural variations:
Lateral view

Ideal Lordosis Flat back Kyphosis Military Sway back

(with kyphosis)

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 Pelvic tilts
• The position of the
pelvis has an important
influence on posture
Developed by D Allison 2013
• Neutral pelvis:
– Males: ASIS equal to or
1cm lower than PSIS
– Females: ASIS 1-2 cm
lower than PSIS
• Anterior pelvic tilt:
– ASIS lower
• Posterior pelvic tilt:
– ASIS higher
Developed by D Allison 2013
 Pelvic tilts
Palpating the ASIS & PSIS

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 Kyphosis
Increased curvature of the mid-thoracic spine

(Dowager’s hump – occurs in upper thoracic spine)

Developed by D Allison 2013

Treatment
• Combination of Thoracic Kyphosis,
rounded shoulders and forward head
• Kyphosis
– Short:
• Int obl, intercostals
– Long:
• T ES
• Ext Obl
• (Rec Ab not necessarily long due to depressed
position of chest)

• Rounded shoulders
(protract/elevation of scapula, int rot/add of
shoulder)
- Short:
- Ser Ant, Pec Mi, Up Trap
- Pec Mj, Subscap
- Long:
- Mid/ low traps, rhom

Developed by D Allison 2013

 Lordosis
• Increased curvature in the lumbar spine
• Can occur at different levels with different
mm imbalances
• Figure A shows a marked anterior pelvic tilt and a
curve that is sharply convex forward in the
lumbosacral area.
– This degree of tilt and lordosis is often associated with
marked shortness of the Iliopsoas and hip flexor
muscles. There is slight counterclockwise rotation of
the pelvis and trunk.

• Figure B shows a high and rather marked lordosis.

– The lumbar spine is inclined forward to the level of
about the second lumbar vertebra. Above this level,
there is a sharp deviation backward. This type of
posture suggests weakness of the anterior abdominal
muscles and shortness of the hip flexors.

• Figure C shows an anterior deviation from the plumb

line in addition to a marked anterior pelvic tilt and
lordosis.
– This forward deviation from the plumb line
compounds the problem of muscle imbalance
associated with the segmental alignment faults, and
puts strain on the forefoot (see also Figure B (side
view), p. 82). (Note the differ ence in appearance of
the feet in Figure C compared to A and B).
Kendall et al: Muscles Testing and Function
Developed by D Allison 2013 with Posture and Pain 2005
 Kyphosis-Lordosis

Kendall et al: Muscles Testing and Function

with Posture and Pain 2005
Developed by D Allison 2013
 Kyphosis-Lordosis: Treatment
Head
Short and Tight
Forward Neck extensors
Hip flexors
Neck
Hyperextended Low back tight
(maybe not short)
Scapulae
Abducted

Thorax
Increased flexion

Hips
Flexed
Lengthened and weak
Pelvis Neck flexors
Anterior tilt Thoracic erector spinae
External obliques
Hamstrings
Abdominals

Knees
Slight hyperextension

Feet
Slight plantarflexion

Kendall et al: Muscles Testing and Function

Developed by D Allison 2013
with Posture and Pain 2005
 Flat back
• Decrease in the
curvature of the lumbar
spine

Kendall et al: Muscles Testing and Function

Developed by D Allison 2013
with Posture and Pain 2005
 Flat back: Treatment
Head
Forward

Neck
Slight extension

Thorax
Hyperextension
(flattened)
Normal kyphosis reduced
Short and Tight
Hamstrings

Lumbar
Flexion
(flattened)
Long and weak
Normal lordosis reduced Hip flexors
iliopsoas
Hips rectus femoris
Extension (Lumbar ES rarely weak)

Pelvis
Posterior tilt

Knees
Extension or
Slight flexion

Ankles
Slight planterflexion

Kendall et al: Muscles Testing and Function

Developed by D Allison 2013
with Posture and Pain 2005
 Sway-back

• Kendall et al: Muscles Testing and Function with Posture and Pain 2005 Developed by D Allison 2013
 Sway-back: Treatment

Long thoracolumbar curve

with posterior positioning

Either anterior or Posterior tilt

Kendall et al: Muscles Testing and Function

Developed by D Allison 2013
with Posture and Pain 2005
 Military: Treatment

• An exaggerated,
rigid posture

Kendall et al: Muscles Testing and Function

with Posture and Pain 2005
Developed by D Allison 2013
 Head
Forward Head

Developed by D Allison 2013

Shoulders & arms

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Common postural variations:
Summary

Ideal lordosis flat back kyphosis military sway back

Ideal high shoulder high hip head tilt S-scoliosis

[C-scoliosis]
Developed by D Allison 2013
What can you see?

Developed by D Allison 2013

What can you see?

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Developed by D Allison 2013