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Joint Structure & Function: A Comprehensive Analysis, 6e

Chapter 13: Posture

Lee N. Marinko; Cynthia C. Norkin

Introduction
The focus of this chapter is to explore how various body structures work together to enable the body as a whole to either maintain a particular posture
or to transition from one posture (or alignment) to another during movement. A brief review of the integrated mechanisms associated with postural
control is included, and knowledge of individual joint and muscle structure and function is used as the basis for determining how each contributes to
equilibrium and stability in an ideal posture. The internal and external forces acting on the body in relation to various postural orientations are
considered, as well as how deviations in initial alignment can alter joint movement and function. This chapter begins with what is considered ideal
alignment for various static positions before considering some common postural deviations, and discusses how these deviations may contribute to, or
be the result of, various conditions encountered in physical therapy practice. Life span differences in postural control and balance will also be
addressed.

Posture and Balance Defined

Posture

Posture is the orientation, or alignment, of the human body, and can be either static or dynamic. In static posture, the body and its segments are
distributed in a manner that maintains the body in equilibrium. Standing, sitting, or lying are all examples of static postures with the body at rest.
Dynamic posture refers to postures in which the body or its segments are moving—walking, running, jumping, throwing, and lifting are all examples
of dynamic postures. All successful human movement is initiated from a static posture and is maintained through the integration of multiple systems.

The force of gravity directly impacts a person’s stability. In order for you to remain stable, your center of mass (CoM) and the vertical projection from
this point, referred to as the line of gravity (LoG), must be maintained within your base of support (BoS; see Chapter 1). Stability is directly related to
how easy or difficult it is to displace the CoM outside of your BoS, as once your LoG moves beyond your BoS, you may fall. You may increase your
stability to avoid a fall by adopting a larger BoS or by lowering your CoM closer to the BoS. The multi­articulating components of the human skeleton
can be arranged in an infinite number of positions. This rearrangement of body segments can influence the position of the body’s CoM and LoG and
hence influence its stability (Figure 13–1).1,2

Figure 13­1

The center of mass (CoM) and base of support (BoS) impact stability. When the CoM is outside of the BoS, stability is affected.

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Balance
hence influence its stability (Figure 13–1).1,2
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Figure 13­1
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The center of mass (CoM) and base of support (BoS) impact stability. When the CoM is outside of the BoS, stability is affected.

Balance

Balance is the process by which upright posture is maintained. Postural control is responsible for achieving, maintaining, or restoring appropriate
balance.3 When forces are in equilibrium, the body remains at rest, or static, and is considered stable. Balance is more than simply a mechanical issue,
and it requires multiple systems to ensure that the body maintains equilibrium. Maintaining the body’s COM within the boundaries of its BoS is a
requirement for maintaining stability, or balance, and is the ultimate goal of postural control. In standing anatomical position, the human’s BoS is
bounded by the area from the back of the heels circling the tips of the toes, and the CoM is located at approximately the level of the second sacral
segment in the midsagittal plane (see Figure 13–1). In a seated posture, the BoS now includes the boundaries of the feet as well as the outline/footprint
of the item that the individual is seated upon. When seated, balance is dependent on the CoM of the head, arms, and trunk because the pelvis and
lower extremities are supported. Therefore, when seated, the CoM shifts superiorly to a region just below the axilla (Figure 13–2). Redistribution of
the limbs as depicted in Figure 13–1 will alter the position of the individual’s CoM and LoG. Characteristics such as age, height, and weight may alter the
CoM and, therefore, vary the requirements for stability.4 Human balance also requires a complex interplay between the mechanical properties of the
musculoskeletal system and the integrity of the central nervous system (CNS).

Figure 13­2

When seated, the CoM is just below the axilla and the BoS includes the boundaries of the feet and the outline of the chair.

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musculoskeletal system and the integrity of the central nervous system (CNS).
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Figure 13­2
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When seated, the CoM is just below the axilla and the BoS includes the boundaries of the feet and the outline of the chair.

Patient Application 13–1

The Romberg and the Sharpened Romberg tests are clinical measurements of an individual’s balance that differ by the position of the feet.5 In the
Romberg test, the individual stands with feet together; in the Sharpened Romberg test, the individual places the heel of one foot directly in front of
the toe of the other (tandem stance). Both positions reduce the BoS in standing compared with the anatomical position (feet approximately
shoulder width apart). In the Romberg test, the BoS in the frontal plane has been reduced from the anatomical position. In the Sharpened Romberg
test the BoS in the frontal plane is reduced even further; however, the BoS in the sagittal plane has been increased. Therefore, someone standing in
Sharpened Romberg may have greater stability in the anteroposterior direction compared with normal standing, but would have significantly
diminished stability in the medial–lateral direction, requiring greater effort to maintain stability. This test progression is an example of how altering
the BoS can impact an individual’s stability.

The Role of Sensorimotor Motor Control in Posture and Balance

Postural control is the act of maintaining balance at rest, during movement, or with positional changes given the constraints of the individual, the
environment, or the task. All successful movement requires postural control. In the past, clinicians believed that postural control was simply a reflexive
function manifested by the CNS. Today it is understood to be a complex motor skill that incorporates multiple processes across many systems and can
be learned or acquired.6 In experimental studies challenging postural control, Scholz and colleagues were able to demonstrate that when stability was
disturbed under varying conditions, individuals consistently realigned their CoM and body segments into the pre­perturbation position, supporting
the concept that the primary goal of postural control is maintenance of the body’s CoM and LoG within the BoS.2 Although only a relatively small
amount of muscular activation is required to maintain a stable, erect standing posture, the maintenance of posture is complex and part of the body’s
motor control system.5 Postural control requires intact and appropriate neuromuscular integration of the peripheral and central nervous systems.
Specifically, information is incorporated from the visual system, the vestibular system, the somatosensory system (proprioceptive, cutaneous, and
joint receptors), and the musculoskeletal system (joints and muscles; Figure 13–3).5,7
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Postural control requires integration of the peripheral and central nervous systems.
disturbed under varying conditions, individuals consistently realigned their CoM and body segments into the pre­perturbation position, supporting
the concept that the primary goal of postural control is maintenance of the body’s CoM and LoG within the BoS.2 Although
Philadelphia onlyofa Osteopathic
College relatively small
Medicine
amount of muscular activation is required to maintain a stable, erect standing posture, the maintenanceAccess
of posture is complex and part of the body’s
Provided by:

motor control system.5 Postural control requires intact and appropriate neuromuscular integration of the peripheral and central nervous systems.
Specifically, information is incorporated from the visual system, the vestibular system, the somatosensory system (proprioceptive, cutaneous, and
joint receptors), and the musculoskeletal system (joints and muscles; Figure 13–3).5,7

Figure 13­3

Postural control requires integration of the peripheral and central nervous systems.

Humans use two primary mechanisms to maintain stability: anticipatory postural adjustments (APA) and compensatory postural
adjustments (CPA).8 APAs have been described as feedforward activations of trunk and limb muscles prior to a self­imposed balance perturbation
or movement of the CoM. Feedforward indicates that the muscles contract in anticipation of movement rather than as the result of movement.

The role of APAs is to reduce any negative known consequences of the intended movement; in Example 13–1, it would be falling forward. Therefore,
there has to be some prior knowledge of the task and the environment for the APAs to be successful.9 CPAs are activated motor compensations
(muscle contractions) that occur when balance is disturbed (also known as feedback motor strategies). CPAs respond to sensory feedback information
in the presence of either predicted or unpredicted perturbations.10 If posture is perturbed unexpectedly, CPAs are the primary strategy used by the
CNS to restore equilibrium. In the presence of known perturbation or planned movement, APAs and CPAs work together. In simplistic terms, APAs
prepare the body for movement and CPAs adjust during and after the movement.

Example 13–1

As a simple example, imagine raising your arms straight out in front of you while standing. Prior to lifting your arms, the ankle plantarflexors should
contract to draw
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13: Posture, Lee N. arm raise Cynthia
Marinko; will allowC.the CoM to return to the middle of the BoS when the arms are raised. Thus, the APA allowsPage
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end of the intended movement.
(muscle contractions) that occur when balance is disturbed (also known as feedback motor strategies). CPAs respond to sensory feedback information
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in the presence of either predicted or unpredicted perturbations.10 If posture is perturbed unexpectedly, CPAs are the primary strategy used by the
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CNS to restore equilibrium. In the presence of known perturbation or planned movement, APAs and CPAs work together. In simplistic terms, APAs
prepare the body for movement and CPAs adjust during and after the movement.

Example 13–1

As a simple example, imagine raising your arms straight out in front of you while standing. Prior to lifting your arms, the ankle plantarflexors should
contract to draw the tibia and rest of the body posteriorly, which will shift the CoM slightly posterior. Shifting the CoM slightly posterior in
preparation for the forward arm raise will allow the CoM to return to the middle of the BoS when the arms are raised. Thus, the APA allows the body
to prepare for an upcoming movement to keep the CoM centered within the BoS at the end of the intended movement.

Sensory information is critical to postural control. The primary sources of sensory information that contribute to postural control are the visual,
vestibular, and somatosensory systems. Vision, for example, plays an important role in regulating APAs. To demonstrate the importance of vision,
Mohapatra and Aruin measured APAs during trunk perturbations under varying visual conditions.11 They observed a significant increase in APAs when
subjects received visual cues, but saw no APAs when vision was completely obstructed, supporting the fact that vision is a requirement that allows
APAs to prepare the body for perturbations. The vestibular system is also involved in triggering postural adjustments and is necessary when there is
conflicting somatosensory or visual information.12 The vestibular system functions as the spatial reference system to gravity. In this role, the vestibular
system responds to changes in the orientation of the head and trunk in space, but it is unaffected by changes in the support surface.13,14 Finally,
somatosensory information provides the CNS with information about the body’s position with respect to a support surface, as well as the inter­
relationship between all the body segment’s positions and movement within space. Specific sensory cells (mechanoreceptors) are located within the
skin, joint, and muscle structures to provide information regarding touch, joint motion, and tendon and muscle stretch, as well as how quickly the limb
is moving (see Figure 13–3). When there is adequate visual information and a stable surface, the majority of balance control is the result of
somatosensory information from the joints of the lower extremities. In the presence of unstable surfaces, the CNS will rely less on somatosensory
information and re­weight information from the visual and vestibular systems, demonstrating the coordinated integration of sensory information in
postural control.6 Overall, it is important to understand the integrated roles of these multiple systems when observing resting posture and movement,
because deviations from ideal alignment may be indicative of underlying sensory, visual, or vestibular disorders. Recognizing these disorders may
assist in predicting static and dynamic postural deficits. Table 13–1 provides a summary of the elements of postural control.

Table 13­1
Postural Control

POSTURAL CONTROL CONTRIBUTORS ROLE IN POSTURE

Visual system5,15 Three different eye movement • Smooth pursuit: stabilization of slowly moving targets provides information regarding object

systems work to provide visual information to the relationship to body position

CNS related to the body and the environment • Saccadic system: responsible for rapid small movements of both eyes simultaneously when the
fixation point changes, providing information regarding object’s relationship to body position
• Optokinetic system: used to stabilize images on the retina when the entire visual field is moving,
providing information of how the body is moving in relation to environment such as when walking

Vestibular system12 • Specialized mechanoreceptors in the semicircular canals of the ear relay information regarding rate
of motion or angular displacement, as well as position of the head in relation to gravity

Somatosensory system5 • Sensory information arriving from the periphery related to pain, temperature, touch, and
proprioception (joint position)
• Muscle spindles: detect instantaneous muscle length (static) and changes in muscle length
(dynamic)
• Golgi tendon organs: detect instantaneous muscle tension (static) and changes in muscle tension
(dynamic)
• Joint receptors: detect changes in tension within the joint capsule and associated ligaments

Anticipatory postural adjustments 8 • Discrete muscle contractions of postural muscles that occur preceding the actual movement
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based upon experience and sensory integration.

Compensatory postural adjustments • Muscle activation and motor patterns that occur as a result of perturbation in response to sensory
information and re­weight information from the visual and vestibular systems, demonstrating the coordinated integration of sensory information in
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postural control.6 Overall, it is important to understand the integrated roles of these multiple systems when observing resting posture and movement,
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because deviations from ideal alignment may be indicative of underlying sensory, visual, or vestibular disorders. Recognizing these disorders may
assist in predicting static and dynamic postural deficits. Table 13–1 provides a summary of the elements of postural control.

Table 13­1
Postural Control

POSTURAL CONTROL CONTRIBUTORS ROLE IN POSTURE

Visual system5,15 Three different eye movement • Smooth pursuit: stabilization of slowly moving targets provides information regarding object

systems work to provide visual information to the relationship to body position

CNS related to the body and the environment • Saccadic system: responsible for rapid small movements of both eyes simultaneously when the
fixation point changes, providing information regarding object’s relationship to body position
• Optokinetic system: used to stabilize images on the retina when the entire visual field is moving,
providing information of how the body is moving in relation to environment such as when walking

Vestibular system12 • Specialized mechanoreceptors in the semicircular canals of the ear relay information regarding rate
of motion or angular displacement, as well as position of the head in relation to gravity

Somatosensory system5 • Sensory information arriving from the periphery related to pain, temperature, touch, and
proprioception (joint position)
• Muscle spindles: detect instantaneous muscle length (static) and changes in muscle length
(dynamic)
• Golgi tendon organs: detect instantaneous muscle tension (static) and changes in muscle tension
(dynamic)
• Joint receptors: detect changes in tension within the joint capsule and associated ligaments

Anticipatory postural adjustments (APAs)8 • Discrete muscle contractions of postural muscles that occur preceding the actual movement
necessary for a given task. Motor output is thought to prepare the body for a self­imposed
perturbation associated with the imminent task, based upon experience and sensory integration.

Compensatory postural adjustments • Muscle activation and motor patterns that occur as a result of perturbation in response to sensory

(CPAs)8 information or feedback. They involve postural muscle activation or movement strategies with the
primary goal to restore balance or recover postural control.

Control of Posture in Static Positions

Stability depends, in part, on the individual’s BoS. Although static posture is emphasized in this chapter, the term static can be misleading. Unless
every part of the body is supported on a fixed surface, the influence of gravity and inertia create constant external forces to produce movement within
the limits of stability. These small amounts of movement represent a subtle and often visually imperceptible motion known as postural sway.5 Static
posture, therefore, is not one single point, but is instead an area within which individuals can maintain their CoM and LoG within their BoS without
requiring a step or change in BoS (Figure 13–4).6 Maintenance of static posture is dependent upon the orientation and integrity of body segments,
resting muscle tone, and small magnitudes of muscle activation. In a static upright posture, the head remains very stable despite the fact that the upper
cervical spine is the most mobile region of the vertebral column (see Chapter 4, The Vertebral Column). This is likely due to the abundance of muscle
spindles and their direct connection to both the visual and vestibular systems within the cerebellum.15 In an upright standing position, the distance
between the relatively small BoS and high CoM results in a need for postural control mechanisms that are influenced by the support surface, available
joint mobility, muscular control, and intact sensory information.

Figure 13­4

Postural sway and limits of stability. A . Stability is controlled by the ankles, hips, and a combination of the two. B . Recording of the movement of the
center of pressure for 60 seconds in a subject standing on a balance platform.
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joint mobility, muscular control, and intact sensory information.
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Figure 13­4

Postural sway and limits of stability. A . Stability is controlled by the ankles, hips, and a combination of the two. B . Recording of the movement of the
center of pressure for 60 seconds in a subject standing on a balance platform.

Postural Control Strategies

Three basic motor strategies can maintain stability during quiet stance: an ankle strategy, a hip strategy, and a combination of the two. The ankle
strategy is often the first strategy employed and is used to manage small perturbations. As the simplest strategy, the ankle strategy describes the
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Chapter 13: Posture,
body’s movement Lee
as an N. Marinko;
inverted Cynthia
pendulum C. the
about ankle.16 When postural sway occurs in the anterior to posterior direction, discrete distal
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proximal muscle activation patterns are observed that are consistent with the direction of sway. Muscle activity begins in the ankle joint, then in the
thigh, and finally in the trunk. For example, when translation of the body is in the posterior direction, muscle activity begins with the tibialis anterior,
17
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Postural Control Strategies

Three basic motor strategies can maintain stability during quiet stance: an ankle strategy, a hip strategy, and a combination of the two. The ankle
strategy is often the first strategy employed and is used to manage small perturbations. As the simplest strategy, the ankle strategy describes the
body’s movement as an inverted pendulum about the ankle.16 When postural sway occurs in the anterior to posterior direction, discrete distal to
proximal muscle activation patterns are observed that are consistent with the direction of sway. Muscle activity begins in the ankle joint, then in the
thigh, and finally in the trunk. For example, when translation of the body is in the posterior direction, muscle activity begins with the tibialis anterior,
followed by the rectus femoris, and then in the rectus abdominis.17 When translation is in the anterior direction, muscle activity begins with the
gastrocnemius, followed by the biceps femoris, and finally the erector spinae.

The second strategy is called the hip strategy and is incorporated when either the perturbation is larger or the base of support is smaller.1,17 This
strategy functions as a multilink pendulum, with motion occurring primarily at the hip such that muscle activation occurs in a proximal to distal
direction.13,17 During this strategy, when postural sway occurs in the anterior to posterior direction, muscle activity begins in the abdominal muscles
followed by the quadriceps. When the sway is in the posterior to anterior direction, activation is initiated in the erector spinae, followed by the
hamstrings.17

Although the hip and ankle strategies have been described as independent and separate events based upon the varying demands placed on the body,
Creath and colleagues suggest that these strategies are always present to a certain extent, therefore inferring a third motor strategy, which is a
combination of both ankle and hip occurring concurrently.13 Muscle activation patterns in all of these strategies appear dependent upon the task or
demands of the environment so that people can demonstrate varying degrees of both ankle and hip strategies.

Patient Application 13–2

Pathologies associated with the central or peripheral nervous system that interfere with normal somatosensory integration, such as multiple
sclerosis or peripheral vascular disease, are associated with balance deficits and an increased risk for falls. These pathologies disrupt the normal
sensory processing at the ankle and can therefore limit postural stability from an ankle strategy. Rehabilitation that targets balance training using a
hip strategy may be incorporated to accommodate these distal impairments.

Supported and Unsupported Upright Sitting

Sitting on a chair will create a more stable situation than standing. Sitting on a chair provides a large BoS that encompasses the person’s feet as well as
the feet of the chair. Likewise, the CoM is lower in a seated position compared with standing. Thus the lower CoM with the larger BoS creates a more
stable circumstance. Sitting can be made relatively less stable, however, by reducing the BoS. Lifting one or both feet from the floor or reducing the
BoS of the chair can create an unstable environment. As an example, sitting on a gym ball creates a more unstable environment than sitting in a chair.

Sitting on a fixed surface is inherently more stable than upright standing. Although unsupported sitting (without the trunk supported) also requires
greater postural demand than supported sitting, standing still requires greater postural demands than even unsupported sitting. In seated positions
most of the sway is observed in the anterior­posterior direction. The system is modeled as a single inverted pendulum with the axis of rotation at the
hip, such that the trunk and upper torso are considered a single rigid unit.18,19 Recent evidence on seated postural control demonstrates that sitting
has significantly less postural sway, and compensatory responses are delayed compared with quiet standing.18–20 The reduced postural sway in a
seated position may be attributed to several factors: (1) greater cutaneous feedback from the body segments in contact with the chair, (2) the larger
BoS during sitting, and (3) the relatively smaller distance between the COM and pendulum axis. When standing, the distance for determining stability is
between the CoM (around the midsacrum) and the axis at the ankle. During sitting, the distance for determining stability is between the CoM at
midsternum and the axis at the hip joint.

Additionally, critical vestibular and somatosensory information is perceived in sitting through perturbations to the head and neck. The direct
connection to both the visual and vestibular systems and rapid relay of information regarding position and movement of the head in relation to the
body may result in more rapid responses to both internal and external moments.21

Patient Application 13–3

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The relationship between the visual, vestibular, and somatosensory systems within the cervical spine is a relatively new area of research inPage
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Chapter 13: Posture, Lee N. Marinko; Cynthia C. Norkin
presence of chronic neck pain, concussion, cervicogenic dizziness, and whiplash associated disorder
©2024 F.A. Davis Company. All Rights Reserved. Terms of Use • Privacy Policy • Notice • Accessibility (WAD). Individuals who have sustained injuries
to the cervical spine demonstrate balance deficits and impaired proprioception in the cervical spine. They often complain of a sensation of dizziness
and deficits in balance or postural control. Treatment that incorporates specific muscle training to the postural control muscles of the neck has
 Philadelphia
Additionally, critical vestibular and somatosensory information is perceived in sitting through perturbations College
to the head of Osteopathic
and neck. The direct Medicine
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connection to both the visual and vestibular systems and rapid relay of information regarding position and movement of the head in relation to the
body may result in more rapid responses to both internal and external moments.21

Patient Application 13–3

The relationship between the visual, vestibular, and somatosensory systems within the cervical spine is a relatively new area of research in the
presence of chronic neck pain, concussion, cervicogenic dizziness, and whiplash associated disorder (WAD). Individuals who have sustained injuries
to the cervical spine demonstrate balance deficits and impaired proprioception in the cervical spine. They often complain of a sensation of dizziness
and deficits in balance or postural control. Treatment that incorporates specific muscle training to the postural control muscles of the neck has
been found to improve these deficits and symptom complaints.15

Control of Posture During Movement

Sometimes, movement of the body is anticipated (planned and controlled), such as when an individual reaches up to a shelf, bends over to pick
something up, or walks to the kitchen. At other times, movements are unplanned, such as when an individual is pushed from behind, trips on a crack in
the sidewalk, or experiences sudden acceleration while standing on a subway train. As with control of static posture, postural control is required
during both planned and unplanned movements. Recent evidence suggests that anticipated and planned movement strategies involve multiple stages
of motor adaptations and muscle synergies that are directly related to the pre­planned movement and are more complex than just maintaining an
upright posture.22–24 APAs are designed to maintain postural stability and occur approximately 100 ms prior to the planned movement.22–24

Anticipatory synergy adjustments (ASAs) are another motor strategy that are present during planned movements, and they occur even earlier
than APAs.25 These synergies generally have two distinct patterns. One is designed to maintain the motor output that is predictive of the intended task
or action, and the other allows for disruption of the movement. ASAs are motor synergies or outputs that occur about 250–300 msec prior to the
planned movement.25 Various neurological conditions will impact this discrete control of motor synergies and may result in poor postural control or
visible motor coordination deficits.

Expanded Concepts 13–1

Quiet Stance

Although quiet stance is considered automatic, newer research has demonstrated that cortical activity precedes postural (feedforward) muscle
reactivity.26 In examining an individual’s posture during movement from rest, deviation from ideal and increased muscle activation may indicate a
deficit in postural control and may require subsequent examination.

Expanded Concepts 13–2

Postural Strategies for Protecting Injured Tissue

Acute musculoskeletal injuries are associated with altered muscle activation patterns such that muscles are activated earlier to protect the injured
tissue. If these motor strategies are maintained for prolonged periods of time they can become problematic to the joint because of the increased
load through the joint and decreased movement and motor variability. This has been demonstrated in individuals with chronic musculoskeletal
conditions like low back pain, neck pain, shoulder impingement, lateral epicondylitis, and hip and knee osteoarthritis.27

Foundational Concepts 13–1

Summary of Posture and Balance

Posture: The orientation or alignment of the human body in space. Posture can be static, (i.e., the body staying still such as in standing or
sitting) or
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©2024Balance: TheCompany.
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Postural control: The act of maintaining, achieving, and restoring the body’s balance.
 tissue. If these motor strategies are maintained for prolonged periods of time they can become problematic to the joint because of the increased
load through the joint and decreased movement and motor variability. This has been demonstrated inPhiladelphia College
individuals with of Osteopathic
chronic Medicine
musculoskeletal
Provided by: 27
conditions like low back pain, neck pain, shoulder impingement, lateral epicondylitis, and hip and kneeAccess
osteoarthritis.

Foundational Concepts 13–1

Summary of Posture and Balance

Posture: The orientation or alignment of the human body in space. Posture can be static, (i.e., the body staying still such as in standing or
sitting) or dynamic (i.e., the body is in motion such as in walking or running).

Balance: The maintenance of the body in an upright posture, requiring sensorimotor, visual, or vestibular feedback.

Postural control: The act of maintaining, achieving, and restoring the body’s balance.

APAs: Specific trunk and limb postural muscle activations that occur prior to planned or anticipated movements, such as reaching for a cup on
a table. APAs prepare the body for the planned motion and occur approximately 100 msec before the movement occurs.

CPAs: CPAs are muscle activations that occur when balance is disturbed to restore balance or reduce movement errors in the direction of a
movement. CPAs respond to feedback (e.g., visual cues, and joint and muscle sensory receptors) for accuracy.

Anticipatory synergy adjustments (ASAs): A motor strategy that occurs prior to APAs when the movement is known to the individual. These
muscle activations seem to have two purposes: (1) maintain the movement that is intended for the task or action, and (2) provide muscle
activation that allows for movement disruption (prepare for perturbations). These occur approximately 250 to 300 msec ahead of the planned
movement.

Kinetics and Kinematics of Posture and Postural Control

When examining posture and postural control we need to consider the concepts of kinetics and kinematics and their influence on the musculoskeletal
system. Forces acting on the human body are generally described as occurring internally or externally. The muscle responses previously described for
balance and postural control are examples of internally generated forces. As a reminder, internal forces are those generated from within the body and
can be produced by active muscle contraction or passive tissue tension (e.g., resting muscle tone, passive muscle stiffness, and tension in joint
capsules and ligaments).28 External forces are those that arise from outside the body or body segments such as gravity (Figure 13–5). Other examples
of external forces include objects carried in the hand, the application of physical contact from the environment (e.g., floor, bed), and physical
interaction with another individual. During normal day­to­day activities, small perturbations and postural sway will result from the application of
gravity as a constant external force that acts at the CoM of the body or its segments. In a static standing or sitting posture, the net forces and moments
of the internal forces from active muscle and passive connective tissue are responsible for offsetting these external forces and moments imposed by
gravity and other objects to maintain an upright position with the head and eyes oriented to the horizon.

Figure 13­5

Location of combined action line formed by ground reaction force vector (GRFV) and the line of gravity (LoG) in the optimal standing posture.

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gravity and other objects to maintain an upright position with the head and eyes oriented to the horizon.
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Figure 13­5
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Location of combined action line formed by ground reaction force vector (GRFV) and the line of gravity (LoG) in the optimal standing posture.

Patient Application 13–4

Individuals who have sustained a cerebrovascular event (i.e., stroke) and subsequent brain damage with loss of muscle control on one side of the
body often demonstrate an inability to maintain upright posture. This lack of postural control is because of the inability to generate active internal
muscle forces sufficient to offset the external gravitational forces. Whenever a therapist examines an individual, all the potential factors that may
contribute to postural abnormality should be considered.

Ground Reaction Forces

When the body comes into contact with the ground, or a muscle acts across a joint to produce joint compression, there is an equal and opposing force
generated. At the joint, the force is called a joint reaction force (JRF), whereas the force produced by the ground in stance or during gait is called
the ground reaction force (GRF). This force has three directional components corresponding to each of the cardinal planes.

Measurement of the ground reaction force can be done through three­dimensional plotting of the forces produced on a force transducer or force
plate.29 Many of the studies on postural control and balance use force plate measurements related to the center of pressure (CoP). Although the
entire foot is making contact with the ground, we can estimate a single point of application that represents the sum of all the contact pressures. The
CoP is therefore a calculated (theoretical) point of application on the contact surface. The CoP measurement has been used to imply the relative
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position of the ground reaction force vector (GRFV) and position of the CoM in upright posture. The path or map of the CoP in a time Page series11
is /used
Chapter 13: Posture, Lee N. Marinko; Cynthia C. Norkin 53
to represent the movement of the CoM during postural sway (Figure 13–6). In quiet stance, the GRFV
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create equal and opposite external forces on the joints of the human body (see Chapter 1).
the ground reaction force (GRF). This force has three directional components corresponding to each of the cardinal planes.
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Measurement of the ground reaction force can be done through three­dimensional plotting of the forces produced
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Provided by:

plate.29 Many of the studies on postural control and balance use force plate measurements related to the center of pressure (CoP). Although the
entire foot is making contact with the ground, we can estimate a single point of application that represents the sum of all the contact pressures. The
CoP is therefore a calculated (theoretical) point of application on the contact surface. The CoP measurement has been used to imply the relative
position of the ground reaction force vector (GRFV) and position of the CoM in upright posture. The path or map of the CoP in a time series is used
to represent the movement of the CoM during postural sway (Figure 13–6). In quiet stance, the GRFV and the LoG have coincident action lines that
create equal and opposite external forces on the joints of the human body (see Chapter 1).

Figure 13­6

Path of the center of pressure (CoP) in erect stance. A . A CoP tracing plotted for a person standing on a force plate. The tracing shows a normal
rhythmic anteroposterior sway envelope during approximately 30 seconds of stance. B . A CoP tracing showing relatively uncontrolled postural sway.

Joint reaction forces occur at the joint as a result of the combined internal and external forces imparted across the joint. Muscle activation, and in
particular, co­activation by antagonist muscles, is the largest internal force, whereas gravity is the largest external force influencing JRFs. An overall
increase in JRFs may contribute to common pain complaints in conditions involving the lower extremity, such as osteoarthritis.30–32

External and Internal Moments

The overall influence of the internal and external forces acting on the body segments during standing or sitting is determined by the location of the
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LoG from the segment’s CoM, in relation to the joint axis of rotation. When the LoG passes directly through a joint, no moment is created. However, if
Chapter 13: Posture, Lee N. Marinko; Cynthia C. Norkin Page 12 / 53
the LoG passes at a distance from the axis of rotation, an external moment is created. Rotation of that
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moment created by passive tissue tension or muscle contraction. The magnitude of the external or internal moment is dependent upon the magnitude
of the applied force and the moment arm. As a reminder, the moment arm is the perpendicular distance between the joint axis of rotation and the
particular, co­activation by antagonist muscles, is the largest internal force, whereas gravity is the largest external force influencing JRFs. An overall
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increase in JRFs may contribute to common pain complaints in conditions involving the lower extremity, such as osteoarthritis.30–32
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External and Internal Moments

The overall influence of the internal and external forces acting on the body segments during standing or sitting is determined by the location of the
LoG from the segment’s CoM, in relation to the joint axis of rotation. When the LoG passes directly through a joint, no moment is created. However, if
the LoG passes at a distance from the axis of rotation, an external moment is created. Rotation of that joint will occur unless it is opposed by an internal
moment created by passive tissue tension or muscle contraction. The magnitude of the external or internal moment is dependent upon the magnitude
of the applied force and the moment arm. As a reminder, the moment arm is the perpendicular distance between the joint axis of rotation and the
applied force vector (see Chapter 1). The direction of the external moment depends on the location of the LoG with respect to the joint axis.

Example 13–2

If the LoG is posterior to the knee joint axis, then gravity is pulling the femur posteriorly on the tibia (flexion), creating an external knee flexion
moment. To maintain equilibrium, the body must generate an equal and opposite internal extension moment (arising from a quadriceps
contraction). This is easily experienced by performing a partial squat, in which the LoG is now posterior to the knee joint axis (i.e., external knee
flexion moment). If you try this yourself, you should be able to feel the quadriceps become active to maintain this position. In such a static posture,
the sum of the internal and external moments is zero.

Foundational Concepts 13–2

Key Points Related to Postural Kinetics and Kinematics

GRFs are the equal and opposing forces acting on the body or body segments during contact with the ground.

CoP measurements are theoretical points of application of the ground reaction force and the GRFV that are used to measure postural control
and sway.

LoG and GRFV are coincidental vectors that are equal and opposing in static upright posture.

The moment arm is the perpendicular distance from the joint axis of rotation to the force vector.

Role of Postural Assessment/Initial Alignment in Physical Therapy

The clinical examination of individuals in any health­care setting generally begins with a visual inspection. In physical therapy this visualization often
begins with an observation of the patient’s posture. For instance, the therapist should take note of how a patient is lying in bed or seated in a chair
when the therapist approaches, or how the patient moves from a chair to approach the therapist. This initial inspection is used early in the
examination process to assist in formulating a clinical hypothesis.33 In particular, therapists often use visual inspection of posture to ask three primary
questions: what can the individual do, how does he/she do it, and why does he/she do it that way?33 The answers to these questions come from
observing the individual’s alignment as well as the movements of body segments relative to each other. Comparing what is observed with what is
expected for normal alignment and movement strategies can inform clinical decision making.

Postural control is also used as a predictor for motor and cognitive development in maturing infants and children.34 Assessing movement variability
during various postural tasks can assist in determining interventions for infants and children.34 An assessment of postural sway and CoP
measurements can also be used as determinants for all risks in various populations.35, 36 Furthermore, an assessment of resting posture can help
identify potential causes for painful musculoskeletal conditions.37,38 Observation of postural control and resting alignment is a fundamental skill that
all clinicians interested in human movement should develop in their practice with a thorough understanding of ideal alignment as an important first
step.

Ideal Standing Alignment

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the body segments are aligned relatively vertically, and the LoG passes through or as close to the joint
Chapter 13: Posture, Lee N. Marinko; Cynthia
axis as possible (Figure 13–7). The closer the LoGC. Norkin Page 13 / 53
lies to the joint axis of rotation, the smaller the external moment will be and hence the smaller the
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opposing internal moment will need to be. This is important for maintaining an upright posture with as little energy expenditure as possible. A position
in which the LoG passes directly through all joint axes, however, is essentially impossible to attain because of the inherent variability in joint shape and
all clinicians interested in human movement should develop in their practice with a thorough understanding of ideal alignment as an important first
Philadelphia College of Osteopathic Medicine
step.
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Ideal Standing Alignment

Ideal upright posture is a position in which all the body segments are aligned relatively vertically, and the LoG passes through or as close to the joint
axis as possible (Figure 13–7). The closer the LoG lies to the joint axis of rotation, the smaller the external moment will be and hence the smaller the
opposing internal moment will need to be. This is important for maintaining an upright posture with as little energy expenditure as possible. A position
in which the LoG passes directly through all joint axes, however, is essentially impossible to attain because of the inherent variability in joint shape and
structure. Optimal posture, therefore, is the position in which internal moments are minimized by having the external moments be as small as
possible. This position can vary based upon anthropometric characteristics such as height, weight, age, and gender.39,40 Because large deviations from
optimal alignment may increase strain on passive supporting structures or require high levels of muscle activation, it is important to identify and
remediate these deviations.

Figure 13­7

Ideal upright posture. All body segments are aligned relatively vertically and the LoG passes through or as close to the joint axis as possible.

Analysis of Standing Posture

The most clinically used postural assessment is visual inspection of the body with respect to a vertical line corresponding to the LoG or a plumb line (a
line with a weight on one end). This observation is typically done from both sagittal and frontal views. Use of visual assessment has been shown to have
limited inter­rater reliability so in clinical practice it may be best to use photographic assessment whenever possible.41 Such measurements are
particularly helpful for determining angular orientation of the spine and extremities.8,42 Photographs may also be useful to demonstrate changes in
posture either with progression of disease, maturation, or treatment effect.

In general, when viewing an individual from the side, the LoG should bisect the body into relatively equal anterior and posterior parts. The visualization
of certain anatomical bony landmarks will assist in observation of postural orientation relative to this LoG.43,44 Although normal postural sway means
that the relationship of the LoG to the body segments is not fixed, this text will use a single description to identify ideal orientation of body segments.
From the side, the LoG will fall (1) just anterior to the ear or be aligned with the mastoid process of the temporal bone, (2) just anterior to the acromion,
(3) through the midline of the ilium bisecting the anterior and posterior superior iliac spines (ASIS, PSIS), (4) through the greater trochanter, (5) slightly
anterior to the femoral condyle (posterior to the patella), and (6) anterior to the lateral malleoli. When viewing the individual from the front or back, the
LoG should bisect the body into equal and symmetric left and right halves.39 The head should be vertical with eyes level, and the shoulders (clavicles),
pelvis (iliac crests), hips (greater trochanters), and knees (patella) should be at equal heights, with the weight distributed evenly through both feet.

Analysis of Standing Posture: Side View

Orientation and angulation of the head and spinal column is often observed in a sagittal view. Mean sagittal plane angles of the spine by age group are
shown in Table 13–2. Important measurements include the following, which are shown in Figure 13–8:

Pelvic incidence: A line drawn from the hip axis to the midpoint of the sacral endplate, and a line perpendicular to the center of the sacral
endplate

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a line drawn parallel to the sacral endplate and a line from the horizontal
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©2024 F.A.tilt:
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the horizontal andTerms of Use between
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Figure 13­8
Orientation and angulation of the head and spinal column is often observed in a sagittal view. Mean sagittal plane angles of the spine by age group are
shown in Table 13–2. Important measurements include the following, which are shown in Figure 13–8:Philadelphia College of Osteopathic Medicine
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Pelvic incidence: A line drawn from the hip axis to the midpoint of the sacral endplate, and a line perpendicular to the center of the sacral
endplate

Sacral slope: The angle created by a line drawn parallel to the sacral endplate and a line from the horizontal

Pelvic tilt: The angle between the horizontal and a line drawn between the PSIS and ASIS

Figure 13­8

Pelvis incidence angle, sacral slope, and pelvic tilt are illustrated to demonstrate various methods of measuring the orientation of the pelvis.

Table 13­2

Mean Sagittal Plane Angles of the Spine by Age Group4 5,4 6

REGION 20–39 YEARS 40–59 YEARS 60+ YEARS

Cervical ~9° lordosis ~7° lordosis ~22° lordosis

Thoracic ~38° kyphosis ~36° kyphosis ~45° kyphosis

Lumbar ~61° lordosis ~60° lordosis ~56° lordosis

Pelvic incidence 52° ~54° ~53°

Sacral slope ~40° ~40° ~36°

Pelvic tilt ~8.74° (21–30 years) ~9.55° (31–50 years) ~9.54° (51–65 years)

Head

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In ideal alignment, the head should be positioned over the shoulders so that the ear is in line with the clavicle. The LoG will pass just anterior to,15
or/ 53
Chapter 13: Posture, Lee N. Marinko; Cynthia C. Norkin Page
directly through, the external auditory meatus (ear canal), approximating the mastoid process of
©2024 F.A. Davis Company. All Rights Reserved. Terms of Use • Privacy Policy • Notice • Accessibilitythe temporal bone (Figure 13–9). This is slightly
anterior to the axis of rotation at C1 to C2, creating an external flexion moment of the cranium on the upper cervical spine. The eyes should be angled
slightly above the ear, horizontally. This angle is known as the sagittal head angle and is calculated by a horizontal line passing directly through the
 Pelvic tilt ~8.74° (21–30 years) ~9.55° (31–50 years) ~9.54° (51–65 years)
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Head

In ideal alignment, the head should be positioned over the shoulders so that the ear is in line with the clavicle. The LoG will pass just anterior to, or
directly through, the external auditory meatus (ear canal), approximating the mastoid process of the temporal bone (Figure 13–9). This is slightly
anterior to the axis of rotation at C1 to C2, creating an external flexion moment of the cranium on the upper cervical spine. The eyes should be angled
slightly above the ear, horizontally. This angle is known as the sagittal head angle and is calculated by a horizontal line passing directly through the
external auditory meatus and a line that passes from the lateral corner of the eye (Figure 13–10).47 The head should be aligned directly over the CoM
of the body, which is just anterior to the S2 spinal segment.45 Maintenance of the head in this position is provided by a balance between the external
flexion moment produced by gravity and the active muscle force of the deep cranio­cervical extensors.

Figure 13­9

Ideal head alignment showing the ear aligned with the clavicle.

Figure 13­10

Sagittal head angle gives an indication of alignment of the head in space.

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 Philadelphia College of Osteopathic Medicine
Figure 13­10
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Sagittal head angle gives an indication of alignment of the head in space.

Vertebral Column

The vertebral column should demonstrate varying degrees of lordosis and kyphosis from the cervical spine to the lumbar spine (see Fig. 4–1 in Chapter
4, The Vertebral Column). Quantification of these spinal angles is commonly described using Cobb angles, which are determined by measuring
region­specific angulations between vertebral endplates on radiographic images (Figure 13–11).48 Mean averages of spinal region angles are listed in
Table 13–2. The degree of spinal curvature at each spinal region is interdependent. For example, an increase in the angle at the T1 vertebral endplate
will increase the degree of cervical lordosis. An increase or decrease in the inclination of the pelvis or sacrum will also increase or decrease lumbar
lordosis.49,50 Deviation from normative values outlined in Table 13–2 has been demonstrated in many painful spinal conditions and may be associated
with deficits in health­related quality of life.51 Visual deviations of curvature may therefore warrant further radiographic testing, as the restoration of
normal angles is the goal of many spinal surgical interventions.

Figure 13­11

Cobb angle.

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normal angles is the goal of many spinal surgical interventions.
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Figure 13­11
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Cobb angle.

In the frontal plane, the LoG should pass directly midline of the trunk. In the cervical and lumbar spine the LoG of the head and trunk passes slightly
posterior to the joint axes with the spine in lordosis, and in the thoracic spine it passes just anterior to the joint axes with the spine in kyphosis. Table
13–3 shows the change in stress on the intervertebral disc and force from muscle activation between a neutral and anteriorly translated posture.

Table 13­3

Percent Increase in Stress of the Intervertebral Disc and Muscle Activation Between Neutral and Anterior Translated Posture5 2

REGION COMPRESSIVE STRESS(kPa) SHEAR STRESS (kPa) MUSCLE FORCE (N)

Cervical +12% –101% +331%

Thoracic +29% +87% +55%

Lumbar +92% +609% +942%

Pelvis and Hip

Sagittal alignment of the pelvis and sacral slope have been shown to predict orientation of the cervical, thoracic, and lumbar spine.3,45,50,53 In an ideal
upright posture the LoG should pass just anterior to the sacrum (S1 on spinal radiograph) and slightly posterior to the axis of rotation (femoral head)
of the hip joint.39 Although often difficult to palpate and visualize, the anterior superior iliac spine (ASIS) of the pelvis is described as being slightly
lower than the posterior superior iliac spine (PSIS), positioning the pelvis in a slight anterior tilt.54 The position of the LoG, therefore creates an
external flexion
Downloaded moment on
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3:32 sacrum
Your (nutation) and external extension moment at the hip.55 In normal quiet standing, this external hip moment is
IP is 208.33.74.62
Chapter
offset by 13: Posture,
muscle Lee
activity of N.
theMarinko; Cynthia
hip flexors C. 13–12).
(Figure Norkin 56 Page 18 / 53
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Figure 13­12
Sagittal alignment of the pelvis and sacral slope have been shown to predict orientation of the cervical, thoracic, and lumbar 3,45,50,53 In an ideal
Philadelphia Collegespine.
of Osteopathic Medicine
upright posture the LoG should pass just anterior to the sacrum (S1 on spinal radiograph) and slightly posterior to the
Access Provided by: axis of rotation (femoral head)

of the hip joint.39 Although often difficult to palpate and visualize, the anterior superior iliac spine (ASIS) of the pelvis is described as being slightly
lower than the posterior superior iliac spine (PSIS), positioning the pelvis in a slight anterior tilt.54 The position of the LoG, therefore creates an
external flexion moment on the sacrum (nutation) and external extension moment at the hip.55 In normal quiet standing, this external hip moment is
offset by muscle activity of the hip flexors (Figure 13–12).56

Figure 13­12

Ideal alignment, line of gravity, and internal moments at the hip joint. A . The LoG passes through the greater trochanter and posterior to the axis of the
hip joint. B . The posterior location of the LoG creates an external extension moment at the hip, which tends to rotate the pelvis posteriorly on the
femoral heads. The arrows indicate the direction of the gravitational moment.

Knee

At the knee, the LoG passes slightly anterior to the joint axis (femoral condyle), and posterior to the patella, creating an external knee extension
moment.55 The small external moment arm requires very little activation of hamstring muscle activity, but may be controlled by the muscle activation of
the gastrocnemius given its proximal insertion.

Ankle

In optimal upright stance, the ankle joint is in neutral position between plantarflexion and dorsiflexion. The LoG passes just anterior to the ankle joint
axis of rotation (lateral malleolus).57 This external moment arm creates an external dorsiflexion moment, which is offset by the internal muscular force
of the gastrocnemius/soleus muscle group.55,56 The soleus demonstrates consistent activity, and contains many Type 1 muscle fibers, indicating its
role as a postural stabilizer. In addition, the biarticular design of the gastrocnemius, with its proximal attachment originating proximal to the knee joint
axis, allows the gastrocnemius to facilitate an internal plantarflexion moment at the ankle and internal knee flexion moment simultaneously.58

Figure 13–13 shows the ideal upright posture (side view) with bony landmarks. Table 13–4 outlines the alignment of the sagittal plane in upright
standing.

Figure 13­13

Ideal upright posture with bony landmarks.

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standing.
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Figure 13­13
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Ideal upright posture with bony landmarks.

Table 13­4

Alignment in Sagittal Plane in Upright Standing3

LINE OF EXTERNAL
JOINTS PASSIVE OPPOSING FORCES ACTIVE OPPOSING FORCES
GRAVITY MOMENT

Cranio­ Slightly Flexion Ligamentum nuchae and Alar ligament; tectorial and Rectus capitus posterior major and minor,
cervical anterior posterior atlanto­occipital membranes semispinalis capitus and cervicis, splenius capitus
C0­C1 and cervicis

Cervical Posterior Extension Anterior longitudinal ligament, anterior annulus fibrosus Anterior scalene, longus capitus and colli
fibers, and zygapophyseal joint capsules

Thoracic Anterior Flexion Posterior longitudinal, supraspinous and interspinous Longissimus thoracis, iliocostalis thoracis,
ligaments, zygapophyseal joint capsules posterior annulus spinalis thoracis, semispinalis thoracis
fibrosusfibers

Lumbar Posterior Extension Anterior longitudinal and iliolumbar ligaments, anterior Rectus abdominis, external and internal oblique,
annulus fibrosus fibers, and zygapophyseal joint capsules transverse abdominis
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Lee N. Flexion
Anterior
Marinko; Cynthia C. Norkin
Sacrotuberous, sacrospinous, iliolumbar, anterior sacroiliac External and internal oblique, transverse
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(sacro­ (nutation) ligaments abdominus
iliac)
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Table 13­4

Alignment in Sagittal Plane in Upright Standing3

LINE OF EXTERNAL
JOINTS PASSIVE OPPOSING FORCES ACTIVE OPPOSING FORCES
GRAVITY MOMENT

Cranio­ Slightly Flexion Ligamentum nuchae and Alar ligament; tectorial and Rectus capitus posterior major and minor,
cervical anterior posterior atlanto­occipital membranes semispinalis capitus and cervicis, splenius capitus
C0­C1 and cervicis

Cervical Posterior Extension Anterior longitudinal ligament, anterior annulus fibrosus Anterior scalene, longus capitus and colli
fibers, and zygapophyseal joint capsules

Thoracic Anterior Flexion Posterior longitudinal, supraspinous and interspinous Longissimus thoracis, iliocostalis thoracis,
ligaments, zygapophyseal joint capsules posterior annulus spinalis thoracis, semispinalis thoracis
fibrosusfibers

Lumbar Posterior Extension Anterior longitudinal and iliolumbar ligaments, anterior Rectus abdominis, external and internal oblique,
annulus fibrosus fibers, and zygapophyseal joint capsules transverse abdominis

Pelvis Anterior Flexion Sacrotuberous, sacrospinous, iliolumbar, anterior sacroiliac External and internal oblique, transverse
(sacro­ (nutation) ligaments abdominus
iliac)

Hip Posterior Extension Iliofemoral ligament Iliopsoas

Knee Anterior Extension Posterior joint capsule Hamstrings, gastrocnemius

Ankle Anterior Dorsiflexion Stiffness in Achilles tendon Soleus, gastrocnemius

Analysis of Standing Posture: Frontal Plane

In viewing posture in the frontal plane from either an anterior or posterior view, the LoG should divide the body into two equal symmetrical halves with
equal height and position of body segments. In both the anterior and posterior views, the head should appear straight with no tilting or rotation
evident and the face should appear to be bisected into equal halves. The eyes, ears, clavicles, and shoulders should be level and horizontal.

From the posterior view, the scapulae should rest flush to the thorax, between the level of the second through seventh ribs, with the inferior angles at
equal heights and equidistant from the vertebral column. The iliac crests should be level and parallel to the floor. Both the anterior and posterior
superior iliac spines should be level and equidistant from the LoG as well as the joint axes of the hips, knees, and ankles. When viewing each body
segment, the femurs and tibia should appear to be vertical, the patellae at equal heights and facing anteriorly, and medial and lateral malleoli at equal
heights to each other, with the feet directed to the front. In the frontal plane, stability is maintained by a balance between the left and right sides as well
as muscle forces on the medial and lateral sides of the limbs.58,59

Tables 13–5 and 13–6 outline the alignment of standing posture in the anterior and posterior views.

Table 13­5
Alignment of Standing Posture: Anterior View

BODY SEGMENT LINE OF GRAVITY OBSERVATION

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Head Directly through the middle of Eyes and ears level and symmetrical
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forehead, nose, chin
segment, the femurs and tibia should appear to be vertical, the patellae at equal heights and facing anteriorly, and medial and lateral malleoli at equal
heights to each other, with the feet directed to the front. In the frontal plane, stability is maintained by a Philadelphia
balance between the left
College and right sides
of Osteopathic as well
Medicine
as muscle forces on the medial and lateral sides of the limbs.58,59 Access Provided by:

Tables 13–5 and 13–6 outline the alignment of standing posture in the anterior and posterior views.

Table 13­5
Alignment of Standing Posture: Anterior View

BODY SEGMENT LINE OF GRAVITY OBSERVATION

Head Directly through the middle of Eyes and ears level and symmetrical
forehead, nose, chin

Neck/Shoulders/Arms Bisects the middle of the neck at Right and left angles between shoulders and neck symmetrical, clavicles symmetrical, arms
epiglottis should hang equidistant from the trunk with the palms facing the thigh and thumbs
forward

Trunk Midline through the sternum and Rib cage and rib angles symmetrical, waist angles equal
umbilicus

Pelvis/Hips Bisects the pelvis and passes Anterior superior iliac spines level
directly though pubic symphysis

Knees Between the knees equidistant Patella symmetrical and facing directly anterior
from medial femoral condyle

Ankles/Feet Between the ankles equidistant Malleoli symmetrical, feet parallel toes all aligned straight out from foot with no
from medial malleoli and first overlapping or deviation
phalange

Table 13­6
Alignment of Standing Posture: Posterior View

BODY SEGMENT LINE OF GRAVITY OBSERVATION

Head Directly through the middle of the head Ears level and symmetrical

Neck/Shoulders/Arms Bisects the middle of the neck Right and left angles between shoulders and neck symmetrical, scapula flush to
the thorax, at equal heights. Arms should hang equidistant from the trunk with
olecranon facing posteriorly

Trunk Midline through the vertebral column Rib cage and angles symmetrical, waist angles equal
bisecting the trunk into two symmetrical
halves

Pelvis/Hips Bisects the pelvis and passes through the Posterior superior iliac spines level
gluteal cleft equidistance from the posterior
superior iliac spines

Knees Between the knees equidistant from medial Popliteal fossa level and facing posteriorly
joint aspects

Ankles/Feet Between the ankles equidistant from medial The calcaneus and Achilles tendon should appear vertical
malleoli
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Foundational Concepts 13–3

 Ankles/Feet Between the ankles equidistant Malleoli symmetrical, feet parallel toes all aligned straight out from foot with no
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from medial malleoli and first overlapping or deviation
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phalange

Table 13­6
Alignment of Standing Posture: Posterior View

BODY SEGMENT LINE OF GRAVITY OBSERVATION

Head Directly through the middle of the head Ears level and symmetrical

Neck/Shoulders/Arms Bisects the middle of the neck Right and left angles between shoulders and neck symmetrical, scapula flush to
the thorax, at equal heights. Arms should hang equidistant from the trunk with
olecranon facing posteriorly

Trunk Midline through the vertebral column Rib cage and angles symmetrical, waist angles equal
bisecting the trunk into two symmetrical
halves

Pelvis/Hips Bisects the pelvis and passes through the Posterior superior iliac spines level
gluteal cleft equidistance from the posterior
superior iliac spines

Knees Between the knees equidistant from medial Popliteal fossa level and facing posteriorly
joint aspects

Ankles/Feet Between the ankles equidistant from medial The calcaneus and Achilles tendon should appear vertical
malleoli

Foundational Concepts 13–3

Postural Assessment

Postural assessment in the clinic is done from the side and from both the front and back. In a side view the LoG should bisect the body into equal
anterior and posterior divisions of the body. In both the front and back views, the LoG should separate the body into two symmetric halves. Using a
photograph increases the reliability and accuracy of postural measurements as well as allows for tracking change over time. Radiographic images
are more accurate and provide for use of quantifiable measures of spinal curvatures. However, exposure to the radiation from radiographs may not
be desirable.

Ideal Sitting Postures

Sitting posture is influenced by the surface on which the individual is seated. The overall goal of sitting posture is to attain a stable alignment of the
body that can be maintained while minimizing energy expenditure and stress to body structures. There are many different sitting postures; four
common ones are shown in Figure 13–14. Active erect sitting posture, which is unsupported posture in which a person attempts to sit up as
straight as possible, is often considered the ideal seated posture. This posture affects forces differently than relaxed erect, slumped, and slouched
sitting postures. In a way, sitting postures are more complex than standing postures. The same gravitational moments as in a standing posture must be
considered, but in addition, we must consider the contact forces that are created when various portions of the body, such as the head and back,
interface with various parts of the chair, such as the foot rest and seat back. The location and amount of support provided to various portions of the
body by the chair or stool may change the position of the body parts and thus the magnitude of the stresses on body structures.

Figure 13­14
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sitting postures. In a way, sitting postures are more complex than standing postures. The same gravitational moments as in a standing posture must be
considered, but in addition, we must consider the contact forces that are created when various portionsPhiladelphia College
of the body, such of Osteopathic
as the Medicine
head and back,
interface with various parts of the chair, such as the foot rest and seat back. The location and amount ofAccess Provided by:
support provided to various portions of the
body by the chair or stool may change the position of the body parts and thus the magnitude of the stresses on body structures.

Figure 13­14

Common seated postures.

Although the ideal seated posture is often advocated, there is limited quantitative data to support this position.60 The LoG passes close to the joint
axes of the head and spine in active erect sitting posture. In the slumped posture, the LoG is more anterior to the joint axes of the cervical, thoracic, and
lumbar spines than it is in either active or relaxed erect sitting. Therefore, it might be assumed that more muscle activity is required in the slumped
posture than in the other sitting postures. In contrast to these expectations, researchers have found that maintaining an active erect sitting posture
requires a greater number of trunk muscles as well as an increased level of activity in some of these muscles compared to both relaxed erect and
unsupported slumped postures.61 The flexion relaxation (FR) phenomenon may provide a possible reason why the slumped sitting posture
requires less muscle activity than does the active erect sitting posture. Flexion relaxation is a cessation of muscular activity, as manifested by electrical
silence of the back extensors during trunk flexion in either sitting or standing postures.

Seated posture in a standard office chair with back support has been shown to result in an increase in posterior pelvic tilt posture with a flattening of
the lumbar lordosis when compared with unsupported sitting on an anteriorly tilted seat.62 Interestingly, despite the presence of a back support,
sitting in the office chair resulted in an increased amount of postural sway and muscle activation. This finding of increased muscle activation in the
back­supported position is interesting, as most other studies on seated posture and pain have examined the influence of unsupported sitting and
therefore may not capture the demands placed on the spine in a standard office chair.61,63,64

Patient Application 13–5

Low back pain is one of the leading causes of disability in the United States.65 Many individuals with low back pain report increased symptoms in the
seated position. The increase in pain may arise from the altered posture of the lumbar spine and pelvis in the seated posture compared with a
standing posture. For example, a patient who states that sitting in a standard chair increases his/her low back pain may be exacerbating the pain
because of a decrease in lordosis. Asking patients about postures that aggravate and ease their pain may lend insight into the underlying cause of
mechanical low back pain.

Common Deviations from Ideal Alignment

The Role of Pain

There is an enormous amount of literature on the role of pain in posture and movement both in pathology and in experimental studies performed on
healthy individuals. The presence of pain can change the behavior of muscles and lead to altered postures or movements. These altered postures in
the presence of pain may be viewed as positive (protective) effects immediately following acute injury or detrimental (compensatory) effects in chronic
conditions.66 For example, it is often easy to identify the painful limb or segment just by observing a person’s posture. Pain in a weightbearing limb is
often observed as a weight shift away from the painful side. In the spine, pain may be observed as changes in the normal spinal curves. Harrison and
colleagues compared the lordosis in the cervical spine between subjects who were healthy (n=72), had acute neck pain (n=52), and had chronic neck
pain (n=70).67 They found that compared with the healthy group, the subjects with pain had reduced lordosis, with the chronic pain group
demonstrating the least lordosis.

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vertebral column, as in a forward head or slouched posture, are associated with changes in the stress and
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strain 52,68
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to the lumbar intervertebral disc as well as the activity
Terms of Use • required to maintain
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• Notice AccessibilityMaintaining this abnormal spinal position
requires balance between the external moment produced by gravity, and the internal moment produced by connective tissue structures (passive) or
muscle support (active). Importantly, greater increases in the internal moment from muscle activation are associated with increased stress to the intra­
conditions.66 For example, it is often easy to identify the painful limb or segment just by observing a person’s posture. Pain in a weightbearing limb is
often observed as a weight shift away from the painful side. In the spine, pain may be observed as changes in the normal
Philadelphia spinalofcurves.
College Harrison
Osteopathic and
Medicine
colleagues compared the lordosis in the cervical spine between subjects who were healthy (n=72), had acute
Access neck pain
Provided by: (n=52), and had chronic neck

pain (n=70).67 They found that compared with the healthy group, the subjects with pain had reduced lordosis, with the chronic pain group
demonstrating the least lordosis.

Changes in the angular alignment of the vertebral column, as in a forward head or slouched posture, are associated with changes in the stress and
strain to the lumbar intervertebral disc as well as the muscle activity required to maintain this position.52,68 Maintaining this abnormal spinal position
requires balance between the external moment produced by gravity, and the internal moment produced by connective tissue structures (passive) or
muscle support (active). Importantly, greater increases in the internal moment from muscle activation are associated with increased stress to the intra­
and extra­articular structures. Other experimental pain studies have demonstrated an increase in muscle activation of the spinal stabilizers as well as
increased postural sway in the presence of low back and neck pain.69–72 Experimental muscle pain in the lower extremities also alters postural control
and challenges postural stability, which may manifest as use of upper extremity support or difficulty transitioning between positions.73,74

Scoliosis

A common postural deviation seen in the vertebral column is scoliosis, a condition that causes excessive curvature of the vertebral column. Scoliosis
is most easily observed in the frontal plane (see Figure 13–10); however, it must be recognized that the curvature is three­dimensional. For example,
scoliosis often occurs in the transverse (rotary), sagittal (flexion/extension), and frontal (lateral bending) planes. These cross­planar curvatures occur
because spinal facet joints don’t lie in a single plane. Thus, a curve in the frontal plane will cause a concomitant change in the transverse plane. This is
the basis for the classically described rib hump that is often used for detecting the initial presence of scoliosis (Figure 13–15). Curves are
conventionally named by the direction of the convexity and the location of the abnormality, such that a right thoracic scoliosis would indicate that the
peak of the convexity occurs on the right side of the vertebral column in the thoracic region (Figure 13–16). Scoliosis may be structural or functional
in nature and can occur at any age, although adult onset is less common. Structural scoliosis is characterized by bony and soft tissue changes that are
not reversible. Structural scoliosis most commonly affects the thoracic spine and results in an ipsilateral rib hump (see Figure 13–15), as well as
compensatory opposite curves in the other regions of the spine. Functional scoliosis is associated with some underlying cause, such as a discrepancy
in leg length, and can be reversed once the cause is corrected. There are a number of categories of scoliosis, with the distinction made primarily based
upon age of onset (Table 13–7). Scoliosis may be idiopathic (no known cause), or because of underlying causes such as neuromuscular, genetic,
environmental, or metabolic secondary to growth­modulating chemical factors, with limited evidence to support any one factor.75

Figure 13­15

Right rib hump on a young woman with scoliosis.

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environmental, or metabolic secondary to growth­modulating chemical factors, with limited evidence to support any one factor.75
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Figure 13­15
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Right rib hump on a young woman with scoliosis.

Figure 13­16

Scoliotic S­shaped curve, with a left lumbar curve and a right thoracic curve.

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 Philadelphia College of Osteopathic Medicine
Figure 13­16
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Scoliotic S­shaped curve, with a left lumbar curve and a right thoracic curve.

Table 13­7
Categories of Scoliosis

ALTERNATIVE
TYPE AGE OF ONSET RISK FACTORS AND COMPLICATIONS
CATEGORIZATION

Congenital Develops during embryonic • More common in boys Early onset scoliosis
development (~6 weeks) • Diagnosed in infancy Onset younger than 5
• May go unnoticed until later in life years

Infantile Diagnosed within the first 3 • If curve greater than 30° risk of respiratory complications
years of life
Seen most often in thoracic
region

Juvenile Between ages 4­10 • Curvature of the spine greater than 10° Late onset scoliosis Onset
• Idiopathic, congenital, or neuromuscular in nature after age 6
• Bracing is considered in curves between 25° and 50°

Adolescent Between ages 10­18 • Curvature of the spine greater than 10°
• Higher prevalence in girls
• Cause is considered idiopathic or multifactorial, including genetic, hormonal,
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• Bracing
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Adult After full skeletal • Idiopathic is the progression of adolescent scoliosis after skeletal maturation
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Table 13­7
Categories of Scoliosis

ALTERNATIVE
TYPE AGE OF ONSET RISK FACTORS AND COMPLICATIONS
CATEGORIZATION

Congenital Develops during embryonic • More common in boys Early onset scoliosis
development (~6 weeks) • Diagnosed in infancy Onset younger than 5
• May go unnoticed until later in life years

Infantile Diagnosed within the first 3 • If curve greater than 30° risk of respiratory complications
years of life
Seen most often in thoracic
region

Juvenile Between ages 4­10 • Curvature of the spine greater than 10° Late onset scoliosis Onset
• Idiopathic, congenital, or neuromuscular in nature after age 6
• Bracing is considered in curves between 25° and 50°

Adolescent Between ages 10­18 • Curvature of the spine greater than 10°
• Higher prevalence in girls
• Cause is considered idiopathic or multifactorial, including genetic, hormonal,
metabolic conditions
• Bracing is considered in curves between 25° and 50°

Adult After full skeletal • Idiopathic is the progression of adolescent scoliosis after skeletal maturation
maturation generally 18+ • Degenerative scoliosis is the result of intervertebral disc degeneration and
facet joint degeneration resulting in wedge deformities of the spine

Spinal Abnormalities

Other common vertebral column disorders are excessive kyphosis, spondylosis, and spondylolisthesis. Although kyphosis is the normal curvature of
the thoracic spine, older adults may present with conditions in which the curvature in the thoracic spine is excessive. This condition is called
hyperkyphosis and can be associated with or is a result from vertebral compression fractures.76 Spondylosis is a reduction in the intervertebral disc
heights and hypertrophy of the zygapophyseal joints, capsule, and ligaments that are commonly associated with aging. Painful disorders, such as
myelopathy or radiculopathy, can be associated with spondylosis.77 Any acute muscular condition associated with the neck or back may also present
with a loss of lordosis in either the cervical or lumbar region; however, this is usually short term and not considered to be spondylosis.
Spondylolisthesis is a condition in which a superior vertebral body slips anterior to the vertebra below it. It may be caused by degeneration of the
segments, bilateral fracture of the pedicles of the vertebra, or occur as the result of trauma. Excessive lumbar extension (e.g., as experienced by
gymnasts and football lineman) is a common mechanism of such injuries. Typically, this is seen in the lower lumbar segments. This condition can
result in the adoption of various lumbar postures, ranging from excessive lumbar lordosis to flattening of the lumbar spine.78

Forward head posture in the cervical spine is also very common and tends to be related to prolonged positioning with poor muscular control. It is
characterized by the head being positioned anterior to the shoulder girdle and involves a combination of craniocervical extension, lower cervical
flexion, and forward position of the shoulder girdles (Figure 13–17). Measurement of this position has been validated using digital photography,
using the angle formed by a line drawn from the most posterior point of C7 to the horizon, and a line from C7 to the posterior aspect of the tragus of
the ear.79,80 Many painful musculoskeletal conditions, such as temporomandibular dysfunction, cervicogenic headache, and mechanical shoulder pain
have been associated with this posture.81–83
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Figure 13­17
Page 28 / 53
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Forward head posture.

Forward head posture in the cervical spine is also very common and tends to be related to prolonged positioning with poor muscular control. It is
characterized by the head being positioned anterior to the shoulder girdle and involves a combination ofPhiladelphia
craniocervical extension,
College lower cervical
of Osteopathic Medicine
flexion, and forward position of the shoulder girdles (Figure 13–17). Measurement of this position hasAccess
beenProvided
validated
by: using digital photography,

using the angle formed by a line drawn from the most posterior point of C7 to the horizon, and a line from C7 to the posterior aspect of the tragus of
the ear.79,80 Many painful musculoskeletal conditions, such as temporomandibular dysfunction, cervicogenic headache, and mechanical shoulder pain
have been associated with this posture.81–83

Figure 13­17

Forward head posture.

Shoulder Girdle

Malposition or abnormal movement of the scapula is a common finding among all age groups.84 This is not surprising given that stabilization of the
scapulothoracic joint is dependent on suitable muscle strength (see Chapter 7). Winging of the scapula is defined as the entire medial border of the
scapula not being positioned flush to the thoracic wall, with the scapula in a position of excessive internal rotation (Figure 13–18).85 This position
may result from serratus anterior or rhomboid muscle weakness. Excessive anterior tilt of the scapula is identified by the inferior angle of the scapula
resting away from the thorax and rib cage, which is often associated with shortened length in the pectoralis minor muscle.84,86 A number of painful
shoulder conditions are related to poor scapular alignment and positioning, so a thorough clinical examination of this region is critical.

Figure 13­18

Winging scapula.

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shoulder conditions are related to poor scapular alignment and positioning, so a thorough clinical examination of this region is critical.
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Figure 13­18
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Winging scapula.

Lumbopelvic and Hip Abnormalities

Excessive anterior or posterior pelvic tilt is often visible in the sagittal plane. Both of these postures can be the result of muscle length deficits, with an
anterior tilt associated with reduced length in hip flexor musculature and posterior pelvic tilt associated with reduced length in the hip extensor
musculature (e.g., hamstrings). An anterior pelvic tilt will typically coincide with an increase in lumbar lordosis and hip flexion, placing increased
compressive forces on the zygapophyseal joints of the lumbar spine (Figure 13–19).87 In contrast, an anterior displacement of the pelvis with a
concomitant posterior displacement (swaying back) of the upper trunk is often referred to as swayback posture (Figure 13–20). Such a posture is
marked by an increase in lumbar lordosis and thoracic kyphosis. The corresponding increase in hip extension allows the person to maintain the GRF
posterior to the hip joint and use the anterior hip ligaments for support. Swayback posture is often associated with an increase in anterior hip pain and
results in increasing compressive forces on the intervertebral disc of the lumbar spine.37,87

Figure 13­19

A . Anterior and B . posterior pelvic tilt. (From Houglum P, Bertoti D. Brunnstroms Clinical Kinesiology, 6E. Philadelphia, PA: F. A. Davis; 2012, with
permission. From Samuels V. Foundation in Kinesiology and Biomechanics. Philadelphia, PA: F. A. Davis; 2018, with permission.)

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 Philadelphia College of Osteopathic Medicine
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Figure 13­20
 Philadelphia College of Osteopathic Medicine
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Figure 13­20

Swayback posture.

Knee

Genu recurvatum (hyperextension of the knee in stance) is a position in which the knee is in ≥10 ° extension (Figure 13–21).88 In this position, the
LoG passes further anterior to the knee joint axis than typical, which places increased tensile stress on the posterior capsule and ligamentous
structures of the knee. There is some evidence that increased laxity of the knee into hyperextension may increase the risk of anterior cruciate ligament
(ACL) injuries.89 Common deviations of the knee in the frontal plane include genu varum and genu valgum (Figure 13–22). Genu varum (bow­legs) is
a medial angulation of the distal tibia in relation to the femur when the feet are together. It usually involves both the femur and the tibia. Genu varum is
a normal finding in children from birth to about age 3.90,91 in the adult, however, the presence of genu varum is a predictor for increasing risk of the
development or progression of medial compartment knee osteoarthritis.38,92 In this alignment, the LoG passes medial to the knee joint axis, placing
greater compression on the medial joint structures. This increased joint loading to the medial meniscus and tibiofemoral joint surfaces may result in
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Chapter 13: Posture,
physical stresses Lee N. tolerance
that exceed Marinko; Cynthia C. Norkin
levels, resulting Page 32 / 38
in tissue breakdown as demonstrated by the development or progression of osteoarthritis. 53
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structures of the knee. There is some evidence that increased laxity of the knee into hyperextension may increase the risk of anterior cruciate ligament
(ACL) injuries.89 Common deviations of the knee in the frontal plane include genu varum and genu valgum (Figure 13–22).
Philadelphia Genu
College varum (bow­legs)
of Osteopathic is
Medicine
a medial angulation of the distal tibia in relation to the femur when the feet are together. It usually involves both
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Provided femur and the tibia. Genu varum is
a normal finding in children from birth to about age 3.90,91 in the adult, however, the presence of genu varum is a predictor for increasing risk of the
development or progression of medial compartment knee osteoarthritis.38,92 In this alignment, the LoG passes medial to the knee joint axis, placing
greater compression on the medial joint structures. This increased joint loading to the medial meniscus and tibiofemoral joint surfaces may result in
physical stresses that exceed tolerance levels, resulting in tissue breakdown as demonstrated by the development or progression of osteoarthritis.38
Genu valgum (knock­knees) is a relative lateral angulation of the distal tibia in relation to the femur. An individual with genu valgum may stand such
that the knees are touching each other, but the feet are unable to come together. This angulation is considered normal in children from 3 to 7 years,
but should resolve by adolescence.90,91 Increased valgus angle of the knee places the LoG on the lateral side of the knee joint axis, increasing
compression to the lateral joint structures. In individuals with knee osteoarthritis, genu valgum is associated with reduced development and
progression of medial compartment cartilage degeneration and more compressive loading on the lateral compartment.38,93 Valgus angulation during
static and dynamic tasks may be associated with increased stress and pain in the patellofemoral joint, as well as increased incidence of ACL injuries.94–
96

Figure 13­21

Genu recurvattum.

Figure 13­22

Common postural deviations at the knee. A . Genu varum of the right leg. B . Genu valgus.

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 Philadelphia College of Osteopathic Medicine
Figure 13­22
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Common postural deviations at the knee. A . Genu varum of the right leg. B . Genu valgus.

Ankle, Feet, and Toes

Because of the complexity of the foot, postural alignment can be extremely variable. The most common descriptors for foot posture are neutral, pes
planus, or pes cavus (Figure 13–23).97 There are a number of different methods for classifying these different foot types, but for a postural
analysis, only visual inspection is required.98 A neutral foot is described as a foot that is well aligned both in the rearfoot (calcaneus and talus) and the
forefoot. In the neutral position, lines drawn down the midline of the posterior tibia and the posterior calcaneus should be parallel. Pes planus is the
most commonly observed postural abnormality.98,99 A pes planus foot, also called pronated or flat foot, can consist of either a low arch with a valgus
angulated hindfoot (calcaneus), or a low arch with a varus angulated forefoot, or both. Research in the area of foot abnormalities and posture has
shown that excessive pronation is associated with lower extremity injuries, increased incidence of low back pain, altered kinematics in gait, and
reduced walking speeds and quality of life scores.98,100–102 These gait deviations may result in increased stress, and subsequent injury or pain to
structures further up the kinetic chain. Furthermore, Molines­Barroso and colleagues found in a cross­sectional study of individuals with diabetes and
sensory disruption in the foot that those individuals with pronated feet had a higher incidence of ulceration than those with supinated or neutral
feet.103 These studies suggest that visualization of pronated feet may assist in identifying individuals at risk for certain impairments or painful
conditions, which may increase their level of disability.

Figure 13­23

Common foot postures.

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conditions, which may increase their level of disability.
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Figure 13­23
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Common foot postures.

Pes cavus feet are often called supinated, or high arched. The foot structure consists of either a high arch with a varus hindfoot, a high arch with a
valgus forefoot, or both (see Chapter 12). Far less literature exists regarding cavus feet than pronated feet; however, there is some evidence to suggest
the presence of an increased incidence of ankle instability and stress fracture with pes cavus feet.104,105 Kinematic studies of gait have demonstrated
that cavus feet in stance demonstrate less motion during loading response and midstance than planus or neutral feet.101,106 This reduction in motion
may result in reduced absorption of ground reaction forces and increased stress to the foot, ankle, and lower limb.

Equinus deformities of the foot are often associated with various neurological conditions and hemiparesis (Figure 13–24).107,108 In children with
cerebral palsy, these deformities are associated with significant gait deviations and proximal limb compensations like excessive pelvic rotation,
increased hip flexion, and internal rotation.109 In this population, these compensations result in increased mechanical work and energy expenditure
compared with healthy controls.110 In 49 adults with hemiparesis and equinus foot deformities, Manca and colleagues found that subjects presented
with a variety of different gait deviations and speeds.108 The severity of ankle and foot deformities was associated with slower walking speeds and
greater compensatory upper limb motion. The speeds demonstrated by this group of patients were associated with those of individuals who were
restricted to household and limited community ambulation. Although the complexity of neurological conditions contributes to these velocity
differences, it is useful for a clinician to understand that equinus foot positioning may inhibit gait progression.

Figure 13­24

Equinus deformities.

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differences, it is useful for a clinician to understand that equinus foot positioning may inhibit gait progression.
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Figure 13­24
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Equinus deformities.

Abnormal toe alignment in stance is often indicative of bony and soft tissue disorders of the foot (Figure 13–25). Hallux valgus is a common
progressive deformity of the first toe, in which the toe abducts or deviates laterally while the first metatarsal deviates medially (Figure 13–25A).111 It is
more common in women than men, but men with pes planus and higher body mass index are at a higher risk than men without pes planus.112 It is
often associated with bunions, which are bony bumps at the base of the first toe that can be painful and often require surgical correction. Other
deformities affecting more than just the first toe are mallet toe, hammer toe (Figure 13–25B), and claw toe. These deformities are usually the result of
abnormal tension between the intrinsic and extrinsic muscles of the feet resulting in altered joint positions (Table 13–8). Deformities such as these may
be the result of trauma, ill­fitting footwear, connective tissue diseases, neuromuscular conditions, or metabolic diseases.113 Observation of these
deformities should be noted as they can result in impaired postural control and may result in abnormal compensatory stresses on the proximal
limb.114 Older individuals with painful foot conditions have a higher risk for falls compared with those without foot pain.114

Figure 13­25

Abnormal toe alignments.

Table 13­8
Abnormal Toe Postures

DEFORMITY MTP JOINT POSITION PIP JOINT POSITION DIP JOINT POSITION

Mallet toe Neutral/extension Neutral/extension Flexion

Hammer2024­10­25
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P Your IP is 208.33.74.62 Flexion Neutral/extension
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Table 13­8
Abnormal Toe Postures

DEFORMITY MTP JOINT POSITION PIP JOINT POSITION DIP JOINT POSITION

Mallet toe Neutral/extension Neutral/extension Flexion

Hammer toe Neutral/extension Flexion Neutral/extension

Claw toe Extension Flexion Flexion

Neurological Conditions That Influence Posture

Maintaining upright posture relies on the interplay between the mechanical properties of the musculoskeletal system and integrity of the CNS.
Conditions that impact either of these systems will result in altered postural control and abnormal alignment. Hemiparesis is a condition where one
side of the body is weaker because of a neurological impairment within the brain, brain stem, or spinal cord. Individuals with either left­ or right­sided
hemiparesis will find upright alignment and trunk control difficult. Postural alignment may present as a lean or a total body collapse toward the paretic
(weak) side. This lean to the paretic side is attributed to muscle weakness because the weakened muscles are unable to counteract the external
moment produced by gravity. The lean may be confounded by additional impairments in the sensory perception of the body’s position in space.

Injuries or conditions that affect the spinal cord may also result in complete or partial loss of motor or sensory deficits distal to the level of the lesion
and reorganization of their visual and somatosensory systems.115 These individuals may rely on the passive supportive structures of the
musculoskeletal system to maintain an upright position. Following an incomplete spinal cord injury, upright stance is often maintained by shifting the
pelvis anteriorly such that the LoG passes farther posterior to the hip and farther anterior to the knee joint than normal, creating external extension
moments in both (Figure 13–26). This enables the individual to rely on passive internal moments to maintain an upright position. Specifically, an
individual may use the large anterior hip ligaments to resist the external extension moment at the hip, whereas the posterior knee capsule and
ligaments can be used to resist the external extension moment at the knee. With the LoG passing anterior to the ankle joint, an external dorsiflexion
moment is created to allow the passive tension in the Achilles tendon and posterior ankle structures to maintain upright standing. If necessary,
additional bracing can be used to maintain these joint positions to allow standing in the absence of muscle activity. In the seated position, injuries
above the thoracic region will often result in a flexed trunk posture, such that stability arises from the passive stiffness of the posterior spinal ligaments
and joint capsules, and anterior compression of the vertebral bodies.

Figure 13­26

Individuals with paraplegia often maintain an upright stance by shifting the pelvis anteriorly, which puts the LoG posterior to the hip joint axis. The
external extension moment is counteracted by the internal flexion moment of the anterior hip ligaments (passive resistance).

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Figure 13­26
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Individuals with paraplegia often maintain an upright stance by shifting the pelvis anteriorly, which puts the LoG posterior to the hip joint axis. The
external extension moment is counteracted by the internal flexion moment of the anterior hip ligaments (passive resistance).

Postural Changes Across the Life Span

Loss of postural control and balance can have a negative impact on the functional capacity of individuals at any age.114,116 Postural stability varies with
age. In a study of 1,724 individuals between the ages of 6 and 97, Schwesig and colleagues found a significant nonlinear relationship between age and
postural stability.117 In this population they found postural stability was reduced in the young, peaked between adolescence and the mid­30s, and
showed the greatest decline between ages 40 and 70, with significant limitations after the eighth decade.117 This information is valuable to the clinician
as decline in postural stability is associated with increased risk for falls.114,116,118

Adults and Older Adults

Deviations in resting alignment may be the result of compensatory mechanisms that are incorporated by the individual to facilitate greater postural
stability. Examples of this in older adults may be seen by forward leaning or reaching for support with their upper extremities.

Age­related changes in sagittal alignment of the spine, pelvis, and lower extremities are common (Figure 13–27).119–124 Alterations in cervical lordosis
can influence, or be influenced by, the amount of thoracic kyphosis in adults.50,125,126 In fact, individuals with reduced cervical lordosis have
demonstrated ~10° reduction in their thoracic kyphosis compared with those with normal cervical lordosis.125 Similarly, Lee and colleagues used
radiographic measurements to demonstrate that the slope of the T1 vertebral body was the key factor to determine the sagittal alignment of the
cervical spine.50 Maintenance of this alignment is integral to upright posture as well as to maintaining horizontal gaze. Many studies have
demonstrated increased anterior translation of the spine relative to the pelvis with increasing age.87,119,124,127 This anterior translation increases
rapidly from the seventh to ninth decade of life.124 Changes in the anterior translation of the spine relative to the pelvis can be compensated for by
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alterations in the position of the lumbopelvic spine or the lower extremities.77,121,122,128,129 Common compensations include reduced lumbar lordosis,
Chapter 13: Posture, Lee N. Marinko; Cynthia C. Norkin Page 38 / 53
increased
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compensations the move of an individual’s CoM anteriorly within the BoS requires greater amounts of muscular effort to maintain upright posture.
Concomitant loss of muscle in the aging population may increase the risk of falling and correlate to the rapid decline in postural stability between 40
demonstrated ~10° reduction in their thoracic kyphosis compared with those with normal cervical lordosis. 125 Similarly, Lee and colleagues used
Philadelphia College of Osteopathic Medicine
radiographic measurements to demonstrate that the slope of the T1 vertebral body was the key factor toAccess
determine the sagittal alignment of the
Provided by:

cervical spine.50 Maintenance of this alignment is integral to upright posture as well as to maintaining horizontal gaze. Many studies have
demonstrated increased anterior translation of the spine relative to the pelvis with increasing age.87,119,124,127 This anterior translation increases
rapidly from the seventh to ninth decade of life.124 Changes in the anterior translation of the spine relative to the pelvis can be compensated for by
alterations in the position of the lumbopelvic spine or the lower extremities.77,121,122,128,129 Common compensations include reduced lumbar lordosis,
increased thoracic kyphosis, and a reduction in the sacral slope, with an increase in posterior tilt of the pelvis.77,121,122,129,130 Without these
compensations the move of an individual’s CoM anteriorly within the BoS requires greater amounts of muscular effort to maintain upright posture.
Concomitant loss of muscle in the aging population may increase the risk of falling and correlate to the rapid decline in postural stability between 40
and 70 years. These postural changes are also related to a reduction in health­related quality of life measures, suggesting the significant increase in
postural deviation may impact overall well­being.

Figure 13­27

Postural changes across the life span.

Pregnancy

Pregnancy is associated with a number of physiological changes, including increased weight in the abdomen and breasts and relaxing of the ligaments
and connective tissue.131 These physiological changes are often associated with alterations in postural alignment and subsequent complaints of low
back, pelvic girdle, and leg pain (Figure 13–28).131–133 Compared with non­pregnant women, pregnant women demonstrate significant increases in
thoracic kyphosis, reduced lumbar lordosis, and sacral posterior inclination.133,134 With increasing abdominal size, maintenance of the CoM over the
BoS may result in compensatory adjustments of the craniocervical region as well as the lower extremities.135 Musculoskeletal complaints of pain in the
low back and pelvic girdle are likely associated with increased stresses placed on the lumbar spine and pelvis through increased axial load and anterior
shear. Distortion of the abdominal and pelvic floor musculature from the expanding uterus may also result in changes in motor control necessary for
postural stability.136,137 McCrory and colleagues found that women who are pregnant walk with greater frontal plane mobility, increased step width,
and greater thoracic extension at initial contact compared with non­pregnant women.138 These gait deviations may vary dependent upon the
characteristics of the individual such as weight gain, distribution, and height.

Figure 13­28

Postural changes associated with pregnancy.

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characteristics of the individual such as weight gain, distribution, and height.
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Figure 13­28
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Postural changes associated with pregnancy.

Foundational Concepts 13–4

Posture Changes Across the Life Span

Postural stability changes across the life span, with the peak of stability occurring from 18 to 30 but rapidly declining between 40 and 70 years.

Interestingly, the peak age for ACL injuries in females is between ages 14 and 18, prior to peak postural stability.

Pregnancy causes an upward and anteriorly directed shift in the CoM that may be accommodated by an increase in lumbar lordosis (posterior
lean) to re­center the CoM over the BoS.
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males and Page 40 / 53
females occurs over the age of 50, during the period of rapid decline in postural stability.
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Assessment of upright posture and balance control in the young female or in an adult over 50 years may be a great clinical screening tool to
help identify individuals at risk for musculoskeletal injury.
 Philadelphia College of Osteopathic Medicine
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Foundational Concepts 13–4

Posture Changes Across the Life Span

Postural stability changes across the life span, with the peak of stability occurring from 18 to 30 but rapidly declining between 40 and 70 years.

Interestingly, the peak age for ACL injuries in females is between ages 14 and 18, prior to peak postural stability.

Pregnancy causes an upward and anteriorly directed shift in the CoM that may be accommodated by an increase in lumbar lordosis (posterior
lean) to re­center the CoM over the BoS.

The highest rate of hip fractures in males and females occurs over the age of 50, during the period of rapid decline in postural stability.

Assessment of upright posture and balance control in the young female or in an adult over 50 years may be a great clinical screening tool to
help identify individuals at risk for musculoskeletal injury.

Dynamic Postural Changes: Kinematics and Kinetics

Control of body alignment during transfers is essential for functional mobility in daily life. When examining dynamic activities, knowledge of normal
kinematic and kinetic function is necessary.

Sit to Stand

Successful transition from a seated position to upright stance requires sufficient muscle strength and joint mobility, and the ability to perform this
transition can be the difference between independence and disability. Elderly individuals, or individuals with musculoskeletal or neurological
impairments, often experience a great deal of difficulty performing sit to stand transitions without use of upper extremity support or assistance.
Yoshioka and colleagues assessed the lower extremity kinematics for sit to stand in healthy young adults and found that for successful
accomplishment of this task the hip angle moves from about 100° of flexion to 0, the knee from 120° of flexion to 0, and the ankle from 30° of
dorsiflexion to 0°.139 The combined hip­knee peak joint moment necessary for success needed to be sufficient to raise the weight of the body. In a
more recent study, the same authors used mathematical modeling to determine that successful sit to stand cannot occur without adequate joint range
of motion (ROM) or combined lower extremity muscle force.140 Any disorder that disrupts adequate joint motion or muscle force will impact the sit to
stand transfer. Individuals with knee osteoarthritis, for example, often exhibit deficits in quadriceps strength. As a result, they often demonstrate
deviations during sit to stand, including increased weightbearing through the contralateral limb, increased trunk flexion, and reduced knee extension
moments and impaired mechanical efficiency.141,142

Returning to sitting from standing requires eccentric control of the leg extensors. Individuals with paresis secondary to spinal cord injury with limited
strength in the lower extremities will demonstrate increased use of the upper extremities, greater trunk lean, longer time to complete the task, or a
higher impact force on the seating surface compared with healthy controls.143 Seat height, the presence of arm rests, and foot position during the task
are all critical components that will influence an individual’s ability to successfully perform a sit to stand task.144,145

Patient Application 13–6

In the presence of weakness in the quadriceps muscles, an individual may have difficulty in rising from a lower seat height, such as a sofa with soft
cushions, but no difficulty at all in rising from a higher seat or standard height seat with a firmer surface, such as a kitchen chair. Patients with weak
quadriceps when seated on a sofa often use momentum or rocking to achieve an upright stance as this helps to compensate for limited strength in
their limbs. Furthermore, a total hip arthroplasty done via a posterior surgical approach has a risk of dislocation when the hip flexes greater than 90°
during the first few weeks of recovery. Use of raised toilet seats or seat cushions is common practice to limit the amount of hip flexion required to
achieve the seated position.

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Lunging
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A lunge is a forward movement of the body with one leg in front of the other. It is a motion that may be necessary to reach into a lower cabinet or to get
Returning to sitting from standing requires eccentric control of the leg extensors. Individuals with paresis secondary to spinal cord injury with limited
Philadelphia
strength in the lower extremities will demonstrate increased use of the upper extremities, greater trunk lean, College
longer time of Osteopathic
to complete the task,Medicine
or a
higher impact force on the seating surface compared with healthy controls.143 Seat height, the presenceAccess
of armProvided by:
rests, and foot position during the task
are all critical components that will influence an individual’s ability to successfully perform a sit to stand task.144,145

Patient Application 13–6

In the presence of weakness in the quadriceps muscles, an individual may have difficulty in rising from a lower seat height, such as a sofa with soft
cushions, but no difficulty at all in rising from a higher seat or standard height seat with a firmer surface, such as a kitchen chair. Patients with weak
quadriceps when seated on a sofa often use momentum or rocking to achieve an upright stance as this helps to compensate for limited strength in
their limbs. Furthermore, a total hip arthroplasty done via a posterior surgical approach has a risk of dislocation when the hip flexes greater than 90°
during the first few weeks of recovery. Use of raised toilet seats or seat cushions is common practice to limit the amount of hip flexion required to
achieve the seated position.

Lunging

A lunge is a forward movement of the body with one leg in front of the other. It is a motion that may be necessary to reach into a lower cabinet or to get
down to the floor. Lunges are exercises that are commonly used to help develop strength, power, and balance in the lower extremity. Inability to
perform a lunge or maintain optimal alignment during a lunge is often a clinical indicator of lower extremity pathology or muscle weakness. Lunges
require knee flexion greater than 90° and ankle dorsiflexion in both the front and back legs, with hip flexion in the forward limb and extension in the
rear limb. Hale and colleagues found different muscle activation patterns between males and females who were performing a lunging movement.146
Specifically, males demonstrated greater activation in biceps femoris, whereas females demonstrated greater semitendinosus activation. Both
demonstrated similar activation patterns in the quadriceps throughout the task. Increased body mass has been shown to increase the hip extensor
moment during lunging and therefore may be a reason that an individual is having difficulty performing this task.147 When observing a lunge from the
front, assessing the frontal plane stability of the femur is essential. An inability to maintain a neutral femur may be indicative of ankle joint limitations
or weakness in the hips and trunk.148,149

Patient Application 13–7

Anterior cruciate ligament tears and patellofemoral pain syndromes are both painful conditions that result in activity and participation limitations.
Some evidence suggests that individuals with poor control of frontal plane motion of the femur during functional tasks such as squatting, lunging,
or stepping down are at a higher risk for these painful conditions. Observation of these functions may help guide further examination.

Jumping

Jumping or landing from a jump is a common task in sporting events and requires a great deal of strength and motor control. A number of injuries
sustained in the lower extremity, including anterior cruciate ligament tears, commonly occur during jumping. There has been extensive research in the
area of jumping with an effort to identify possible variables that may correlate to higher risk for injury. Landing from a jump requires the lower
extremity to attenuate ground reaction forces while simultaneously decelerating the body. Landing techniques can impact the stability requirements of
the knee. During a soft landing, which is described as a peak knee flexion angle of > 90°, the forces attenuated through the knee are less than when
landing on a stiff knee.150–152 Observing an individual’s ability to maintain the knee in frontal and transverse plane alignment as knee flexion is
controlled may assist a clinician in recognizing potential impairments that may lead to risk of injury.

Summary
The maintenance of both static and dynamic balance occurs through the integration of sensory information from visual, vestibular, and
somatosensory systems. Postural control maintains the CoM over the BoS using feedforward and feedback response systems.

Optimal standing and sitting posture are often achieved by having the LoG pass as close to the joint axes as possible to minimize the need for
internal joint moments.

Observation of seated and standing posture is accomplished by the examination of multiple landmarks from multiple viewpoints (i.e., anterior,
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During seated and standing postures, the internal and external moments about each joint should maintain equilibrium.

Assessment of static posture and ideal alignment were introduced with specific reference to various regions of the body, including the extremities
 The maintenance of both static and dynamic balance occurs through the integration of sensory information from visual, vestibular, and
somatosensory systems. Postural control maintains the CoM over the BoS using feedforward and feedback response
Philadelphia systems.
College of Osteopathic Medicine
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Optimal standing and sitting posture are often achieved by having the LoG pass as close to the joint axes as possible to minimize the need for
internal joint moments.

Observation of seated and standing posture is accomplished by the examination of multiple landmarks from multiple viewpoints (i.e., anterior,
posterior, lateral).

During seated and standing postures, the internal and external moments about each joint should maintain equilibrium.

Assessment of static posture and ideal alignment were introduced with specific reference to various regions of the body, including the extremities
and vertebral column. Common postural abnormalities were described introducing various conditions that may affect ideal posture and life­span
variabilities.

The role of postural alignment during dynamic functional movement was introduced.

Study Questions
1. What is the difference between posture and balance?

2. What is the role of each of the following systems for postural control: visual, vestibular, and somatosensory?

3. What is postural sway and what are the different strategies used to maintain upright posture?

4. How do we maintain our posture in the presence of known and unknown postural perturbations?

5. Describe the moments that would be acting on all body segments as a result of an unexpected forward movement of a supporting surface in a fixed
support strategy. Describe the muscle activity that would be necessary to bring the body’s LoG over the BoS.

6. What is the role of postural assessment in clinical practice?

7. In ideal upright posture, where is the LoG relative to each of the following regions: head, vertebral column, hip, knee, and ankle? How does this
influence muscle activity in those areas?

8. What is the relationship between the GRFV, LoG, and CoM in the erect static posture?

9. For the erect standing posture, identify the type of stresses that would be affecting the following structures: apophyseal joints in the lumbar region,
apophyseal joint capsules in the thoracic region, annulus fibrosus in L5 to S1, anterior longitudinal ligament in the thoracic region, and the
sacroiliac joints.

10. What effect might tight hamstrings have on the alignment of the following structures during erect stance: pelvis, lumbosacral angle, hip joint, knee
joint, and the lumbar region of the vertebral column?

11. How would you describe a typical idiopathic lateral curvature of the vertebral column?

12. Identify the changes in body segments that are commonly used in scoliosis screening programs.

13. Describe various abnormalities of scapulothoracic position and what muscles may be involved.

14. Compare a flexed lumbar spine posture with an extended posture in terms of the stresses on the vertebral discs, ligaments, and joint structures.

15. Compare intradiscal pressures in erect standing with erect, slumped, and relaxed sitting.

16. Describe the effects of genu varum and genu valgum on the medial and lateral tibiofemoral compartments.

17. What are the risks associated with pes planus?

18. Describe the different joint positons of the metatarsal­phalangeal, proximal phalangeal, and distal phalangeal joints for hammer toe, claw toe and
hallux valgus.

19. Explain how an individual who lacks lower extremity strength and elements of postural control can maintain upright stance.

20. How does 2024­10­25

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impact the following structures: head, vertebral column, hip,
knee, and ankle?
 Philadelphia
18. Describe the different joint positons of the metatarsal­phalangeal, proximal phalangeal, and distal phalangeal College
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for hammer toe, clawMedicine
toe and
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19. Explain how an individual who lacks lower extremity strength and elements of postural control can maintain upright stance.

20. How does aging affect postural alignment in the spine and how might this influence postural control?

21. What is the effect of pregnancy on upright posture and identify how this posture may impact the following structures: head, vertebral column, hip,
knee, and ankle?

22. Describe the role of joint ROM in sit to stand and lunging activities, and how does this influence muscle requirements?

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