POSTURAL

ASSESSMENT
LECTURER: Çiçek Günday, PT, MSc.
Posture
Posture is the position in which someone holds their body when standing, sitting or
lying down.

Posture is the placement of each part of the body in the most appropriate position
relative to the adjacent segment and the whole body.

The body acquires a proper posture as a result of the harmonious work of many
muscles (with the support of the ligaments) in order
• to provide stability during muscular activity or
• to form the basis of a movement.
◦Inactive postures: Attitude adopted for resting or sleeping. All essential
muscular activity reduces to minimum and used for training general relaxation.
◦Active postures: Muscular activity is required. Many muscles must work
integrated. May be static or dynamic.
◦Static posture: In static postures, the body and its segments are aligned and
maintain in certain positions like sitting, standing, or sleeping. This is usually
achieved by coordination and interaction of various muscle groups which are
working statically (concentrically) to counteract gravity and other forces.
◦Dynamic posture: It refers to postures in which the body or its segments are
moving like walking, running, or bending over to pick up something. It is usually
required to form an efficient basis for movement. Muscles and non-contractile
structures have to work to adapt to changing circumstances.
Postural Control
Postural control refers to maintain the stability of the body as a whole
and body segments “against gravity” or “movement of different body
segments”.

The postural reflexes help to maintain the body in upright and balanced
position. They also provide adjustments necessary to maintain a stable
posture during voluntary activity.

Control depends on the integrity of nervous system, musculoskeletal

system and special senses.
Postural Reflex Arch

• Reflex is an efferent answer for an afferent impuls.

• Afferent Pathway – comes from the eyes, the vestibular apparatus and
the proprioceptive system.
• Integrating Centers – are formed by neuronal network in the brain stem
and spinal cord
• Efferent Pathway – alpha-motor neurons supplying the various skeletal
muscles
Proprioceptive System Mechanoreceptors

Sole
sensation
is also
important!

Muscle Spinde Golgi Tendon Organ

 Vestibular Apparatus
The semicircular canals: They are interconnected
tubes located in the inner ear. The three canals are the
horizontal, superior and posterior semicircular canals.
At one end of each of the semicircular canals is a
dilated sac called an osseous ampulla. Each ampulla
contains an ampulla crest, the crista ampullaris
which consists of many hair cells. They indicate
rotational movements.

Otoliths: The utricle and saccule are the two otolith

organs in the vertebrate inner ear. They provide
information about acceleration. The utricle is more
sensitive to horizontal acceleration, whereas the
saccule is more sensitive to vertical acceleration.
 Eyes
Visual sensation records alteration in the body with regard to its surroundings
and eyes form one of the receptors for the righting reflexes which enable the
head and body to restore its erect position.
The righting reflex, also known
The vestibulo-ocular reflex (VOR)
as the Labyrinthine righting
is a reflex acting to stabilize gaze
reflex, is a reflex that corrects
during head movement, with eye
the orientation of the body when
movement due to activation of the
it is taken out of its normal
vestibular system. The reflex acts to
upright position. It is initiated by
stabilize images on the retinas of the
the vestibular system, which
eye during head movement, holding
detects that the body is not erect
gaze is held steadily on a location, by
and causes the head to move
producing eye movements in the
back into position as the rest of
direction opposite to head movement
the body follows.
Spinal Cord
 Muscle Contractions
Muscle contractions are primarily responsible for keeping the body in the
upright position in both static and dynamic posture.

The muscles most involved are called antigravity muscles.

Antigravity Muscles:
Any of the muscles involved in the stabilization of the joints or other body
parts by opposing the effects of gravity.
 Antigravity Muscles

◦Usually extensors
◦Multipennat
◦Their function is to generate
force rather than velocity.
◦They can contract for a long
time without getting tired
◦Slow twitch muscle fibers
◦Aerobic type
Muscles mainly extensors of knee,
hip, trunk and neck are called
antigravity muscles that by their
tone resist the constant pull of
gravity in the maintenance of
normal posture.

Other muscles, perhaps less

involved, but also important in
maintaining the upright position, are
the trunk and neck flexors, hip
abductors and adductors, and the
ankle pronators and supinators.
Good Posture
◦A posture is said to be good when it fulfils the purpose
for which it is used with maximum efficiency and
minimum effort.
◦Varies from individual to individual
◦Perfect balance of one body segment over another.
◦Minimum muscular effort.
◦Minimum stress on the joints.
◦Pleasing to someone’s eyes.
◦Organs can work adequately and properly.
 Body type
Race
Fashion of the time
Gender
FACTORS Profession and occupation
AFFECTING Psychological state
POSTURE Good hygiene conditions
Sleep quality
Good nutrition
Exercising outdoors and in the fresh air
Emotional state
Bad (Poor) Posture
 If your body is not held in a good position, many
organs cannot work or grow properly.
 For example, if your shoulders sag forward, your chest
will be cramped and your lungs will not be able to
expand fully, preventing you getting enough oxygen.
 A bent backbone will cramp your digestive system,
causing digestive problems. This will also put strain on
the muscles and ligaments of your back, which could
result in serious back problems.
 Generally, a poor posture will result in muscle aches,
weakened ligaments, stressed and therefore painful
joints, cramped organs, poor blood and lymph flow and
a feeling of tiredness.
  Muscle weakness (Muscular imbalance)
 Muscle tone
 Laxity of ligamentous structure
 Joint position and mobility
 Fascial and musculotendinous tightness
FACTORS  Pain
CAUSING POOR  Pelvic angle
POSTURE  Neurogenic outflow and inflow
 Prolonged fatigue
 Occupational stress

Postures that disappear immediately when the

causes disappear are excluded from the
classification of bad posture.
Assessment of posture forms the very basis of physiotherapy assessment.
It helps in identifying the defects in body, which lead to various
musculoskeletal problems.

The gravity line is represented by a vertical line drawn

through the body’s center of gravity, located at 1-2 cm
anterior to the second sacral vertebra (S2). Gravity line is
obtained from the intersection of sagittal and frontal
planes.

The closer a person’s postural alignment lies to the center of

all joint axes; the less gravitational stress is placed on the
soft tissue components of the supporting system.
 First, determine the body type….

There are three body types:

a) Ectomorph: Taller, but naturally relatively skinny, with a very low-fat mass
percentage, thin bones as well as long-limbed body.

b) Endomorph: They would have fat in excess, low muscle definition, hence not
lean at all nor skinny and most of all, it is very hard to drop down weight

c) Mesomorph: It is a mix of the two previous body types being characterized by a

larger frame (bone structure) like the endomorph and low body fat, hence leaner
muscles, like the ectomorph.
A variety of postural assessment Visual observation • commonest method
method • does not require any equipment
methods have been in use:
• very common
Plumbline method • posture is evaluated in accordance with the guidelines which are
given by Kendall

• Measurement of postural angles, such as neck inclination angle

Goniometry (Craniovertebral angle) and cranial rotation angle (sagittal head tilt)
by using manual goniometry

• Patients are photographed in anterior/posterior/lateral

Photographic and • views by using a camera. The images are analyzed by
digitization method • using the “Posture Analysis” software.

Radiographic • gold standard method

method • risk of exposure towards harmful radiations

• Photographs of the subjects are taken in frontal or sagittal plane. There

Photogrammetric are markers on he certain points. Angles are drawn between the markers
method by drawing horizontal and/or vertical lines on the computer.
 The plumb line is used to
determine where gravity line
passes in the standing
position.
 POSTERIOR VIEW

From the posterior view the plumb line bisects the body into symmetrical
left and right sides.

The Gravity Line Passes Through

 Occipital Protuberance
 Midline of the vertebrae (C7 – L5 spinous processes)
 Midline of the sacrum and coccyx
 A point midway between both medial malleoli
 LATERAL VIEW

The Line of Gravity Passes Through

 Slightly posterior to coronal suture

 Mastoid process
 Posterior to the center of cervical vertebrae
 C7 vertebra
 Shoulder joint
 Anterior to the center of thoracic vertebrae
 T10 vertebra
 Posterior the center of lumbar vertebrae
 Slightly posterior to the axis of the hip joint
 Slightly anterior to the axis of the knee joint
 Anterior to the axis of ankle joint
Referance Points for Gravity Line

• Head – Ear lobe

• Shoulder – Akromion
• Trunk – midline
• Hip – greater trochanter
• Knee – anterior to midline, posterior to patella
• Ankle – 3-3,5 cm anterior to lateral malleolus
Kyphotic-Lordotic Posture

Head Forward (Protracted)

Cervical spine Hyper-lordosis (Hyperextended)
Scapula Abduction (protraction)
Thoracic spine Increased flexion (kyphosis)
Lumbar spine Hyperlordosis
Pelvis Anterior pelvic tilt
Hip joints Flexion
Knee joints Slight hyperextension
Ankle joints Plantar flexed, legs are behind midline
 Flat Back Posture

Head Forward (Protracted)

Cervical spine Slight extension
Thoracic spine Increased flexion on upper thoracic
vertebrae while the lower thoracic
vertebrae are flattened (Reduced
curvature)
Lumbar spine Lumbar lordosis flattened (flexion)
Pelvis Posterior pelvic tilt
Hip joints Extension
Knee joints Extension
Ankle joints Slight plantar flexion
 Sway Back Posture
Head Forwad (Protracted)
Cervical spine Upper part: extended (hyperlordosis)
Lower part: flexed (hypolordosis or kyphosis)
Thoracic spine Upper part: increased flexion (hyperkyphosis)
Lower part: normal (kyphosis)
Lumbar spine Upper part: flexion (kyphosis or hypolordosis)
Lower part: increased extension
(hyperlordosis)
Pelvis Posterior pelvic tilt and shifted anteriorly
Hip joints Hyperexension due to the position of pelvis
Knee joints Hyperextension
Ankle joints Neutral or plantar flexion
 Forward Posture
The plumb line is posterior to the body; body weight is carried on the metatarsal heads of the
feet.
- Ankles in dorsiflexion with forward inclination of the legs; posterior musculature stretched.
- Tightness of dorsal musculature.
- Posterior muscles of the trunk remain contracted.
 Postural Examination

The whole posture is assessed from head to toes in different views:

a) Lateral views
b) Posterior views
c) Anterior views
Lateral Posture Analysis
 Foot
◦ The foot has three arches: two longitudinal (medial and
lateral) arches and one anterior transverse arch. They are
formed by the tarsal and metatarsal bones, and supported
by ligaments and tendons in the foot.
◦ Especially medial longitudinal arch is important for
posture. It is formed by first three metatarsals, three
cuneiforms, navicular, talus, and calcaneus bones of the
foot.
◦ Pes Planus: Low arch of the foot – excessive pronation
◦ Pes Cavus: high arch of the foot that does not flatten with
weighztbearing
 Feiss Line

Feiss Line is an ankle examination procedure that tests for

pes planus, flatfoot, fallen medial longitundinal arch.

■ Starting at the distal part of the medial malleolus,

draw a straight line connecting it to the first MTP
joint. (Feiss Line)
■ Mark the navicular tuberosity.
■ In a normal foot, the navicular tuberosity should
be directly on the line.
■ If the navicular tuberosity dropping below the
Feiss Line, it implies the patient has pes planus.
■ There are 3 stages of the pes planus according to
the distance to the floor: 1/3; 2/3; 3/3
 Navicular Drop Test

Mark the location of the navicular tuberosity

a) Measure its distance from the supporting surface in sitting position (non-
weight bearing, neutral)
b) Measure its distance from the supporting surface in standing position (full
weight bearing, relaxed)
Note the distance between a and b.
>10 mm difference is considered excessive foot pronation
 Knees
Genu recurvatum: Knee is hyperextended and the Flexed knee: The plumb line falls posterior to
gravitational stresses lie far forward of the joint axis. It the joint axis. It may be due to:
may be due to - Tightness of and hamstring muscles at the
- Tightness of quadriceps knee
- Stretched popliteus and hamstring muscles at the knee - Stretched quadriceps and tight gastrocnemius
- Compression forces anteriorly muscles
- Shape of tibial plateau. - Posterior compression forces
- Bony and soft tissue limitations.
 Pelvis
Normal pelvis: The anterior superior iliac spines are located on the same
frontal plane with the pubic symphysis.
Anterior pelvic tilt: The anterior Posterior pelvic tilt: The symphysis
superior iliac spines lie anterior to the pubis lies anterior to the anterior
pubic symphysis. Increased pelvic superior iliac spines. Decreased
inclination. pelvic inclination
Columna Vertebralis

a) Lordosis
b) Kyphosis
c) Kypholordosis
d) Swayback
e) Flat back
 Shoulders
Forward shoulders: The acromion process lies anterior to the plumb line; the
scapulae are abducted. It may be due to:
- Tight pectoralis major and minor,
- Excessive thoracic kyphosis and forward head
- Weakness of thoracic extensor, middle trapezius and rhomboid muscles
 Head
Flattened Cervical Curve: is a Excessive Cervical Curve: The gravity line lies Forward head:
condition in which the normal posterior to the vertebral bodies. It may be due to: The head lies
lordosis of the cervical spine - Anterior longitudinal ligaments and flexor anterior to the
diminishes, or is even fully lost. muscles are stretched plumb line.
- Stretched posterior cervical - Tightness of posterior ligaments and neck
ligaments and extensor muscles extensor muscles
- Tight cervical flexor muscles. - Distance between occiput and C7 is less than 5-
7.5 cm

Check for tilt and protraction

Anterior Posture Analysis
 Toes
Hallux valgus: Lateral Claw toes: Hyperextension of Hammer toes: Hyperextension
deviation of the first digit at the metatarso-phalangeal joint of the metatarsophalangeal
the metatarso-phalangeal and flexion of the proximal joints and distal
joint. interphalangeal joints, interphalangeal joints and
associated with pes cavus. flexion of the proximal
interphalangeal joints.
 Knees
External tibial torsion: Internal tibial torsion: Genu varum: The distal Genu Valgum: The
Normally, the distal end of the The feet face directly segment (leg) deviates to­ mechanical axis for
tibia is rotated laterally 25° forward or inward. ward midline in relation the lower limbs is
from the proximal end. Excess Check the patella while to the proximal segment displaced laterally.
of 25° rotation is an increase in feet facing forward. If (thigh);
torsion and is referred to as they facing each other,
lateral tibial torsion (toeing out). there could be internal
torsion. When medial malleolus touching each other, there
should be 1-2 cm between knees
 Hips

 Levels of the SIAS (ASIS)

 Length measurement
 Chest
Harrison Groove (Harrison Pectus excavatum (Funnel Barrel chest: Increased Pectus cavinatum
Sulcus): A depression on both chest): Pectus excavatum, also overall antero-posterior (Pigeon chest): The
sides of the chest wall of a known as sunken or funnel diameter of rib cage. It sternum pro­jects
person between the pectoral chest, is a congenital chest may be due to respiratory anteriorly and
muscles and the lower margin wall deformity in which difficulties downward.
of the ribcage. several ribs and the sternum stretched intercostals and
- Rickets grow abnormally, producing a anterior chest muscles
concave, or caved-in,
appearance in the anterior chest
wall.
 Shoulders
Dropped or elevated shoulder: Clavicle and joint asymmetry: It may be due to:
- Prominences secondary to joint trauma.
- Subluxation or dislocation of sterno-clavicular or acromio-
clavicular joints.
- Clavicular fractures.
 Elbow
Cubitus valgus: The forearm deviates Cubitus varus: The forearm deviates
laterally from the arm at angle greater medially (adducts) from the arm, at an
than 15° (female) and 10° (male). angle of less than 15° for females and
10° for males.
 Head and Neck
Lateral Tilt Rotation Mandibular asymmetry: The upper and lower teeth are not aligned and
the mandible is deviated to one side. It may be due to:
- Tightness of the mastication muscles on one side.
- Stretched mastication muscles on the contralateral side.
- Malalignment of temporo-mandibular joints.
- Malalignment of teeth.
Posterior Posture Analysis
 Ankle and Foot
Pes planus (Pronated): There is Pes Cavus (supinated): The medial
decreased medial longitudinal arch, the longitudinal arch is high and the navicular
Achilles tendon is convex medially and bone lies above Feiss’ line.
the tuberosity of the navicular bone lies
below the Feiss line.
 Pelvis and Hip
Lateral pelvic tilt: One side of the pelvis is higher than the Pelvic rotation: The plumb line
other due to: falls to the right or left of the
- Scoliosis with ipsilateral lumbar convexity. gluteal cleft. It may be due to:
- Leg-length discrepancies. - Tightness of medial rotator
- Shortening of the contralateral quadratus lumborum. and hip flexor muscles on the
rotated side.
- Ipsilateral lumbar rotation.
 Shoulder
Dropped shoulder / Adducted scapulae: Abducted scapulae: Winging of the
Elevated shoulder: One The scapulae are too The scapulae have scapulae: The
shoulder is lower than close to the midline moved away from the medial borders
the other. of the thoracic midline of the thoracic of the scapulae
vertebrae. vertebrae. lift off ribs.
 Head and Neck
Head tilt: Subject’s head lies more to one Head rotated: The plumb line is to the right or
side of the plumb line. It may be due to: left of the midline. It may be due to:
- Tightness of lateral neck flexors on one - Tightness of the sternocleidomastoid, upper
side. trapezius, scalene and intrinsic rotator muscles on
- Stretched lateral neck flexors contra- one side.
laterally.
- Compression of vertebrae ipsi-laterally.
 Columna Vertebralis
Lateral deviation (Scoliosis): The spinous processes of the vertebrae are
lateral to the midline of the trunk.
 Scoliosis
An abnormal lateral curvature of the spine.
 The spine's normal curves occur at the cervical,
thoracic and lumbar regions in the so-called
“sagittal” plane. These natural curves position
the head over the pelvis and work as shock
absorbers to distribute mechanical stress during
movement.
 Scoliosis can arise from a variety of causes and is
defined as a lateral curvature of the spine greater
than 10 on an anterior-posterior standing
radiograph.

 However, in reality, it is a 3-dimensional

structural deformity that includes a curvature in
the frontal plane, angulation in the sagittal
plane, and rotation in the transverse plane.
• Any sideways —or lateral —spinal
curvature of at least 10 degrees, as
measured on an X-ray of the spine,
is considered scoliosis.

• Small curve size would not show

signs or symptoms.

• As the curve progresses to 20 degrees or beyond, there is an increased

chance that the person or an observer, such as a parent or teacher, might
notice abnormalities such as clothes hanging unevenly or the body tilting to
one side.
 Classification: Structural - Nonstructural
Scoliosis

Functional Structural
Scoliosis Scoliosis

Results from a Idiopathic Congenital

Neuromuscular
temporary Scoliosis Scoliosis
cause and only
involves a side-
to-side Infantile Failure of Failure of Neuropathic
Segmenta- Myopathic
curvature of the (0-2) Formation Upper motor
spine (no spinal tion neuron
Juvenile *Wedge
rotation). The vertebra *Unilateral
(2-10) Lower motor
spine’s bar
Adolescent *Hemi- neuron
structure is still
(>10) vertebra *Block
normal.
vertebra
•Nonstructural scoliosis:

This type of scoliosis, also known as

functional scoliosis, occurs due to a
temporary cause that only affects lateral
curvature without spinal rotation.

For example, a difference in leg

heightscould potentially cause a
sideways curve in the spine that is
corrected with a shoe insert.
• Idiopathic Scoliosis:

Idiopathic means a condition is of

unknown cause.
As such, idiopathic scoliosis
technically cannot be diagnosed
until other types of scoliosis are
ruled out.
•Congenital scoliosis:

This type of scoliosis is

present from birth and is the
result of the spine not
forming properly.
•Neuromuscular scoliosis:

Many types of neuromuscular conditions

can lead to muscle problems in the
backthat result in scoliosis.

A few examples include cerebral palsy

and myelodysplasia.
Classification: Location of Curve
Classification: Shape of the Curve
Classification: According to Size of Curve

• Mild scoliosis - conditions where the Cobb angle measures at

25 degrees or less.
• Moderate scoliosis - conditions where the Cobb angle
measures between 25 and 40 degrees.
• Severe scoliosis - conditions where the Cobb angle measures
at 40+ degrees for adolescents and 50+ degrees for adults.
Factor Affecting Severity of the Curve
•Gender: Girls have a much higher riskof progression than do
boys.
•Severity of curve: Larger curves are more likely to worsen with
time.
•Curve pattern: Double curves, also known as S-shaped curves,
tend to worsen more often than do C-shaped curves.
•Location of curve: Curves located in the center (thoracic) section
of the spine worsen more often than do curves in the upper or
lower sections of the spine.
•Maturity: If a child's bones have stopped growing, the risk of
curve progression is low.(That also means that braces have the
most effect in children whose bones are still growing.)
 Assessment in Scoliosis
•Anamnese;
-Genetic diseases, family history, passed surgeries,
menarche date, brace usage

•Physical Assessment of Asymmetries;

-shoulders, scapulae, waistline and the distance of the
arms from the trunk, as well as the "balance" of the head.
-antropometric measurements; like muscle shortness, leg
lenght, height & weight etc.
-Soft tissue palpation, flexibility tests

• Posture Analysis
Symptoms of Cervical
Scoliosis
 Ear Level: The ear on the convex side is higher than the one
on the concave side.
 The neck may be shortened and the head held in lateral
flexion on one side.
 The angles between the neck and the shoulder are different.
 There is a narrow angle on the concave side and a wide
angle on the convex side.
Symptoms of Thoracic
Scoliosis:
 The shoulder on the convex side is higher than
the one on the concave side.
 The scapula on the convex side is higher than
on the concave side.
 The scapula on the convex side is further away
from the body midline (in abduction).
 Anterior gibosity is seen on the concave side
ribs, while posterior gibosity is seen on the
convex side.
 The arm on the convex side is further away
from the body.
 There is folding in the skin of the concave side.
 The thorax is asymmetrical.
 The lumbar region is asymmetrical.
Symptoms of Lumbar
Scoliosis

 Lateral pelvic tilt.

 The waist lines are different on both
sides. It is exaggerated on the
concave side and completely
disappeared on the convex side.
 The lower line of the gluteal mass is
asymmetrical on the right and left
sides.
• Adams Forward-Bending Test

-The bending test (Adams test) is performed in both

standing and sitting forward bending positions.

-In the standing forward bending position, the

examined person is asked to bend forward looking
down, keeping the feet approximately 15 cm apart,
knees braced back, shoulders loose and hands
positioned in front of knees or shins with elbows
straight and palms opposed.

-Any leg length inequality is not usually corrected.

• Bunnel’s Scoliometer Measurement

- The scoliometeris used at three areas of

interest: at upper thoracic (T3-T4), main
thoracic (T5-T12) and at the thoraco-lumbar
area (T12-L1 or L2-L3).

- Scoliometer measurement equal to 0°is

defined as symmetry at the particular level of
the trunk.

- Any other scoliometer value is defined as

asymmetry.
• Radiographic Evaluation

- The Cobb angle, which is considered the

golden standard, is the angle between lines
drawn along the upper end plate of the most
tilted vertebrae above the curve's apex and
the lower end plate of the most tilted
vertebrae below the apex.

- The Cobb angle describes only one planeof

the 3D deformity.
- The Ferguson method identifies both the end
vertebrae (first vertebrae which are not joining
the curve) and the apical vertebra (the most
laterally deviated vertebra), and uses the points
of intersection of the diagonals within each
vertebral body to identify three points and
form an angle.
- The Ferguson method cannot accurately
represent a curve over 50 degrees.
- The Risser method consists of assigning
stages (0 to 5) to the steps of ossification and
attachment of the iliac apophysis (sections of
the pelvis).

- Put simply, ossification is the process by

which bone tissue is formed, and the purpose
of the Risser method is to gauge a patient’s
overall skeletal development.

- The higher the stage, the further along the

patient is in reaching skeletal maturity, and
this has a big impact on the chosen course of
treatment for patients with scoliosis.