Professional Documents
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Gluteus
maximus
Soleus
835
P A R T
V
The first part of this textbook presents the basic principles needed to understand the
mechanics and pathomechanics of the musculoskeletal system and presents the me-
chanical properties of the individual components of the musculoskeletal system. Most
of the text then examines the structural and functional properties of the individual
joint complexes in the body. This final portion of the textbook applies this knowl-
edge to the analysis of two intrinsically human functions, erect standing and bipedal
locomotion. The goals of this final segment are to:
Patients seek help from rehabilitation experts typically for complaints of pain or dif-
ficulty in performing a task rather than with complaints of impairments in specific
anatomical structures. Clinicians must be able to observe the activity in question, an-
alyze the biomechanical demands of the activity, and determine what, if any, impair-
ments contribute to the pathomechanics producing the complaints. Examination and
evaluation of posture and gait require an understanding of the basic biomechanical
principles introduced in the first two chapters of this book and use knowledge of
muscle and joint function to explain how an individual produces these characteristic
human behaviors. Clinicians who can evaluate posture and gait and can identify im-
pairments that contribute to an abnormal movement pattern will be able to apply
these same skills to evaluate and treat any abnormal movement, including activities
as diverse as lifting boxcar hitches, performing a grand plié, typing at a computer,
or operating a cash register at the local supermarket.
836
CHAPTER
47
Characteristics of Normal
Posture and Common
Postural Abnormalities
Posture is the relative position of the parts of the body, usually associated with a static
position. Clinicians evaluate posture with the underlying assumptions that abnormal pos-
ture contributes to patients’ complaints and that many impairments within the neuro-
musculoskeletal system are reflected in an individual’s posture. Thus clinical interpretation
of an individual’s posture requires blending a description of an individual’s posture with
an understanding of the person’s physical condition and complaints.
Posture in erect standing is the focus of much clinical attention, but postures in sitting and
during activities, such as lifting or assembly line work, also may contribute to muscu-
loskeletal complaints. This chapter focuses on standing posture, but the issues considered
to understand erect standing posture are applicable to any other posture as well. It is im-
portant to recognize that even seemingly static postures such as erect standing exhibit
small, random movements, and typically, humans move in and out of several postures. As
a result, assessment of a single posture may be insufficient to understand the link between
posture and a patient’s complaints.
Analysis of posture is a well-established clinical tradition and forms a basic part of the
physical examination for many different health disciplines. Despite the frequency with
which such evaluations are carried out, there remains a surprising lack of unanimity in the
description of “normal” posture. Although faulty posture has been associated with such
diverse complaints as headaches, respiratory and digestive problems, and back pain
throughout the centuries, the direct consequences of faulty posture are not well docu-
mented. The purposes of this chapter are to describe the current understanding of normal
837
838 Part V | POSTURE AND GAIT
posture and to describe some common postural faults. Specifically, the objectives of this
chapter are to
■ Describe the alignment of the body in erect standing posture and its variability
■ Discuss the current understanding of the muscles needed to control erect standing
posture
■ Describe common postural faults
■ Briefly discuss the purported consequences of postural faults
TABLE 47.1 Alignment in the Sagittal Plane of Body Landmarks with Respect to the Ankle
during Erect Standing
Opila et al. [40]a Danis [6]b
Description of Landmark Locationc (cm) Description of Landmark Locationc (cm)
Ankle Lateral malleolus Calculated joint center
Knee Lateral epicondyle of femur 5.1 Calculated joint center 4.24 2.14
Hip Greater trochanter 5.4 Calculated joint center 5.42 2.86
Shoulder Acromioclavicular joint 3.0 Acromion process 1.89 3.01
Head/neck Just inferior to the external auditory meatus 5.4 Approximately the atlanto-occipital joint 4.84 4.03
a
Based on 19 unimpaired males and females aged 21 to 43 years. Originally reported with respect to the body’s center of gravity.
b
Based on 26 unimpaired males and females aged 22 to 88 years. Originally referenced to the ankle joint.
c
Positive numbers indicate that the landmark is anterior to the ankle joint.
T1
Thoracic
Cobb angle
T12
L1
Lumbar
Cobb angle
L5
Figure 47.3: Cobb angles in the thoracic and lumbar spines are
determined radiographically by determining the angles formed
between the superior surface of the most superior vertebra of
the region and the inferior surface of the most inferior vertebra
of the region.
tissue asymmetries. As noted in Chapter 29, idiopathic A popular theory in rehabilitation suggests that hand dom-
scoliosis is the most common form of scoliosis. It is a struc- inance induces muscle imbalances that lead to functional
tural scoliosis that is found most frequently in adolescent girls. scolioses and asymmetry in shoulder and hip alignment [27].
The curve usually involves at least two spinal regions, and the Few objective studies exist that test this hypothesis, but a study
curves typically are compensated, so that adjacent regions of 15 females aged 19 to 21 years reports no statistically sig-
have opposite convexities (Fig. 47.10). A structural scoliosis nificant differences in frontal plane alignment of the scapula
in the thoracic region is accompanied by a rib hump on the between the dominant and nondominant sides, although 11 of
same side as the convexity as a result of the coupled move- 15 subjects demonstrated a lower right shoulder [47]. Hori-
ments of the thoracic spine and their effects on the joints of zontal distances between the medial border of the scapula and
the ribs. (Chapter 29 reviews the mechanics producing a rib the vertebral column range from 5 to 9 cm [5,44,47]. Although
hump.) asymmetry in hip height, or pelvic obliquity, also is allegedly
Chapter 47 | CHARACTERISTICS OF NORMAL POSTURE AND COMMON POSTURAL ABNORMALITIES 845
Lateral Medial
flexion contractures. In addition, range of motion assess- moments to the joints, which are balanced by internal mo-
ments revealed that the patient had a complex contracture ments supplied by the surrounding muscles and noncontrac-
of the left hip, holding it flexed, laterally rotated, and ab- tile connective tissue. The alignment of the body’s center of
ducted. The patient stood with an anterior pelvic tilt and mass relative to joint axes in quiet standing defines the exter-
increased lordosis, consistent with the hip flexion contrac- nal moments applied to the joints during erect standing. These
tures, but the lateral rotation and abduction contractures external moments then are balanced by either active or pas-
on the left effectively shortened the left lower extremity sive support to maintain the upright posture against the ever-
while turning the toes outward. The patient stood with the present gravitational forces tending to press the body into the
left hip in obligatory abduction secondary to the abduction ground. Examination of the external moments applied to the
contracture, while the right hip was adducted, and conse- joints of the lower extremities, trunk, and head by the ground
quently, the pelvis was higher on the right. Correction of reaction forces helps explain the forces needed to support
standing posture required reduction of the contractures of these joints (Fig. 47.14). Using the data from the studies pre-
both the left and right hip. Although conservative treat- sented in Table 47.1, the sagittal plane external moments on
ment failed to reduce the contractures on the left, a total
hip replacement on the left restored normal joint alignment,
and standing posture was immediately improved.
Add
Abd
Hip joint
axis
Knee axis
Ankle
Figure 47.13: A patient with an abduction contracture of the joint axis
left hip stands with the left hip abducted. To maintain an
upright posture with the feet close together, the individual
adducts the right hip, producing a pelvic obliquity in the frontal Figure 47.14: In quiet standing, the ground reaction force
plane. The left hip is abducted and the right hip is adducted. applies a dorsiflexion moment at the ankle, extension moments
The right ankle plantarflexes to equalize limb length. at the knee and hip, and flexion moments on the spine.
Chapter 47 | CHARACTERISTICS OF NORMAL POSTURE AND COMMON POSTURAL ABNORMALITIES 847
TABLE 47.3 External Moments Applied to the Joints Based on the Center of Mass Line
Opila et al. [40]a External Moment Danis [6]b External Moment
Ankle Dorsiflexion Dorsiflexionc
Knee Extension Extension
Hip Extension Extension
Back Flexion Flexion
Head/neck Flexion Approximately zerod
a
Based on 19 unimpaired males and females aged 21 to 43 years. Originally reported with respect to the body’s center of gravity.
b
Based on 26 unimpaired males and females aged 22 to 88 years. Referenced to the ankle joint.
c
Moment is reported directly in the study but is derived from the available data.
d
Although the moment arm is 0.03 cm, the standard deviation is almost 4 cm, suggesting that some individuals sustain a flexion moment, and others sustain an
extension moment.
many joints of the body are presented in Table 47.3. Biome- moment [1]. Understanding the role of muscles and ligaments
chanical analysis of these moments and electromyographic in generating the internal moments needed to balance the ex-
(EMG) studies combine to help explain the mechanisms used ternal moments exerted by body weight and ground reaction
to maintain upright posture. forces allows the clinician to intervene to provide postural sta-
Although the external moments described in Table 47.3 bility in the absence of muscular support.
are the predominant moments applied during quiet standing,
it is important to recall that standing posture is dynamic and
that even so-called quiet standing is characterized by oscilla- CLINICAL RELEVANCE: MAINTAINING ERECT POSTURE IN
tions of the body over the fixed feet. Panzer et al. report that THE PRESENCE OF MUSCLE WEAKNESS: A PATIENT WITH
during quiet standing, the EMG activity of muscle groups is PARAPLEGIA
less than 10% of each group’s activity during a maximum vol- A patient with a spinal cord injury resulting in loss of mus-
untary contraction (MVC) [42]. These investigators also note cle function from the level of L2 is beginning rehabilita-
that many of these muscle groups exhibit sudden, brief ac- tion. Functional goals include standing for stimulation of
tivity levels of 30–45% of their MVC and suggest that these bone growth and limited ambulation. Weakness second-
sudden bursts may reflect a muscle group’s response to the ary to the spinal cord injury begins at the hip flexors and
sway of the body’s center of mass. extends throughout the rest of the lower extremities. To
Because the body’s center of mass generates a dorsiflexion teach the individual safe and efficient standing, the clini-
moment on the ankle during quiet standing, the plantar flexor cian uses an understanding of the effects of external
muscles generate a plantarflexion moment to maintain static moments on the joints of the lower extremities and a
equilibrium. EMG data demonstrate activity of both the recognition of the passive structures that are available to
soleus and the gastrocnemius during quiet standing [1,42]. support the joints.
Brief, intermittent, and slight EMG activity is also found in The individual lacks muscular support at the hip, knee,
the dorsiflexor muscles, apparently in response to postural and ankle, but the astute clinician knows that the hip
sway [1,42]. possesses strong anterior ligaments, the iliofemoral,
In contrast to the ankle, the knee exhibits minimal mus- pubofemoral, and ischiofemoral ligaments. By maintain-
cle activity during quiet standing [1,42]. In erect posture, the ing the hip in hyperextension, the individual can “hang
ground reaction force applies an extension moment to the on” these anterior ligaments, even in the absence of the
knee allowing it to maintain extension using its passive con- hip flexors. Similarly, the knee normally maintains ex-
straints, including the collateral and anterior cruciate liga- tension in erect standing without muscular support,
ments. Reports of slight electrical activity in the quadriceps since the body’s center of mass falls anterior to the knee
muscles (4–7% of MVC) and hamstrings (1% of MVC) are joint and exerts an extension moment on the knee. As
consistent with the use of passive supports to sustain the ex- long as the knee remains extended, no additional mus-
tended knee during quiet standing [42]. However, like the cular support is needed. Thus the individual can stand in
muscle activity at the ankle, larger brief bursts of activity in hip and knee hyperextension using passive supports at
the quadriceps and hamstrings muscles may reflect the mus- these joints.
cles’ response to sway. Stable erect posture requires that the body’s center of
Few studies examine activity of the hip musculature dur- mass remain over the base of support. To maintain hip and
ing erect posture. The ground reaction force produces an knee hyperextension while keeping the body’s center of
extension moment at the hip, and EMG data reveal activity mass over the base of support, the individual’s ankles as-
of the iliacus in quiet standing, exerting a stabilizing flexion sume a dorsiflexed position, and the ground reaction force
848 Part V | POSTURE AND GAIT
A B
The role of the abdominal muscles during quiet standing [21,27]. Complaints attributed to postural deviations of the
continues to be debated. EMG studies of the abdominal mus- head and spine include circulatory, respiratory, digestive, and
cles identify activity, particularly in the internal oblique mus- excretory dysfunctions; headaches; backaches; depression;
cle, with some activity in the external oblique muscle during and a generalized increased susceptibility to disease
quiet standing [1,12,43,46]. Yet studies that investigate the as- [4,21,38,39]. Pain in the back and lower extremities also is at-
sociation between abdominal muscle strength as measured by tributed to abnormal alignment in the hips, knees, and feet
leg-lowering maneuvers and postural alignment of the pelvis [10,28,29,32,59].
report either no association [55] or weak associations in fe- Despite the presumption of associations between postural
males and no association in males [63]. The leg-lowering ex- abnormalities and patients’ complaints, studies examining
ercise recruits the rectus abdominis more than the oblique these associations vary in their findings. Correlations between
abdominal muscles in most individuals and, consequently, the incidence of reported head, neck, and shoulder pain are
may not reflect the ability of the oblique abdominal muscles reported in people with forward head, rounded shoulders, and
to participate in postural support [43]. Chapter 34 discusses increased thoracic kyphoses [21]. Studies investigating the as-
the role of the abdominal muscles in stabilizing the spine. The sociation between low back postural deviations and low back
data presented here suggest that the oblique abdominal mus- pain draw variable conclusions, with some reporting little or
cles are important in erect posture, although their role may no difference in posture between those with and without low
be to function with the transversus abdominis muscle to sta- back pain [7,11,62], and others finding differences between
bilize the spine rather than to position the pelvis. the two groups [24]. Malalignments of the patellofemoral joint
The role played by muscles to maintain shoulder position are associated with a variety of pain syndromes at the knee
during quiet standing also lacks definitive conclusions. Inman [22,35,45]. Considerably more research is required to deter-
et al. demonstrate active contraction of the levator scapulae mine the role that postural abnormalities play in muscu-
along with the upper trapezius and upper portion of the ser- loskeletal complaints and to determine the effectiveness of
ratus anterior muscles in quiet standing, suggesting that these treatments directed toward improving posture to reduce pain.
muscles are providing upward support for the shoulder gir- Typical postural deviations are listed and defined in Tables
dle and upper extremity [23]. However, Johnson et al. note 47.4 and 47.5. These postural abnormalities are presumed to
that only the levator scapulae and the rhomboid major and produce excessive or abnormally located stresses (force/area)
minor muscles can directly suspend the scapula [26]. EMG on joint surfaces or to contribute to altered muscle mechan-
studies show that in the presence of voluntary relaxation of ics by putting some muscles on slack while stretching others
the upper trapezius in quiet standing, there is an increase in [27]. Although evidence supports these effects in some cases,
EMG activity of the two rhomboid muscles but a decrease in evidence is lacking for others [9,29,32]. Determining the role
activity in the levator scapulae [41]. These data support the posture plays in the pathomechanics of musculoskeletal dis-
notion that the rhomboid muscles can and do support the up- orders requires continued research in basic anatomy and
right position of the shoulder girdle, at least under certain biomechanics, as well as well-controlled outcome studies
circumstances. Whether the levator scapulae contributes ad- examining the effectiveness of treatments directed toward
ditional support remains debatable. posture reeducation.
TABLE 47.5 Common Postural Abnormalities in the Frontal and Transverse Planes
Postural Deviation Description
Head tilt The line through the center of the head deviates from the midsagittal plane
Asymmetrical shoulder height Measured by the height of the acromions or the inferior angles of the scapulae
Scoliosis Frontal plane deviation of the vertebral column as assessed by the spinous processes
Pelvic obliquity Asymmetrical height of the pelvis as measured by the iliac crests
Asymmetrical hip height Measured by the height of the greater trochanters or gluteal folds
Genu varum/valgus Angle between the mechanical axes of the leg and thigh in the frontal plane
Foot pronation/supination Indicated by several different measures including (1) the frontal plane alignment of the heel and leg, (2) the
height of the navicular relative to the medial malleolus and the head of the first metatarsal, and (3) the
subtalar neutral position
In-toeing/out-toeing The angle between the long axis of the foot and the malleoli is less than/greater than approximately 20
the malaligned joints. Specifically, it is believed that muscles independent investigation of the relationship with each mus-
on one side of the joint are held in a lengthened position and cle. The complexity of the association helps explain the ab-
the antagonistic muscles are maintained in a shortened posi- sence of clearly defined associations.
tion. Clinicians also suggest that these length changes pro- Attempts to confirm the expected muscle impairments with
duce joint impairments including weakness and limited range postural abnormalities have failed to yield clear relationships.
of motion that contribute to a patient’s complaints. Although Individuals with idiopathic scoliosis exhibit atrophy of the mus-
these hypotheses are logical and may still prove true, studies cles of the posterior thorax, particularly on the concave side,
to date have failed to identify clear associations between and a higher percentage of type I muscle fibers than normal
malalignments and joint impairments [9,37]. on the convex side of the deformity [13,61,65]. The muscles
As noted in Chapter 4, studies in animals demonstrate that of the thorax on the concave side of the curve are likely short-
prolonged length changes in muscles produce structural ened, while those on the convex side are lengthened; yet both
changes in muscle, although those changes depend upon muscle groups exhibit atrophy. Although this atrophy may pre-
many factors besides length. These additional mitigating fac- cede the development of the scoliosis, the expected adaptive
tors include age, fiber arrangement within the muscles, and changes with prolonged lengthening apparently are lacking.
fiber type within the muscle [31,33]. In general, prolonged Similarly, attempts to relate scapular alignment and muscle
stretch of a muscle induces protein synthesis and the pro- performance fail to reveal associations [9]. However, the
duction of additional sarcomeres [18,19,50,58,60]. The scapula moves in a complex, three-dimensional way, and stud-
lengthened muscle hypertrophies, and as a result, peak con- ies so far may not accurately reflect the effects of scapular
tractile force increases with prolonged stretch [31,33]. The malalignment on muscle length. These data demonstrate the
structural remodeling that accompanies prolonged lengthen- need for careful anatomical, biomechanical, and clinical stud-
ing appears to maintain the muscle’s original length–tension ies to identify and explain any detrimental effects of postural
relationship so that, although the muscle has a larger peak malalignment.
torque, it generates the peak torque at a different joint posi-
tion. The clinical literature describes stretch weakness in
which a muscle that has been held in a stretched position long SUMMARY
enough to remodel appears weak when tested in the tradi-
tional test position [20,27]. For example, at the shoulder, This chapter describes the relative alignment of body seg-
stretch weakness suggests that a posture characterized by ments identified in healthy adults during quiet standing. In
rounded shoulders applies a prolonged stretch to the middle the absence of a validated description of “ideal posture,” the
trapezius, which undergoes the structural adaptations that documented alignments provide clinicians with a view of the
lead to weakness when assessed in the traditional manual mus- variability of alignments found in individuals without muscu-
cle test position. Although the changes described here are loskeletal complaints. Although individuals demonstrate a
logical and plausible, they remain unproved. wide spectrum of alignments, the overall image of upright pos-
Animal studies examining prolonged shortening reveal that ture shows a head well balanced over the pelvis, which in turn
shortening produced by immobilization appears to accelerate is well balanced over the feet. Using these alignments, the
atrophy, and muscles demonstrate a loss of sarcomeres chapter also demonstrates the external moments applied to
[18,50,60]. Studies examining the effect of prolonged length the joints of the lower extremities and trunk during upright
changes in muscle reveal that the relationship between mus- standing. The external moments are balanced by internal mo-
cle length and muscle performance is complex, requiring ments generated by muscle contractions and noncontractile
Chapter 47 | CHARACTERISTICS OF NORMAL POSTURE AND COMMON POSTURAL ABNORMALITIES 851
connective tissue support. EMG data are consistent with 14. Gajdosik RL, Simpson R, Smith R, Dontigny RL: Intratester re-
the mechanical data, demonstrating low levels of activity in the liability of measuring the standing position and range of motion.
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Ther 1993; 17: 155–160.
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the dorsiflexor muscles, the quadriceps, and the hamstrings tal spinal alignment in 100 asymptomatic middle and older aged
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additional research is required to identify such relationships
20. Gossman MR, Sahrmann SA, Rose SJ: Review of length-
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