POSTURE Sagar Naik, PT

POSTURE
Sagar Naik, PT

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Posture can be defined as the relative arrangement of different parts of
the body with line of gravity.

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U Static & Dynamic Posture:
 In static postures the body and its segments are aligned and maintained in
certain positions.
Eg – Standing, kneeling, lying, and sitting
 A dynamic posture refers to postures in which the body or its segments are
moving.
4a
Eg – Walking, running, jumping, throwing, and lifting
 The study of any particular posture includes kinetic and kinematic analyses of
all body segments.
 The erect posture allows persons to use their upper extremities for the
performance of large and small motor tasks.
 When the upper extremities are engaged by the use of crutches, canes, or other
assistive devices to maintain the erect posture, an important human attribute is
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either severely compromised or lost.
 Erect bipedal stance gives us freedom for the upper extremities, but in
comparison with the quadrupedal posture, erect stance has certain
disadvantages.
y Erect bipedal stance increases the work of the heart
y Places increased stress on the vertebral column, pelvis, and lower
extremities
y

y Reduces stability
 In the quadruped posture the body weight is distributed between the upper and
lower extremities.
ph

 In human stance the body weight is borne exclusively by the two lower
extremities.
 The human species base of support (BOS), defined by an area bounded
posteriorly by the tips of the heels and anteriorly by a line joining the tips of the
toes, is considerably smaller than the quadruped base.
 The human’s center of gravity (COG), which is sometimes referred to as the
body’s center of mass, is located within the body approximately at the level of
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 POSTURE Sagar Naik, PT

the second sacral segment, a location that is relatively distant from the base of
support.
 Despite the instability caused by a small base of support and a high center of
gravity, maintaining stability in the static erect posture requires very little
energy expenditure in the form of muscle contraction.

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 The bones, joints, and ligaments are able to provide the major torques needed
to counteract gravity and frequent changes in body position assist in producing

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circulatory return.

U Postural Control:
 Although only a minimal amount of muscular activity is required to maintain a
stable erect standing posture, the control of posture is complex and is a part of
the body’s motor control system.
 Postural control, which can be either static or dynamic, refers to a person’s
4a
ability to maintain stability of the body segments in response to forces that
threaten to disturb the body’s structural equilibrium.
 The ability to maintain stability in the erect standing posture is a skill that the
central nervous system (CNS) learns using information from passive
biomechanical elements, sensory systems, and muscles.
 The CNS interprets and organizes inputs from the various structures and
systems and selects responses based on past experience and the goal of the
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response.
 Reactive (compensatory) responses occur as reactions to external forces that
displace the body’s center of gravity.
 Proactive (anticipatory) responses occur in anticipation of internally
generated destabilizing forces such as raising one’s arms to catch a ball or
bending forward to tie one’s shoes.

Ö Goals & Basic Elements of Postural Control:

y

 The major goals of postural control in the erect position are

y To control the body’s orientation in space
ph

y Maintain the body’s center of gravity over the base of support

y Stabilize the head with respect to the vertical so that the eye gaze is
approximately oriented
 Maintenance and control of posture depends on the integrity of the CNS,
visual system, vestibular system, and the musculoskeletal system. In
addition, postural control depends on information from receptors located in

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 POSTURE Sagar Naik, PT

and around the joints (in joint capsule, tendons, & ligaments) as well as on
the soles of the feet.
 The CNS must be able to detect and predict instability and must be able to
respond to all of this input with appropriate output to maintain the
equilibrium of the body.

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 Joints in the musculoskeletal system must have a range of motion (ROM)
that is adequate for responding to specific tasks, and the muscles must be

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able to respond with appropriate speeds and forces.
D Absent or Altered Inputs & Outputs:
 When inputs ore altered or absent, the control system must respond to
incomplete or distorted data and thus the person’s posture may be altered
and stability compromised.
 Altered or absent inputs may occur either in the absence of the normal
gravitational force in weightless conditions during space flight, or when
4a
someone has decreased sensation in the lower extremities. Another
instance in which inputs may be disturbed is following injury.
 In addition to altered inputs, a person’s ability to maintain the erect
posture may be affected by altered outputs such as the inability of the
muscles to respond appropriately to signals from the CNS.
D Muscle Synergies:
 A normally functioning CNS selects the appropriate combination of
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muscles to complete the task based on an analysis of sensory inputs.
 Variations in an individual’s past experience and customary patterns of
muscle activity will also affect the response.
 Muscle activation is based primarily on input from the hip and trunk
proprioceptors. A second level of input includes cues from the vestibular
system and proprioceptive input from all body segments.
 A perturbation is any sudden change in conditions that displaces the
y

body posture away from equilibrium. Perturbation can be sensory or

mechanical.
 Altering of visual input such as might occur when one’s eyes are covered
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unexpectedly might cause a sensory perturbation.

 Mechanical perturbation is displacements that involve direct changes in
the relationship of center of gravity to the base of support. These
displacements may be caused either by movements of the body segments
or of the entire body.
 One method of producing mechanical perturbations experimentally is by
placing subjects on a movable platform.
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 POSTURE Sagar Naik, PT

 The postural responses to perturbations are reactive or compensatory

responses in that they are involuntary reactions.
 These postural responses are referred to as either synergies or strategies.
 Synergies are centrally organized patterns of muscle activity that occur
in response to perturbation of standing postures.

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 The synergies are task specific and appear to vary with a number of
factors including

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y Amount and direction of motion of the supporting surface
y Location, magnitude, and velocity of the perturbing force
y Initial posture of the individual at the time of the perturbation
™ Fixed – Support Synergies:
 Fixed – support synergies are patterns of muscle activity in which the
base of support remains fixed during the perturbation and recovery
of equilibrium.
4a
 Stability is regained through movements of parts of the body but the
feet remain fixed on the base of support.
 Examples of fixed – support synergies are the ankle and hip synergy.
 The ankle synergy consists of discrete bursts of muscle activity on
either the anterior or posterior aspects of the body that occur in a
distal-to-proximal pattern in response to forward and backward
movements of the supporting platform, respectively.
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 Forward motion of the platform results in a relative displacement of
the line of gravity (LOG) posteriorly.
 The muscles respond in an attempt to restore the line of gravity to a
position within the base of support. Bursts of muscle activity occur in
the ankle dorsiflexors, hip flexors, abdominal muscles, and neck
flexors.
 The tibialis anterior contributes to the restoration of stability by
y

pulling the tibia anteriorly (reverse muscle action) and hence the
body forward so that the line of gravity remains or centers within the
base of support.
ph

 Backward motion of the platform results in a relative displacement of

the line of gravity anteriorly.
 The muscles respond in an attempt to restore the line of gravity to a
position within the base of support. Bursts of activity in the
plantarflexors, hip extensors, trunk extensors, and neck extensors
are used to restore the line of gravity over the base of support.

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 POSTURE Sagar Naik, PT

 The hip synergy consists of discrete bursts of muscle activity on the

side of the body opposite to the ankle pattern in a proximal-to-distal
pattern of activation.
 Fixed – support hip synergy may be used primarily in situations where
change – in – support strategies (stepping or grasping synergies) are

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not available.
™ Change – In – Support Strategies:

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 The change – in – support strategies include stepping (forward,
backward or sidewise) and grasping (using one’s hands to grab a bar
or other fixed support) in response to movements of the platform.
 Stepping and grasping differ from fixed – support synergies because
stepping/grasping moves or enlarges the body’s base of support so
that it remains under the body’s center of gravity.
 Previously it was thought that the stepping synergy was used only as a
4alast resort, being initiated when ankle and hip strategies were
insufficient to bring and maintain the center of gravity over the base of
support.
 Change – in – support strategies are common responses to
perturbations among both the young and the old.
 Change – in – support synergies are the only synergies that are
successful in maintaining stability in the instance of a large
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perturbation.
 In change – in – support strategy, the younger subjects have a tendency
to take only one step, whereas the elderly subjects have a tendency to
take multiple steps that are shorter and of less height than their younger
counterparts.
 However, no differences are apparent in the speed at which the young
and elderly initiate the change – in – support strategy.
y

™ Head Stabilizing Strategies:

 Two head stabilizing strategies are described which differ from
reactive strategies because head stabilizing strategies occur in
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anticipation of the initiation of internally generated forces.

 Head strategies are used to maintain the head during sustained
movement of the body, such as walking.
 Two strategies for maintaining the vertical stability of the head are as
follows:
y Head Stabilization in Space (HSS)
y Head Stabilization on Trunk (HST)
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 POSTURE Sagar Naik, PT

 The head stabilization in space is a modification of head position in

anticipation of displacements of the body’s center of gravity.
 The anticipatory adjustments of head position are independent of trunk
motion.
 The head stabilization on trunk is one in which the head and trunk

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move as a single unit.

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U Kinetics & Kinematics of Posture:
 The external forces that will be considered are inertia, gravity, and ground
reaction forces (GRFs).
 The internal forces are produced by muscle activity and passive tension in
ligaments, tendons, joint capsules, and other soft tissue structures.
 The external and internal forces must be balanced and the sum of all the
forces and torques acting on the body and its segments must be equal to zero
4a
for the body to be in equilibrium.
 The body attempts to attain and maintain a state of equilibrium in erect standing
with minimum of energy expenditure as it attempts to keep the body’s center of
gravity over the base of support and the head in a position that permits gaze to
be appropriately oriented.

Ö Inertial & Gravitational Forces:

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 Inertial forces are ignored in static postures because little or no acceleration
is occurring except during postural sway.
 In erect standing posture the body undergoes a constant swaying motion
called postural sway or sway envelope. The extent of the sway envelope for
a normal individual standing with 4 inches between the feet can be as large
as 12° in the sagittal plane and 16° in the frontal plane.
 Inertial forces must be considered in postural analysis of all dynamic
y

postures such as walking, running, and jogging.

 Gravitational forces act downward from the body’s center of gravity.
 In the static erect standing posture the vertical projection of the body’s center
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of gravity (the line of gravity) falls within the base of support.

 In dynamic postures such as walking and running, the line of gravity falls
outside the base of support during a large portion of the activity.
 The line of gravity must fall within the base of support to maintain
equilibrium in the static erect posture.

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 POSTURE Sagar Naik, PT

Ö Ground Reaction Forces:

 Whenever the body contacts the ground, the ground pushes back on the
body. This force is known as the ground reaction force (GRF).
 Ground reaction force is a composite (resultant) force typically described as
having three components:

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y A vertical component force
y Two force components directed horizontally, one of the two horizontal

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forces is in a medial-lateral direction, whereas the other horizontal force is
in an anterior- posterior direction along the ground
 The composite or resultant ground reaction force vector (GRFV) is equal
in magnitude but opposite in direction to the gravitational force in the erect
static standing posture.
 The ground reaction force vector indicates the magnitude and direction of
loading applied to the foot.
4a
 The point of application of the ground reaction force vector is at the body’s
center of pressure (COP), which is located in the foot in unilateral stance
and between the feet in bilateral stance.
 The center of pressure is the theoretical point where the force is considered
to act, although the body surface that is in contact with the ground may
have forces acting over a large portion of its surface area.
 The path of the center of pressure that defines the extent of the sway
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envelope.
 The ground reaction force vector and line of gravity have coincident action
lines in the static erect posture.

Ö Coincident Action Lines:

 In an ideal erect posture, body segments are aligned so that the torques and
stresses on body segments are minimized and standing can be maintained
with a minimal amount of energy expenditure.
y

 The coincident action lines formed by the ground reaction force vector and
the line of gravity serve as a reference for the analysis of the effects of these
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forces on the body segments.

Ö Sagittal Plane:
 The effect of forces on the body segments in the sagittal plane is determined
by the location of the line of gravity relative to the axis of motion of body
segments.

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 POSTURE Sagar Naik, PT

 When line of gravity passes directly through a joint axis, no gravitational

torque is created around that joint.
 If line of gravity passes at a distance from the axis, a gravitational torque
is created. This torque will cause rotation of the superimposed body
segments around that joint axis unless a counterbalancing torque opposes the

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gravitational torque.
 The magnitude of the gravitational moment of the force increases as the

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distance between the line of gravity and the joint axis increases.
 The direction of the gravitational moment of the force depends on the
location of the gravity line relative to a particular joint axis.
 If the gravity line is located anterior to the joint axis, the torque will tend to
cause anterior motion of the proximal segment of the body supported by
that joint (Flexion).
 If the gravity line falls posterior to the joint axis, the torque will tend to
4a
cause posterior motion of the proximal segment of the body supported by
that joint (Extension).

U Lateral View – Optimal Alignment in Sagittal Plane:

Ö Ankle:
 In the optimal erect posture the ankle joint is in the neutral position, or
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midway between dorsiflexion and plantarflexion.
 The line of gravity falls slightly anterior to the lateral malleolus and,
therefore, anterior to the ankle joint axis.
 The anterior position of the line of gravity relative to the ankle joint axis
creates a dorsiflexion moment.
 Muscle activity of the plantarflexors is necessary to prevent forward
motion of the tibia.
y

 The soleus muscle acting in reverse action exerts a posterior pull on the
tibia and is able to oppose the dorsiflexion moment.
 Tibialis anterior, tibialis posterior and peroneals provide transverse
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stability in the foot during postural sway.

Ö Knee:
 The knee joint is in full extension and the line of gravity passes anterior to
the midline of the knee and posterior to the patella. This places the line of
gravity just anterior to the knee joint axis.

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 POSTURE Sagar Naik, PT

 The anterior location of gravitational line relative to the knee joint axis
creates an extension moment.
 Passive tension in the posterior joint capsule and associated ligaments is
sufficient to balance the gravitational moment and prevent
hyperextension.

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 Little or no muscle activity is required to maintain the knee in extension in
the optimal erect posture. However, a small amount of activity has been

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found in the hamstrings.

Ö Hip and Pelvis:

 In optimal posture, hip is in a neutral position and the pelvis is level with
no anterior or posterior tilt.
 In a level pelvis position, lines connecting the symphysis pubis and the
anterior superior iliac spines are vertical; and the lines connecting the
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anterior superior iliac and posterior superior iliac spines are horizontal.
 In this optimal position, the line of gravity passes slightly posterior to the
axis of the hip joint, through the greater trochanter.
 The posterior location of the gravitational line relative to the hip joint axis
creates an extension moment at the hip that tends to rotate the pelvis
posteriorly on the femoral heads.
 Iliopsoas is acting to create a balancing flexion moment at the hip.
 If the gravitational extension moment at the hip is allowed to act without
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muscular balance, as in so-called relaxed standing posture, hip
hyperextension ultimately would be checked by passive tension in the
ilifemoral, pubofemoral, and ischifemoral ligaments.
 The relaxed standing posture does not require any muscle activity at the hip
but causes an increase in the tension stresses on the anterior hip ligaments.

Ö Lumbosacral and Sacroiliac Joints:

y

 The optimal lumbosacral angle is about 30°. Anterior tilting of the sacrum
increases the lumbosacral angle and results in an increase in the shearing
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stress at the lumbosacral joint and may result in an increase in the anterior
lumbar convexity in standing.
 In the ideal posture the line of gravity passes through the body of the 5th
lumbar vertebra and close to the axis of rotation of the lumbosacral joint.
 Gravity, therefore, creates a very slight extension moment at L5 to S1 that
is opposed by the anterior longitudinal ligament.

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 POSTURE Sagar Naik, PT

 When the sacrum is in optimal position, the line of gravity passes slightly
anterior to sacroiliac joints.
 The gravitational moment that is created at sacroiliac joints tends to cause
the anterior superior portion of the sacrum to rotate anteriorly and
inferiorly while the posterior inferior portion tends to move posteriorly

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and superiorly.
 Tension in the sacrospinous and sacrotuberous ligaments

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counterbalances the gravitational torque and prevents the inferior
portion of the sacrum from moving posteriorly.
 The superior portion of the sacrum is kept from thrust anteriorly by the
sacroiliac ligaments.

Ö Vertebral Column:
 When the vertebral curves are in optimal alignment, the line of gravity
4a
will pass through the midline of the trunk.
 The line of gravity passes through the bodies of the lumbar and cervical
vertebrae and anterior to the thoracic vertebrae in the optimal posture.
 In this instance, the stress on the supporting structures would be greatest
in the thoracic area, where the line of gravity would fall at a distance from
the vertebrae.
 Stress in the lumbar and cervical regions would be comparatively less
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because the line of gravity falls close to or through the joint axes of these
regions.
 Ligamentous structures and passive muscle tension are unable to provide
enough force to oppose all gravitational moments acting around the joint
axes of the vertebral column. So logissimus dorsi, rotators, and neck
extensor muscles have to work to produce the counterbalanced force.
 In lumbar region, where minimal muscle activity appears to occur,
tension in the anterior longitudinal ligament and passive tension in the
y

trunk flexors apparently is sufficient to balance the gravitational

extension moment.
ph

Ö Head:
 The line of gravity relative to the head passes through the external
auditory meatus, posterior to the coronal suture and through the
odontoid process.

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 POSTURE Sagar Naik, PT

 Therefore, the line of gravity falls slightly anterior to the transverse

(coronal) axis of rotation for flexion and extension of the head and
creates a flexion moment.
 The gravitational moment, which tends to tilt the head forward, is
counterbalanced by tension in the ligamentum nuchae, tectorial

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membrane, posterior aspect of the zygapophyseal joint capsules, and
posterior fibres of the annulus pulposus, and by activity of the capital

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extensors.

U Lateral View – Deviations from Optimal Alignment:

 Minimizing energy expenditure and stress on supporting structures is one of
the primary goals of any posture.
 Any change in position or malalignment of one body segment will cause
changes to occur in adjacent segments as well as changes in other segments
4a
as the body seeks to adjust or compensate for the malalignment.
 Changes from optimal alignment increase stress or increase force per unit area
on body structures.
 If stresses are maintained over long period of time, the body structures may be
altered.
 Muscles may lose sarcomeres if held in shortened positions for extended
periods. Such adaptive shortening may accentuate and perpetuate the abnormal
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posture, as well as prevent full ROM from occurring.
 Muscles may add sarcomeres if maintained in a lengthened position and as a
consequence the muscle’s length-tension relationship will be altered.
 Shortening of the ligaments will limit normal ROM, whereas stretching of
ligamentous structures will reduce the ligament’s ability to provide sufficient
tension to stabilize and protect the joints.
 Prolonged weight-bearing stresses on the joint surfaces increase cartilage
y

deformation and may interfere with the nutrition of the cartilage. As a result,
the joint surfaces become susceptible to early degenerative changes.
 Postural problems may originate in any part of the body and cause increased
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stresses and strains in throughout the musculoskeletal system.

 Postures that represent an attempt to either improve function or normalize
appearance are called compensatory postures.

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 POSTURE Sagar Naik, PT

Ö Foot and Toes:

D Claw Toes:
 Claw toes is a deformity of the toes characterized by hyperextension of
the metatarsophalangeal joint (MTP) combined with flexion of the
proximal (PIP) and distal (DIP) interphalangeal joints.

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 Sometimes the proximal phalanx may subluxate dorsally on the
metatarsal head. A callus may develop on the dorsal aspects of the flexed

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phalanges.
 Etiologies for this condition are as follows:
y Restrictive effect of shoes
y A cavus – type foot
y Muscular imbalance
y Ineffectiveness of intrinsic foot muscles
y Neuromuscular disorders
4a
y Age–related deficiencies in the plantar structures
D Hammer Toe:
 Hammer toe is described as a deformity characterized by
hyperextension of the metatarsophalangeal (MTP) joint, flexion of the
proximal interphalangeal (PIP) joint, and hyperextension of distal
interphalangeal (DIP) joint.
 Callosities (painless thickening of epidermis) may be found on the
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superior surface of the proximal interphalangeal (PIP) joints over the
heads of the 1st phalanges as a result of pressure from shoes or on the tips
of the distal phalanges because of abnormal weight bearing.
 The flexor muscles are stretched over the metatarsophalangeal (MTP)
joint and shortened over the interphalangeal (IP) joint. The extensor
muscles are shortened over the metatarsophalangeal (MTP) joint and
stretched over the interphalangeal (IP) joint.
y

 If the long and short toe extensors and lumbricales are selectively
paralyzed, the intrinsic and extrinsic toe flexors acting unopposed will
buckle the proximal (PIP) and distal (DIP) interphalangeal joints and
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cause a hammer toe deformity.

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 POSTURE Sagar Naik, PT

Ö Knee:
D Flexed Knee Posture:
 In the flexed knee standing posture the line of gravity falls posterior to
the knee joint axes.
 The posterior location of the line of gravity creates a flexion moment at

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the knees that must be balanced by activity of the quadriceps muscles to
maintain the erect position.

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 The increase in quadriceps muscle activity subjects the tibiofemoral and
patellofemoral joints to greater than normal compressive forces.
 Because knee flexion in upright stance is accompanied by hip flexion and
ankle dorsiflexion, the location of the line of gravity also will be altered in
relation to these joint axes.
 At the hip, the line of gravity will fall anterior to the hip joint axes.
Activity of the hip extensors may be necessary to balance the
4a
gravitational flexion moment acting around hip.
 At the ankle, the line of gravity will fall anterior to the ankle joint axes.
Increase soleus muscle activity may be required to counteract the
increased gravitational dorsiflexion moment at the ankle.
 The additional muscle activity subjects the hip and ankle joints to
greater than normal compression stress.
 Thus, the increased muscle activity would appear to substantially
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increase the energy requirements for stance.
D Hyperextended Knee Posture (Genu Recurvatum):
 The hyperextended knee posture is one in which the line of gravity is
located considerably anterior to the knee joint axis.
 The anterior location of the line of gravity causes an increase in the
gravitational extensor moment acting at the knee, which tends to increase
the hyperextension deviation and put the posterior joint capsule under
y

considerable tension stress.

 A continual adoption of the hyperextended knee posture is likely to result
in adaptive lengthening of the posterior capsule.
ph

 The anterior joint surfaces on the femoral condyles and anterior

portion of the tibial plateaus are subject to degenerative changes of the
cartilaginous joint surfaces.
 The length-tension relationship of the anterior and posterior muscles also
may be altered and the muscles may not be able to provide the force
necessary to provide adequate joint stability and mobility.

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 POSTURE Sagar Naik, PT

 Hyperextension at the knee is usually caused by limited dorsiflexion at

the ankle or a fixed plantarflexion position of the foot and ankle called
equinus. It may also be the result of habits formed in childhood in which
the child or adolescent stands with hips and knees hyperextended.

Ö Pelvis:

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D Excessive Anterior Pelvic Tilt:

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 In posture in which the pelvis is excessively tilted anteriorly, the lower
lumbar vertebrae are forced anteriorly. The upper lumbar vertebrae
move posteriorly to keep the head over the sacrum, thereby increasing
the lumbar anterior convexity (lordotic curve).
 The line of gravity, therefore, is at a greater distance from the lumbar
joint axes than is optimal and the extension moment in the lumbar spine
is increased.
4a
 The posterior convexity of the thoracic curve increases and become
kyphotic to balance the lordotic lumbar curve and maintain the head
over the sacrum.
 Similarly, the anterior convexity of the cervical curve increases to bring
the head back over the sacrum.
 In optimal posture the lumbar discs are subject to anterior tension and
posterior compression in erect standing. A greater diffusion of nutrients
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into the anterior compared to the posterior portion of the disc occurs in the
optimal erect posture.
 Increases in the anterior convexity of the lumbar curve during erect
standing increases the compressive forces on the posterior annuli and
may adversely affect the nutrition of the posterior portion of the
intervertebral discs.
 Also excessive compressive forces may be applied to the zygapophyseal
y

joints.

Ö Vertebral Column:
ph

D Lordosis:
 The term lordosis refers to an abnormal increase in the normal anterior
convexities in either the cervical or lumbar regions of the vertebral
column.
 An increase in the lumbar curve may be accompanied by a compensatory
increase in both the anterior convexity of the cervical curve and in the
posterior convexity of the thoracic curve.
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 POSTURE Sagar Naik, PT

D Kyphosis:
 The term kyphosis refers to an abnormal increase in the normal
posterior convexity of the thoracic vertebral column.
 Sometimes kyphosis may develop as a compensation for an increase in
the lumbar lordosis or the kyphosis may also develop as a result of poor

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postural habits.
 Diseases such as tuberculosis or ankylosing spondylosis also may cause

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increases in the posterior convexity of the thoracic region.
Eg – 1) Gibbus or humpback deformity may occur as a result of
tuberculosis, which causes vertebral fractures. Gibbus or
humpback deformity is easily recognized by the Gibbus (hump),
which forms a sharp posterior angulation in the upper thoracic
vertebral column.
2) Dowager’s hump is another easily recognizable kyphotic
4a condition that is found most often in postmenopausal women
who have osteoporosis. The anterior aspect of the bodies of a
series of vertebrae collapse due to osteoporotic weakening. The
vertebral body collapse causes an immediate lack of anterior
support for the vertebral column, which bends forward causing
an increase in the posterior convexity of the thoracic area (hump)
and an increase in compression on the anterior aspect of the
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vertebral bodies.

Ö Head:
D Forward Head Posture:
 A forward head posture is one in which the head is positioned anteriorly
at an increased distance from the line of gravity and the normal
anterior cervical convexity is also increased with the apex of the lordotic
y

curve is considerable distance from the line of gravity compared to

optimal posture.
 The constant assumption of a forward head posture causes unrelieved
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increased compression on the posterior zygapophyseal joints and

posterior portions of the intervertebral discs and narrowing of the
intervertebral foramina in the lordotic areas of the cervical region.
 The cervical extensor muscles may become ischemic because of the
constant isometric contraction required to maintain the head in its
forward position.

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 POSTURE Sagar Naik, PT

 The posterior aspect of the zygapophyseal joint capsules may become

adaptively shortened and the narrowed intervertebral foramen may
cause nerve root compression.
 In addition, the structure of the temporomandibular joint may become
altered by the forward head posture and as a result the joint’s function

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may be disturbed.
 In forward head posture the scapulae may rotate medially, a thoracic

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kyphosis may develop, the thoracic cavity may be diminished, vital
capacity can be reduced, and overall body height may be shortened.

U Anterior–Posterior View – Optimal Alignment:

 In an anterior view the line of gravity bisects the body into two symmetrical
halves. The head is straight with no tilting or rotation evident. The eyes,
clavicles, and shoulders should be level.
4a
 In posterior view the inferior angles of the scapulae should be parallel and
equidistant from the line of gravity. The waist angles and gluteal folds should
be equal and the anterior superior iliac spines (ASIS) and posterior superior
iliac spines (PSIS) should lie on a parallel line with the ground as well as
being equidistant from the line of gravity.
 The joint axes of the hip, knee, and ankle are equidistant from the line of
gravity, and the gravitational line transects the central portion of the vertebral
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bodies.
 When postural alignment is optimal, little or no muscle activity is required to
maintain media-lateral stability.
 The gravitational torques acting on one side of the body are opposed by equal
torques acting on the other side of the body.

U Anterior-Posterior View – Deviations from Optimal

y

Alignment:
 Any asymmetry of body segments caused either by movement of a body
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segment or by a unilateral postural deviation will disturb optimal muscular

and ligamentous balance.
 Symmetrical postural deviations, such as bilateral knock knee (genu valgum),
that disturb the optimal vertical alignment of body segments, cause an abnormal
distribution of weight bearing or compressive forces on one side of a joint and
increased tensile forces on the other side.

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 POSTURE Sagar Naik, PT

 The increased gravitational torques that may occur require increased muscular
activity and cause ligamentous stress.

Ö Foot and Toes:

D Pes Planus (Flatfoot):

.
 Normally the plumb line should lie equidistant from the malleoli, and the
malleoli should appear to be of equal size and directly opposite from one

ll..
another.
 When one malleolus appears more prominent or lower than the other
and calcaneal eversion is present, it is possible that a common foot
problem known as pes planus, or flatfoot, may be present.
 Flatfoot, which is characterized by a reduced or absent arch, may be
either rigid or flexible.
 A rigid flatfoot is a structural deformity that may be hereditary. In this
4a
the medial longitudinal arch is absent in non-weight bearing, toe
standing, and normal weight bearing situations.
 In flexible flatfoot, the arch is reduced during normal weight bearing
situations, but reappears during toe standing or non-weight bearing
situations.
 In either the rigid or flexible type of pes planus, the talar head is
displaced anteriorly, medially, and inferiorly.
sio
 The displacement of the talus causes depression of the navicular,
tension in the plantar calcaneonavicular (spring) ligament and
lengthening of the tibialis posterior muscle.
 The pronated flatfoot results in a relatively overmobile foot that may
require muscular contraction to support the osteoligamentous arches
during standing.
 It also may result in increased weight bearing on the 2nd through 4th
y

metatarsal heads with subsequent plantar callus formation, especially at

the 2nd metatarsal.
 The rigid form of flatfoot interferes with push-off during walking
ph

because the foot is unable to assume the supinated position and become a
rigid lever for push-off in gait.
 Weight bearing pronation in the erect standing posture also causes
medial rotation of the tibia and may affect knee function.
D Pes Cavus:
 A high medial longitudinal arch of the foot is called pes cavus.

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 POSTURE Sagar Naik, PT

 The weight in pes cavus is borne on the lateral borders of the foot and
the lateral ligaments and the peroneus longus muscle may be stretched.
 In walking, the cavus foot is unable to adapt to the supporting surface
because the subtalar and transverse tarsal joints tend to be near or the
locked supinated position.

.
D Hallux Valgus:
 Hallux valgus is a fairly common deformity in which there is a medial

ll..
deviation of the 1st metatarsal at the tarsometatarsal joint and a lateral
deviation of the phalanges at the metatarsophalangeal joint.
 The bursa on the medial aspect of the 1st metatarsal head may become
inflamed and form bunion in response to an increase in contact forces
between the shoe and the side of the 1st metatarsophalangeal joint.
 In addition, bony overgrowth may occur on the medial aspect of the joint
in an attempt by the body to increase the joint surface area.
4a
 The combination of excess bone and bunion formation and possible
metatarsophalangeal dislocation not only enlarge the joint but also are a
source of pain and may require surgical intervention.
 The mot common cause of hallux valgus is abnormal pronation in
combination with forefoot adducts, which leads to a hypermobile first
ray.
 Flexor muscles are stretched over the metatarsophalangeal joints and
sio
shortened over the proximal interphalangeal joints. The extensor
muscles are shortened over the metatarsophalangeal joints and
stretched over the proximal interphalangeal joints.

Ö Knee:
D Genu Valgum (Knock Knees):
 In genu valgum the mechanical axes of the lower extremities are
y

displaced laterally. If genu valgum exceeds 30° and persists beyond 8

years of age structural changes may occur.
 As a result of the increased torque acting around the knee, the medial
ph

knee joint structures are subjected to abnormal tensile or distraction

stress, and the lateral structures are subjected to abnormal compressive
stress.
 The patella may be laterally displaced and therefore predisposed to
subluxation.
 The foot also is affected as the gravitational torque acting on the foot in
genu valgum tends to produce pronation of the foot with an
19
 POSTURE Sagar Naik, PT

accompanying stress on the medial longitudinal arch and its supporting

structures as well as abnormal weight bearing on the posterior medial
aspect of the calcaneus.
 Additional related changes may include flatfoot, lateral tibial torsion,
lateral patellar subluxation, and lumbar spine contralateral rotation.

.
D Genu Varum (Bow Legs):
 Genu varum is a condition in which the knees are widely separated

ll..
when the feet are together and malleoli are touching.
 Physiologic bowing is symmetrical and involves both the femur and the
tibia.
 Cortical thickening on the medial concavity of both the femur and tibia
may be present as a result of the increased compressive forces and the
patellae may be displaced medially.
 Some of the more commonly suggested cause of genu varum are vitamin
4a
D deficiency, renal rickets, osteochondritis, or epiphyseal injury.
D Squinting or Cross-Eyed Patella:
 Squinting or cross-eyed patella (in-facing patella) is a tilted/rotated
position of the patella in which the superior medial pole of the patella
faces medially and the inferior pole points laterally.
 This altered patella position may be present in one or both knees and may
by a sign of increased medial femoral torsion or medial tibial rotation.
sio
 The Q angle may be increased in this condition and patella tracking
may be adversely affected.
D Grasshopper Eyes Patella:
 Grasshopper eyes patella refers to a high, laterally displaced position of
the patella in which the patella faces upward and outward.
 An abnormally long patella ligament may be responsible for the higher
than normal position of the patella (patella alta).
y

 The medially rotated position of the patella is due to either femoral

retroversion or lateral tibial torsion.
ph

 Grasshopper eyes patella leads to abnormal patellar tracking and a

decrease in the stability of the patella.

20
 POSTURE Sagar Naik, PT

Ö Vertebral Column:
D Scoliosis:
 Normally, when viewed from the posterior aspect, the vertebral column is
vertically aligned and perfectly bisected by the line of gravity and the
structures on either side of the column are symmetrical.

.
 The line of gravity falls through the midline of the occiput, through the
spinous processes of all vertebrae, and directly through the gluteal cleft.

ll..
 In an optimal posture the vertebral structures, ligaments, and muscles are
able to maintain the column in vertical alignment with little stress or
energy expenditure.
 If one or more of the medial-lateral structures fails to provide adequate
support, the column will bend to the side.
 The lateral bending will be accompanied by rotation of the vertebrae
because lateral flexion and rotation are coupled motions below the level
4a
of the 2nd cervical vertebra.
 Consistent lateral deviations of a series of vertebrae from the line of
gravity in one or more regions of the spine may indicate the presence of
a lateral spinal curvature called scoliosis.
 Adolescent idiopathic scoliosis curves are defined as structural curves.
These curves involve changes in the structure of the vertebral bodies,
transverse and spinous processes, intervertebral discs, ligaments, and
sio
muscles.
 Asymmetrical growth and development of the vertebral bodies leads to
wedging of the vertebrae.
 Nonstructural scoliosis curves are called functional curves in that they
can be reversed if the cause of the curve is correlated and structural
changes are not present.
 These curves are the result of correctable imbalances such as leg length
y

discrepancy or muscle spasm.

 The curves in scoliosis are named according to the direction of the
convexity and the location of the curve.
ph

y If the curve is convex to the left in the cervical area, the curve is
designated as a left cervical scoliosis.
y If more than one region of the vertebral column is involved, the superior
segment is named first. A lateral curvature of the vertebral column that
is convex to the right in the thoracic region and convex to the left in the
lumbar region is named as right thoracic, left lumbar scoliosis.

21