CLINICAL ANATOMY, KINESIOLOGY AND BIOMECHANICS
MODULE 3: POSTURE
POSTURE OVERVIEW
Taken from the ILS Lesson
Definition
• Posture, which is the relative disposition of the body at
any one moment, is a composite of the positions of the
different joints of the body at that time.
• The position of each joint has an effect on the position of the
other joints.
• Classically, ideal static postural alignment (viewed from the
side) is defined as a straight line (line of gravity) that passes
through the earlobes, the bodies of the cervical vertebrae,
the tip of the shoulder, midway through the thorax, through
the bodies of the lumbar vertebrae, slightly posterior to the
hip joint, slightly anterior to the axis of the knee joint, and just
anterior to the lateral malleolus.
Definition of other relevant terms
These are the terms that you are bound to encounter during this
lesson. Here is an overview.
Postural control - involves controlling the body’s position in space for
the dual purposes of stability and orientation.
Postural orientation - the ability to maintain an appropriate
relationship between the body segments, and between the body and
the environment for a task
Posture - is often used to describe both biomechanical alignment of
the body and the orientation of the body to the environment.
Postural stability (also referred to as balance) - is the ability to control
the center of mass in relation to the base of support.
Center of mass (COM) - a point that is at the center of the total body
mass, which is determined by finding the weighted average of the
COM of each body segment. It has been hypothesized that the COM
is the key variable that is controlled by the postural control system.
Center of gravity (COG) - The vertical projection of the COM
Base of support (BOS) is defined as the area of the body that is in
contact with the support surface.
Line of gravity (LOG) - is an imaginary vertical line from the center of
gravity to the ground or surface the object or person is on
Significance of a Good Posture
• Minimum stress is applied to each joint
© Shamerry Adato – BSPT 2023
• upright posture allows one to see farther and provides
freedom to move the arms
• Maximize function
• Better quality of life
Correct Posture vs Faulty Posture
• Correct posture - is the position in which minimum stress is applied
to each joint. Upright posture is the normal standing posture for
humans. If the upright posture is correct, minimal muscle activity is
needed to maintain the position.
• Faulty posture - Any position that increases the stress to the joints.
If a person has strong, flexible muscles, faulty postures may not affect
the joints because he or she has the ability to change position readily
so that the stresses do not become excessive. If the joints are stiff
(hypomobile) or too mobile (hypermobile), or the muscles are weak,
shortened or lengthened, however, the posture cannot be easily
altered to the correct alignment, and the result can be some form of
pathology.
Static vs Dynamic Posture
An understanding of static posture forms the basis for understanding
dynamic posture.
Static posture - the body and its segments are aligned and
maintained in certain positions. Examples of static postures include
standing, sitting, lying, and kneeling.
Dynamic posture - refers to postures in which the body or its
segments are moving—walking, running, jumping, throwing, and
lifting.
The study of any particular posture includes kinetic and kinematic
analyses of all body segments. Here are some facts regarding the
erect posture of human beings:
• Humans and other living creatures have the ability to
arrange and rearrange body segments to form a large
variety of postures, but the sustained maintenance of erect
bipedal stance is unique to humans.
• The erect standing posture allows persons to use their upper
extremities for the performance of large and small motor
tasks. If the upper extremities need to be engaged by the
 use of crutches, canes, or other assistive devices to maintain
the erect posture, an important human attribute is 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. Erect bipedal
stance increases the work of the heart; places increased
stress on the vertebral column, pelvis, and lower extremities;
and reduces stability.

• In the quadrupedal posture, the body weight is distributed

between the upper and lower extremities.

• 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 quadrupedal BoS. The human’s center of
gravity (CoG) is the point where the mass of the body is
centered and will be referred to in this chapter as the center
of mass (CoM). The position of the CoM is not fixed and
changes in different postures such as sitting and kneeling,
with movements of the extremities or trunk, and when a
person is carrying something. When a person is wearing a
leg cast on one leg, the CoM moves lower and towards the
casted leg. In the sitting posture, the CoM of the body above
the seat is located near the armpits.

• In the young child in the standing posture, the CoM is located

within the body about at the level of the 12th vertebra. As
the child becomes less “top heavy,” the CoM moves lower to
a location in the standing adult at about the level of the
second sacral segment in the midsagittal plane. The adult
position of the CoM is relatively distant from the BoS.
• Despite the instability caused by a small BoS and a high
CoM, maintaining stability in the static erect standing posture
requires only low levels of muscle activity. Passive tension
in the joint capsules, muscles, and ligaments are able to
provide some of the forces needed to counteract gravity.
Postural Control
Refers to a person’s ability to maintain stability of the body and body
segments in response to forces that threaten to disturb the body’s
equilibrium
• Although only a relatively small 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.
• 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 on the basis of past experience and the goal of
the response.
• Reactive (compensatory) responses occur as reactions to
external forces that displace the body’s CoM.
• Proactive (anticipatory) responses occur in anticipation of
internally generated destabilizing forces such as raising
arms to catch a ball or bending forward to tie shoes.

© Shamerry Adato – BSPT 2023

Major Goals of Postural Control
• To control body’s orientation in space
• Maintain the body’s CoM over the BoS
• Stabilize the head with regard to the vertical so that the eye
gaze is appropriately oriented
Basic Elements of Postural Control
• Central Nervous System
• Visual System
• Vestibular System
• Musculoskeletal System
• Postural control depends on information received from
receptors located in and around the joints (in joint capsules,
tendons, and 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.
• The 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 able to respond with
appropriate speeds and forces.
Absent or Altered Inputs and Outputs
• When inputs are 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.
• Alteration or absence of inputs may occur for a number of
reasons, including, among others, the absence of the normal
gravitational force in weightless conditions during space
flight or decreased sensation in the lower extremities.
• A more common example of altered inputs occurs when a
person attempts to attain and maintain an erect standing
posture when a foot has “fallen asleep.”
• Attempts at standing may result in a fall because input
regarding the position of the foot and ankle, as well as
information from contact of the “asleep” foot with the
supporting surface, is missing.
© Shamerry Adato – BSPT 2023
• Another instance in which inputs may be disturbed is after
injury. A disturbance in the kinesthetic sense about the ankle
and foot after ankle sprains has been implicated as a cause
of poor balance or loss of stability.
• In a study of gymnasts 1 to 12 months after an ankle sprain,
found that these individuals were less able to detect passive
ROM in the previously injured ankle than they were in the
uninjured ankle. The gymnasts in the study also reported
that they believed that they were less stable in the standing
posture than before their injury. Sometimes ankle sprains
are followed by chronic functional instability.
• 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. In sedentary elderly persons, muscles that
have atrophied through disuse may not be able to respond
with either the appropriate amount of force to counteract an
opposing force or with the necessary speed to maintain
stability.
• In persons with neuromuscular disorders, both agonists and
antagonists may respond at the same time, thus reducing
the effectiveness of the response.
MUSCLE SYNERGIES
Muscle Synergies
Centrally organized patterns of muscles activity that occur in response
to perturbations of standing postures
Factors affecting synergies:
• amount and direction of motion of the supporting surface
• width and compliance of the supporting surface
• location, magnitude, and velocity of the perturbing force
• initial posture of the individual at the time of the perturbation
Nice to knows about muscle synergies and posture:
• The term static can be misleading, especially with regard to
standing posture, because the maintenance of standing
posture is the result of dynamic control mechanisms.
• Postural control researchers have suggested that for any
particular task such as standing on a moving bus, standing
on a ladder, or standing on one leg, many different
combinations of muscles may be activated to complete the
task.
• A normally functioning CNS selects the appropriate
combination of muscles to complete the task on the basis of
an analysis of sensory inputs.
 • Afferent input from Golgi tendon organs in the leg extensors TYPES OF SYNERGIES
signal changes in the projection of the body’s CoM with
regard to the feet. Variations in an individual’s past Fixed Support Synergies
experience and customary patterns of muscle activity will
also affect the response. Are patterns of muscle activity in which the BoS remains fixed during
the perturbation and recovery of the equilibrium. Stability is regained
• Proprioceptive input from the hip or trunk may be more through the movement of parts of the body, but the feet remain fixed
important than input from the legs in signaling and initiating on the BoS.
responses. Muscle activation is based primarily on input
from the hip and trunk proprioceptors. A second level of input Examples: Ankle Synergy and Hip Synergy
includes cues from the vestibular system and proprioceptive
input from all body segments. Ankle Synergy
• Monitoring of muscle activity patterns through
electromyography (EMG) and determinations of muscle
peak torque and power outputs are some of the methods
used to study postural responses during perturbations of
upright postural stability.

• A perturbation is any sudden change in conditions that

displaces the body posture away from equilibrium. The
perturbation can be sensory or mechanical.

• Sensory perturbation might be caused by altering of visual

input, such as might occur when a person’s eyes are
covered unexpectedly.
Forward motion of the platform
• Mechanical perturbations are displacements that involve
direct changes in the relationship of CoM to the BoS. These
displacements may be caused by movements of either body
segments or the entire body.

• Even breathing can displace the CoM. Perturbations in

standing that result from respiratory movements of the rib
cage are counterbalanced by movements of the trunk and
lower limbs. As detemined by EMG, muscle activity in the
trunk and hip muscles provides a counterbalance to motions
of the rib cage.

• One method of studying how people respond to naturally Backward motion of the platform
occuring perturbations is to produce mechanical
perturbations experimentally by placing subjects on a
Muscles Distal to Proximal Response
movable platform. The platform can be moved forward,
backward, or from side to side. Some platforms can be
Tibialis Anterior Gastrocnemius
tipped, and the velocity of platform motion can be varied.
Quadriceps Femoris Hamstrings
The postural responses to perturbations caused by either
Abdominals Paraspinals
platform movement or by pushes and pulls are reactive or
Neck Flexors Neck Extensors
compensatory responses in that they are involuntary
reactions. These postural responses are referred to in the
The ankle synergy consists of discrete bursts of muscle activity on
literature as either synergies or strategies. Therefore, in
either the anterior or posterior aspects of the body that occur in a
this text, the terms will be used interchangeably.
distal-to-proximal pattern in response to forward and backward
movements of the support platform, respectively.
• The synergies are task specific and appear to vary with a
number of factors, including the amount and direction of Forward motion of the platform (1st picture above) results in a
motion of the supporting surface; width and compliance of relative displacement of the line of gravity (LoG) posteriorly and would
the supporting surface and the location, magnitude, and be similar to starting to fall backward in a free-standing posture. The
velocity of the perturbing force; and initial posture of the group of muscles that responds to the perturbation is activated in an
individual at the time of the perturbation. attempt to restore the LoG to a position within the BoS. Bursts of
muscle activity occur in the ankle dorsiflexors, hip flexors, abdominal

© Shamerry Adato – BSPT 2023

muscles, and possibly the neck flexors. The tibialis anterior muscle
contributes to the restoration of stability by pulling the tibia anteriorly, In summary, here is the difference between ankle and hip synergy
and hence the body forward, so that the LoG remains or centers within
the BoS.

Backward motion of the platform (2nd picture above) results in a

relative displacement of the LoG anteriorly and is similar to starting to
fall forward in a freestanding posture. The muscles responds in an
attempt to restore the LoG to a position within the BoS. Bursts of
activity in the plantarflexors, hip extensors, trunk extensors, and neck
extensors are used to restore the LoG over the BoS.

What if the body itself was either pushed or pulled? Can you imagine
somehow how will the ankle synergy might help in restoring the LoG
within the BoS?

Hip Strategy

Change in Support Strategy

The only synergies that are successful in maintaining stability in the
instance of a large perturbation.

• 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 shifts in the BoS.

• Stepping and grasping differ from fixed-support synergies

because stepping/grasping moves or enlarges the body’s
Muscles Proximal to Distal Response BoS so that it remains under the body’s CoM.

Paraspinals Abdominals • Change in support strategies are common responses to

Hamstrings Quadriceps Femoris perturbations among both the young and the old.
Gastrocnemius Tibialis Anterior

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 in which

change-in-support strategies (stepping or grasping synergies) are not
available.

© Shamerry Adato – BSPT 2023

 • Comparisons of the stepping strategies used by the young
and the old show that 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 those of their younger counterparts. However,
no differences are apparent in the speed at which the young
and the elderly initiate the change-in-support stepping
strategy. Older subjects lifted their feet just as quickly as did
the younger subjects.

• In quiet standing, the older person’s center of pressure

(CoP) is located closer to edge of the BoS than in younger
subjects. Therefore, older individuals may have less time to
react to a perturbation before exceeding stability limits.

Example of HSS strategy

KINETICS AND KINEMATICS OF POSTURE

Quiet stance is characterized by small amounts of spontaneous

A visual representation that ankle strategy is being used for small
perturbations while step strategy is used for greater perturbations.
Head Stabilizing Strategy
postural sway (sway envelope).
The extent of the sway envelope for a normal individual standing with
about 4 inches between the feet can be as large as 12deg. in the
sagittal plane and 16deg. in the frontal plane

Used to maintain the head during dynamic tasks Factors that contribute to stability in quiet stance:

• These proactive strategies differ from the previously
described reactive strategies because head-stabilizing
strategies occur in anticipation of the initiation of
internally generated forces caused by changes in
position from sitting to standing.
• The head-stabilizing strategies are used to maintain the
head during dynamic tasks such as walking, in contrast to
ankle and hip strategies, which are used to maintain the
body in a static situation.
• Two strategies for maintaining the vertical stability of the
head: head stabilization in space (HSS) and head
stabilization on trunk (HST)
.
• The HSS strategy is a modification of head position in
anticipation of displacements of the body’s CoG. The
anticipatory adjustments to head position are independent of
trunk motion.
• The HST strategy is one in which the head and trunk move
as a single unit.
1. Body alignment can minimize the effect of gravitation forces,
which tend to pull us off-center
2. Muscle tone keeps the body from collapsing in response to
the pull of gravity
Three main factors that contribute to the background of muscle
tone during quiet stance:
1. Intrinsic stiffness of the muscles themselves
2. The background muscle tone, which exists normally in all
muscles because of neural contributions
3. Postural tone, the activation of antigravity muscles during
quiet stance
In an ideal erect posture, body segments are aligned so that the
torques and stresses on body segments minimized and standing can
be maintained with a minimal amount of energy expenditure. The
location of the LoG shifts continually (as does the CoP - Center of
Pressure) because of the postural sway. As a result of the continuous
motion of the LoG, the moments acting around the joints are
continually changing. Receptors in and around the joints of lower body
segments and on the soles of the feet detect these changes and relay
this information to the CNS.

© Shamerry Adato – BSPT 2023

Tonically Active Muscles During Quiet Stance

• soleus and gastrocnemius, because the line of gravity falls

slightly in front of the knee and ankle
• tibialis anterior, when the body sways in backward
direction
• gluteus medius and tensor fasciae latae but not the
gluteus maximus
• iliopsoas, which prevents hyperextension of the hips, but
not the hamstrings and quadriceps
• thoracic erector spinae in the trunk (along with intermittent
activation of the abdominals), because the line of gravity falls
in front of the spinal column
• Research has suggested that appropriate activation of
abdominal and other trunk muscles often discussed in
relation to “core stability” is important for efficient postural
control, including postural compensation for respiration-
induced movement of the body.

External and Internal Moments

• The effect of external forces on body segments in the sagittal
plane during standing is determined by the location of the
LoG in relation to the axis of motion of body segments.
• When the LoG passes directly through a joint axis, no
external gravitational torque is created around that joint.
• However, if the LoG passes at a distance from the axis, an
external gravitational moment is created. This moment will
cause rotation of the superimposed body segments around
that joint axis unless it is opposed by a counterbalancing
internal moment (an isometric muscle contraction).
• If the LoG passes anterior to the ankle joint axis, the external
gravitational moment will tend to rotate the tibia (proximal
segment) in an anterior direction.
• Anterior motion of the tibia on the fixed foot will result in
dorsiflexion of the ankle. Therefore, the moment of force is
called a dorsiflexion moment.
• An internal plantarflexion moment of equal magnitude will be
necessary to oppose the external dorsiflexion moment and
establish equilibrium.

• The magnitude of the gravitational moment of force

increases as the distance between the LoG and the joint axis
increases. The direction of the external gravitational moment
of force depends on the location of the LoG in relation to a
particular joint axis.

• If the LoG is located anterior to a particular joint axis, the

gravitational moment will tend to cause anterior motion of the
proximal segment of the body supported by that joint.
• If the LoG is posterior to the joint axis, the moment will tend
to cause motion of the proximal segment in a posterior
direction

• In a postural analysis, external gravitational torques

producing sagittal plane motion of the proximal joint segment
are referred to as either flexion or extension moments.

© Shamerry Adato – BSPT 2023


• If the LoG passes anterior to the axis of rotation of the knee
joint, the gravitational moment will tend to rotate the femur
(proximal segment) in an anterior direction
• An anterior movement of the femur will cause extension of
the knee. Therefore, the moment of force is called an
extension moment.
• An internal flexion moment of equal magnitude will be
necessary to balance the external extension moment.
ANALYSIS OF POSTURE
Optimal Posture
As with the so-called good movement, good posture is a subjective
term reflecting what the clinician believes to be correct based on ideal
models.
The ability to maintain correct posture appears to be related to a
number of factors:
• Energy cost - The increase in metabolic rate over the basal
rate when standing is so small, compared with a metabolic
cost of moving, as to be negligible. The type of posture that
involves a minimum metabolic increase over the basal rate
is one in which the knees are hyperextended, the hips are
pushed forward to the limit of extension, the thoracic curve
© Shamerry Adato – BSPT 2023
is increased, the head is projected forward, and the upper
trunk is inclined backward in a posterior lean.
• Strength and flexibility - Strong, flexible muscles are able
to resist the detrimental effects of faulty postures for longer
phases and provide the ability to unload the structures
through a change of position. However, control of these
changes in position is not possible if the joints are stiff
(hypomobile) or too mobile (hypermobile), or the muscles
are weak, shortened, or lengthened.
• Age - As discussed, at birth, a series of primary curves
cause the entire vertebral column to be concave forward, or
flexed, giving a kyphotic posture to the whole spine, although
the overall contour in the frontal plane is straight. In contrast,
the contour of the sagittal plane changes with development.
At the other end of the lifespan, the aging adult tends to alter
posture in several ways. A common function of aging, at
least in women, is the development of a stooped posture
associated with osteoporosis.
• Psychological aspects - Not all posture problems can be
explained in terms of physical causes. Atypical postures may
be symptoms of personality problems or emotional
disturbances.
• Evolutionary and heredity influences - The transformation
of the human race from arboreal quadrupeds to upright
bipeds is likely related to the need of the male hominid to
have the hands and arms available for carrying a wider
variety of foods for fairly long distances. In attempting to
correct an individual’s posture, one must be realistic and
accept the limits imposed by possible hereditary factors.
• Structural deformities - The normal frontal and sagittal
alignment of the spine can be altered by many conditions,
including leg-length inequality, congenital anomalies,
developmental problems, trauma, or disease.
• Disease - he normal coronal alignment of the spine can be
altered by many conditions, including joint degeneration and
scoliosis. Scoliosis, which is a descriptive term for lateral
curvature, is usually accompanied by a rotational
abnormality. Sagittal plane alignment can also be altered by
disease and injury. This alteration is manifested clinically
with areas of excessive kyphosis or lordosis, or a loss of the
normal curves. Respiratory conditions (e.g., emphysema),
general weakness, excess weight, loss of proprioception, or
muscle spasm (as seen in cerebral palsy or with trauma)
may also lead to poor posture.
• Pregnancy - Although as yet substantiated, postural
changes have often been implicated as a major cause of
back pain in pregnant women. The relationship between
posture and the back pain experienced during pregnancy is
unclear. This may be because significant skeletal alignment
changes that are related to back pain that are occurring at
the pelvis during pregnancy but may not be directly
 measured by postural assessments, such as lumbar gravitational moment, the tibia will move the ankle into dorsiflexion and
lordosis, sacral base angle, and pelvic tilt. the soleus muscle will undergo an eccentric contraction while trying to
oppose the forward motion of the tibia.
• Habit - The most common postural problem is a poor
postural habit and its associated adaptive changes. Poor
posture, and, in particular, poor sitting posture, is considered
to be a major contributing factor in the development and
perpetuation of shoulder, neck, and back pain. Muscles
maintained in a shortened or lengthened position eventually
will adapt to their new positions. Although these muscles
initially are incapable of producing a maximal contraction in
the newly acquired positions, changes at the sarcomere
level eventually allow the muscle to produce maximal
tension at the new length. Although this may appear to be a
satisfactory adaptation, the changes in length produce
changes in tension development, as well as changes in the
angle of pull. It is theorized that, if a muscle lengthens as
part of a compensation, muscle spindle activity increases
within that muscle, producing reciprocal inhibition of that
muscle’s functional antagonist and resulting in an alteration
in the normal force–couple and arthrokinematic relationship,
thereby effecting the efficient and ideal operation of the
movement system.

Observational analysis of posture in the sagittal plane involves

locating body segments in relation to the LoG.

A plumb line, or line with a weight on one end, dropped from the
ceiling and passing through the external auditory meatus of the ear
may be used to represent the LoG. Evaluators of posture should be
able to determine whether a body segment or joint deviates widely
from the normal optimal postural alignment by using their
observational skills. A skilled observational analysis can yield basic
information about an individual’s posture that can be used either for
developing a treatment regimen for the correction of poor posture or to
decide whether a more sophisticated analysis such as radiography is
warranted.
ANKLE
Joints Ankle Joint (Neutral)
Line of Gravity Anterior
External Moment Dorsiflexion
Passive Opposing Forces
Active Opposing Forces Soleus*
Gastrocnemius
In the optimal erect posture, the ankle joint is in the neutral position, or
midway between dorsiflexion and plantarflexion. The LoG passes
slightly anterior to the lateral malleolus and, therefore, anterior to the
ankle joint axis. The anterior position of the LoG in relation to the ankle
joint axis creates an external dorsiflexion moment that must be
opposed by an internal plantarflexion moment to prevent forward
motion of the tibia. In the neutral ankle position, there are no
ligamentous checks capable of counterbalancing the external
dorsiflexion moment; therefore, activation of the plantarflexors creates
the internal plantarflexion moment that is necessary to prevent forward
motion of the tibia. The soleus muscle contracts and exerts a posterior
pull on the tibia and in this way is able to oppose the dorsiflexion
moment. If the force that the muscle can exert is less than the
EMG studies have demonstrated that soleus and gastrocnemius
activity is fairly continuous in normal subjects during erect standing.
This activity suggests that these muscles are exerting a minimal but
constant internally generated plantarflexion torque about the ankles to
oppose the normal external gravitational dorsiflexion moment. Ankle
joint muscles that have shown inconsistent activity in EMG recordings
during standing are the tibialis anterior, peroneal, and tibialis posterior
muscles. It is possible that these muscles may be helping to provide
transverse stability in the foot during postural sway rather than acting
to oppose the external dorsiflexion at the ankle joint.
KNEE
Joints Knee Joint (Extended)
Line of Gravity Anterior
External Moment Extension
Passive Opposing Forces Posterior Joint Capsule
Active Opposing Forces Hamstrings
Gastrocnemius
In optimal posture, the knee joint is in full extension, and the LoG
passes anterior to the midline of the knee and posterior to the patella.
This places the LoG just anterior to the knee joint axis. The anterior
location of the gravitational line in relation to the knee joint axis creates
an external extension moment. The counterbalancing internal flexion
moment created by passive tension in the posterior joint capsule and
associated ligaments is usually sufficient to balance the gravitational
moment and prevent knee hyperextension.

© Shamerry Adato – BSPT 2023

However, a small amount of activity has been identified in the
hamstrings. Activity of the soleus muscle may augment the
gravitational extension moment at the knee through its posterior pull
on the tibia as it acts at the ankle joint. In contrast, activity of the
gastrocnemius muscle may tend to oppose the gravitational extension
moment because the muscle crosses the knee posterior to the knee
joint axis.

In this optimal position, the LoG passes slightly posterior to the axis of
the hip joint, through the greater trochanter. However, during postural
sway, the LoG may pass anterior to the hip joint axis, and contraction
of the hip exterior may be required.

The posterior location of the gravitational line in relation to the hip joint
axis creates an external extension moment at the hip that tends to
rotate the pelvis (proximal segment) posteriorly on the femoral heads.
EMG studies have shown activity of the iliopsoas muscle during
standing, and it is possible that the iliopsoas is acting to create an
internal flexion moment at the hip to prevent hip hyperextension. If the
gravitational extension moment at the hip were allowed to act without
muscular balance, as in a so called relaxed or swayback posture, hip
PELVIS AND HIP hyperextension ultimately would be checked by passive tension in the
Joints Hip Joint (Neutral) iliofemoral, pubofemoral, and ischiofemoral ligaments. In the
Line of Gravity Posterior swayback standing posture, the LoG drops farther behind the hip joint
External Moment Extension axes than in the optimal posture.
Passive Opposing Forces Iliofemoral Ligament
Active Opposing Forces Iliopsoas Therefore, the swayback posture does not require any muscle activity
at the hip but causes an increase in the tension stresses on the anterior
In optimal posture, the hip is in a neutral position and the pelvis is level hip ligaments, which could lead to adaptive lengthening of these
with no anterior or posterior tilt. In a level pelvis position, lines ligaments if the posture becomes habitual. Also, because of the
connecting the symphysis pubis and the anterior-superior iliac spines diminished demand for hip extensor activity, the gluteal muscles may
(ASISs) are vertical, and the lines connecting the ASISs and posterior- be weakened by disuse atrophy if the swayback posture is habitually
superior iliac spines (PSISs) are horizontal. adopted. The relaxed standing or sway posture may also increase the
magnitude of the gravitational torque at other joints in the body.

© Shamerry Adato – BSPT 2023

 LUMBOSACRAL AND SACROILIC JOINTS
Joints Lumbosacral Sacroiliac
Line of Gravity Body of the L5 & Anterior
close to the axis
of rotation of L5
joint
External Moment Slight extension Nutation
moment at L5-S1
Passive Anterior Sacrotuberous
Opposing Longitudinal Sacrospinous
Forces Ligament and Iliolumbar
Iliolumbar Anterior Sacroiliac
ligaments Ligament
Active Opposing Transversus Abdominis
Forces

The average lumbosacral angle measured between the bottom of the

L5 vertebra and the top of the sacrum (S1) is about 30 but can vary
between 6 and 30. Anterior tilting of the sacrum increases the
lumbosacral angle and results in an increase in the shearing stress at
the lumbosacral joint and may result in an increase in the anterior
lumbar convexity in standing.

In the optimal posture, the LoG passes through the body of the fifth
lumbar vertebra and close to the axis of rotation of the lumbosacral VERTEBRAL COLUMN
joint. Gravity therefore creates a very slight extension moment at L5 to Joints Cervical Thoracic Lumbar
S1 that tends to slide L5 and the entire lumbar spine down and forward Line of Posterior Anterior Posterior
on S1. This motion is opposed primarily by the anterior longitudinal Gravity
ligament and the iliolumbar ligaments. Bony resistance is provided by External Extension Flexion Posterior
Moment
the locking of the lumbosacral zygapophyseal joints. Passive ALL PLL ALL & Iliolumbar
Opposing Ant. Annulus Supraspinous & lig; ant. fibers of
When the sacrum is in the optimal position, the LoG passes slightly Forces Fibrosus Interspinous Lig. the annulus
anterior to the sacroiliac joints. The external gravitational moment that Facet Jt. Facet jt. capsules; & fibrosus
capsules post. Annulus Facet jt. capsules
is created at the sacroiliac joints tends to cause the anterior superior Fibrosus
portion of the sacrum to rotate anteriorly and inferiorly, whereas the Active Ant. Scalene Ligamentum Flavum Rectus abdominis
posterior inferior portion tends to move posteriorly and superiorly. Opposing Longus Capitis Longissimus t. Ext and Internal
Passive tension in the sacrospinous and sacrotuberous ligaments Forces Longus Colli Iliocostalis t. oblique muscles
provides the internal moment that counterbalances the gravitational Spinalis t.
Semispinalis t.
torque by preventing upward tilting of the lower end of the sacrum.
In the optimal configuration, the curves of the vertebral column should
be fairly close to average or normal configuration described earlier.
The optimal position of the plumb line LoG is through the midline of the
trunk.

EMG studies have shown that the longissimus dorsi, rotatores, and
neck extensor muscles exhibit intermittent electrical activity during
normal standing. This evidence suggests that ligamentous structures
and passive muscle tension are unable to provide enough force to
oppose all external gravitational moments acting around the joint axes
of the upper vertebral column.

In the lumbar region, where minimal muscle activity appears to occur,

passive tension in the anterior longitudinal ligament and passive
tension in the trunk flexors apparently are sufficient to balance the
external gravitational extension moment.

© Shamerry Adato – BSPT 2023

 HEAD
Joints Atlantooccipital joint
Line of Gravity Anterior
Anterior to transverse axis for flexion and extension

External Moment Flexion

Passive Opposing Forces
Active Opposing Forces
Ligamentum nuchae
Alar ligament
Tectoria
Atlantoaxial
Post. Atlanto-occipital membranes
Rectus capitis posterior major and minor
Semispinalis Capitis and Cervicis
Splenius Capitis and Cervicis
Inferior and superior Oblique Muscles

The LoG in relation to the head passes slightly anterior to the transverse (frontal) axis of rotation for flexion and extension of the head and creates an
external flexion moment. This external flexion moment, which tends to tilt the head forward, may be counteracted by internal moments generated by
tension in the ligamentum nuchae, tectorial membrane, and posterior aspect of the zygapophyseal joint capsules and by activity of the capital extensors.
Ideally, a plumb line extending from the ceiling should pass through the external auditory meatus of the ear, and the head should be directly over the
body’s CoM at S2.

© Shamerry Adato – BSPT 2023

 Summary of Alignment in Sagittal plane in Standing Posture
SAGITTAL ANALYSIS DEVIATIONS
Foot and Toes
Claw Toes
• Claw toes is a deformity of the toes characterized by
hyperextension of the metatarsophalangeal (MTP) joint,
combined with flexion of the proximal interphalangeal (PIP)
and distal interphalangeal (DIP) joints.
• The abnormal distribution of weight may result in callus
formation under the heads of the metatarsals or under the
end of the distal phalanx. Sometimes the proximal phalanx
may subluxate dorsally on the metatarsal head.
• Calluses may develop on the dorsal aspects of the flexed
phalanges from constant rubbing on the inside of shoes.
• In essence, this deformity reduces the area of the BoS and,
as a result, may increase postural sway and decrease
stability in the standing position.
• A few of the many suggested etiologies for this condition are
as follows: the restrictive effect of shoes, a cavus-type foot,
muscular imbalance, ineffectiveness of intrinsic foot
muscles, neuromuscular disorders, and age-related
deficiencies in the plantar structures.
© Shamerry Adato – BSPT 2023
Hammer Toes
• In general, hammer toe is described as a deformity
characterized by hyperextension of the MTP joint, flexion of
the PIP joint, and hyperextension of the DIP joint.
• Callosities (painless thickenings of the epidermis) may be
found on the superior surfaces of the PIP joints over the
heads of the first phalanges as a result of pressure from the
shoes. The tips of the distal phalanges also may show
callosities as a result of abnormal weight-bearing.
• The flexor muscles are stretched over the MTP joint and
shortened over the PIP joint. The extensor muscles are
shortened over the MTP joint and stretched over the PIP
joint.
• If the long and short toe extensors and lumbrical muscles
are selectively paralyzed, the instrinsic and extrinsic toe
flexors acting unopposed will buckle the PIP and DIP joints
and cause a hammer toe.
 In the flexed-knee standing posture, which can result from knee flexion
contractures, the LoG passes posterior to the knee joint axes. The
posterior location of the LoG creates an external flexion moment at the
knees that must be balanced by an internal extension moment created
by activity of the quadriceps muscles in order to maintain the erect
position.

The quadriceps force required to maintain equilibrium at the knee in

erect stance increases from zero with the knee extended to 22% of a
maximum voluntary contraction (MVC) with the knee in 15º of flexion.

A rapid rise in the amount of quadriceps force is required between 15º

and 30º of knee flexion. When the knee reaches 30º of flexion, the
necessary quadriceps force rises to 51% of a MVC. The increase in
muscle activity needed to maintain a flexed knee posture
subjects the tibiofemoral and patellofemoral joints to greater-
than-normal compressive stress and can lead to fatigue of the
quadriceps femoris and other muscles if the posture is
maintained for a prolonged period.

Other consequences of a flexed-knee erect standing posture are

related to the ankle and hip. Because knee flexion in the upright stance
is accompanied by hip flexion and ankle dorsiflexion, the location of
the LoG also will be altered in relation to these joint axes. At the hip,
the LoG may pass anterior to the hip joint axes, creating an external
flexion moment.

Activity of the hip extensors may be necessary to create an internal

extensor moment to balance the external flexion moment acting
around the hip. Increased soleus muscle activity may be required to
Knees create an internal plantarflexion moment to counteract the increased
external dorsiflexion moment at the ankle. The additional muscle
activity subjects the hip and ankle joints to greater-than-normal
Flexed Knee Posture
compression stress. Overall, the increased need for quadriceps,
gastrocnemius, soleus and, perhaps, hip extensor activity appears to
substantially increase the energy requirements for stance.

© Shamerry Adato – BSPT 2023

Hyperextended Knee Posture (Genu Recurvatum) Pelvis

Excessive Anterior Pelvic Tilt

The hyperextended knee posture is one in which the LoG is located

considerably anterior to the knee joint axis. The anterior location of the
LoG causes an increase in the external extensor moment acting at the
knee, which tends to increase the extent of hyperextension and puts
the posterior joint capsule under considerable tension stress.

A continual adoption of the hyperextended knee posture is likely

to result in adaptive lengthening of the posterior capsule and of
In a posture in which the pelvis is excessively tilted anteriorly, the lower
the cruciate ligaments and, consequently, in a more unstable
lumbar vertebrae are forced anteriorly. The upper lumbar vertebrae
joint. The anterior portion of the knee joint surfaces on the femoral
move posteriorly to keep the head over the sacrum, thereby increasing
condyles and anterior portion of the tibial plateaus will be subject to
the lumbar anterior convexity (lordotic curve). The LoG is therefore at
abnormal compression and therefore are subject to degenerative
a greater distance from the lumbar joint axes than is optimal and the
changes of the cartilaginous joint surfaces. The length-tension
extension moment in the lumbar spine is increased. The posterior
relationship of the anterior and posterior muscles also may be altered,
convexity of the thoracic curve increases and becomes kyphotic to
and the muscles may not be able to provide the force necessary to
balance the lordotic lumbar curve and maintain the head over the
provide adequate joint stability and mobility.
sacrum. Similarly, the anterior convexity of the cervical curve
increases to bring the head back over the sacrum.
Hyperextension at the knee is usually caused either by limited
dorsiflexion at the ankle or by a fixed plantarflexion position of
In the optimal posture in erect standing, the lumbar disks are subject
the foot and ankle called equinus. It may also be the result of habits
to tension anteriorly and compression posteriorly. A greater diffusion
formed in childhood in which the child or adolescent always elects to
of nutrients into the anterior than into the posterior portion of the disk
stand with hips and knees hyperextended in the relaxed or swayback
occurs in the optimal erect posture. Increases in the anterior
standing posture.
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
disks. Also, excessive compressive forces may be applied to the
zygapophyseal joints.

© Shamerry Adato – BSPT 2023

 Vertebral Column

LORDOSIS
Description Manifestations
An excessive anterior curvature of the spine. Pathologically, it is an
exaggeration of the normal curves found in the cervical and lumbar Causes of increased lordosis include
spines
The pelvic angle, normally approximately 30 degrees, is increased 1. Postural deformity
with lordosis
2. Lax muscles, especially the abdominal muscles, in
There are two types of exaggerated lordosis: pathological lordosis and combination with tight muscles, especially hip flexors or
swayback deformity lumbar extensors

Pathological lordosis: 3. A heavy abdomen, resulting from excess weight or

pregnancy
Involves scapulae protraction, internally rotated arms, internally
rotated legs, and forward head, accompanied by weakness of the 4. Hip flexion contractures
deep lumbar extensors and tightness of the hip flexors and tensor
fasciae latae, combined with weak abdominals 5. Spondylolisthesis

Swayback deformity: 6. Congenital problems, such as bilateral congenital

dislocation of the hip
Increased pelvic inclination to approximately 40 degrees and kyphosis
of the thoracolumbar spine. A swayback deformity results in the 7. Failure of segmentation of the neural arch
spine’s bending back rather sharply at the lumbosacral angle. With
this postural deformity, the entire pelvis shifts anteriorly, causing the 8. Fashion (e.g., wearing high-heeled shoes)
hips to move into extension. To maintain the center of gravity in its
normal position, the thoracic spine flexes on the lumbar spine. The
result is an increase in the lumbar and thoracic curves. Such a
deformity may be associated with tightness of the hip extensors, lower
lumbar extensors, and upper abdominals, along with weakness of the
hip flexors, lower abdominals, and lower thoracic extensors

© Shamerry Adato – BSPT 2023

 KYPHOSIS
Description Manifestations

Excessive posterior curvature of the spine

Pathologically, it is an exaggeration of the normal curve found in the
thoracic spine
There are four types of kyphosis:
1. Round back—a long, rounded curve with decreased pelvic
inclination (<30 degrees) and thoracolumbar kyphosis. The patient
often presents with the trunk flexed forward and a decreased lumbar
curve. On examination, there are tight hip extensors and trunk flexors,
with weak hip flexors and lumbar extensors
There are several causes of kyphosis, including tuberculosis,
vertebral compression fractures, Scheuermann disease, ankylosing
spondylitis, senile osteoporosis, tumors, compensation in conjunction
with lordosis, and congenital anomalies
The congenital anomalies include a partial segmental defect, as seen
in osseous metaplasia, or centrum hypoplasia and aplasia
In addition, paralysis may lead to a kyphosis because of the loss of
muscle action needed to maintain the correct posture, combined with
the forces of gravity

2. Humpback or gibbus—a localized, sharp posterior angulation in

the thoracic spine

3. Flat back—decreased pelvic inclination to 20 degrees and a

mobile lumbar spine

4. Dowager hump—often seen in older patients, especially women.

The deformity commonly is caused by osteoporosis, in which the
thoracic vertebral bodies begin to degenerate and wedge in an
anterior direction, resulting in a kyphosis

© Shamerry Adato – BSPT 2023

 In addition, the structure of the temporomandibular joint may become
altered by the forward head posture, and as a result, the joint’s function
may be disturbed. In the forward head posture, the scapulae may
rotate medially, a thoracic kyphosis may develop, the thoracic cavity
may be diminished, vital capacity can be reduced, and overall body
height may be shortened. Other possible effects of habitual forward
head posture, including adverse effects on the temperomandibular
joint.

A forward head posture is one in which the head is positioned

anteriorly and the normal anterior cervical convexity is increased with
the apex of the lordotic cervical curve at a considerable distance from
the LoG in comparison with optimal posture. The constant
assumption of a forward head posture causes abnormal
compression on the posterior zygapophyseal joints and posterior
portions of the intervertebral disks 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 counteract the larger than
normal external flexion moment and maintain the head in its forward
position. The posterior aspect of the zygapophyseal joint capsules may
become adaptively shortened, and the narrowed intervertebral
foramen may cause nerve root compression.

© Shamerry Adato – BSPT 2023

 STANDING POSTURE IN FRONTAL PLANE

Optimal Posture

• In an anterior view, the LoG bisects the body into symmetrical halves.

• The head is straight, with no tilting or rotation evident.

• The LoG bisects the face into equal halves. The eyes, clavicles, and shoulders should be
level (parallel to the ground).

• In a posterior view, the inferior angles of the scapulae should be parallel and equidistant
from the LoG.

• The waist angles and gluteal folds should be equal, and the ASIS and PSIS should lie on
a line parallel to the ground, as well as being equidistant from the LoG.

• The joint axes of the hip, knee, and ankle are equidistant from the LoG, and the
gravitational line transects the central portion of the vertebral bodies.

• When postural alignment is optimal, little or no muscle activity is required to maintain

medial-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

© Shamerry Adato – BSPT 2023

© Shamerry Adato – BSPT 2023
 FRONTAL PLANE DEVIATIONS

Foot and Toes

Pes Planus (Flat foot/ Pronated foot)

An evaluation of standing posture from the anterior-posterior aspect

should include a careful evaluation of the feet. 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 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 flat foot, may be present.
Calcaneal eversion of 5 to 10 is normal in toddlers, but by 7 years of
age, no calcaneal eversion should be present.

Flat foot, which is characterized by a reduced or absent medial arch,

may be either rigid or flexible. A rigid flat foot is a structural deformity
that may be hereditary. In the rigid flat foot, the medial longitudinal arch
is absent in non–weight-bearing, toe-standing, and normal weight-
bearing situations. In the flexible flat foot, the arch is reduced during
normal weightbearing 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. The displacement of the
talus causes depression of the navicular bone, tension in the plantar
calcaneonavicular (spring) ligament, and lengthening of the tibialis
posterior muscle. The extent of flat foot may be estimated by noting
the location of the navicular bone in relation to the head of the
first metatarsal. Normally, the navicular bone should be intersected
by the Feiss line. If the navicular bone is depressed, it will lie below the
Feiss line and may even rest on the floor in a severe extent of flat foot.
Flat foot 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 second
through fourth metatarsal heads with subsequent plantar callus
formation, especially at the second metatarsal. Weight-bearing
pronation in the erect standing posture causes medial rotation of the
tibia and may affect knee joint function.

© Shamerry Adato – BSPT 2023

Pes Cavus (Hollow Foot/Rigid foot/ Supinated foot) There is pain in the tarsal region after time because of osteoarthritic
changes in these joints. The longitudinal arches are high on both the
medial and lateral aspects so that a lateral longitudinal arch occurs in
some severe cases, and the forefoot is thickened and splayed. The
metatarsal heads are prominent on the sole of the foot, and the toes
do not touch the ground, even on active or passive movement. This
type of deformity leads to a rigid foot with little ability to absorb shock
and adapt to stress. People with this deformity have difficulty doing
repetitive stress activity (e.g., long-distance running, ballet) and
require a cushioning shoe. In severe cases, the cavus foot is often
associated with neurological disorders.

Knee

Genu varum (Bowleg)

The medial longitudinal arch of the foot, instead of being low (as in flat
foot), may be unusually high. A high arch is called pes cavus. Pes
cavus is a more stable position of the foot than is pes planus. 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 at
the locked supinated position.
Genu varum (bowleg) is a condition in which the knees are widely
A pes cavus may be caused by a congenital problem; a neurological separated when the feet are together and the malleoli are touching.
problem, such as spina bifida, poliomyelitis, or Charcot-Marie-Tooth Some extent of genu varum is normal at birth and during infancy up to
disease; talipes equinovarus; or muscle imbalance. There may also be 3 or 4 years of age. Physiologic bowing is symmetrical and involves
a genetic factor, because it tends to run in families. The longitudinal
both the femur and the tibia. Cortical thickening on the medial
arches are accentuated, and the metatarsal heads are lower in relation
concavity of both the femur and tibia may be present as a result of the
to the hindfoot so that there is a dropping of the forefoot on the hindfoot
at the tarsometatarsal joints. The soft tissues of the sole of the foot are increased compressive forces, and the patellae may be displaced
abnormally short, which gives the foot a shortened appearance. medially. Some of the more commonly suggested cause of genu
varum are vitamin D deficiency, renal rickets, osteochondritis, or
If the deformity persists, the bones eventually alter their shape, epiphyseal injury.
perpetuating the deformity. The heel is normal, at least initially. Claw
toes are often associated with the condition because of the dropping
of the forefoot combined with the pull of the extensor tendons. The
examiner often finds painful callosities beneath the metatarsal heads
that are caused by the loss of the metatarsal arch and tenderness
along the deformed toes.

© Shamerry Adato – BSPT 2023

Genu valgum (Knock Knee) Squinting Patella (Cross-eyed patella)

Genu valgum (knock knee) is considered to be a normal alignment

of the lower extremity in children from 2 to 6 years of age. However, Squinting or cross-eyed patella (patella that faces medially) is a
by about 6 or 7 years of age, the physiologic valgus should begin to tilted/rotated position of the patella in which the superior medial pole
decrease, and by young adulthood, the extent of valgus angulation at faces medially and the inferior pole faces laterally. This abnormal
the knee should be only about 5 to 7. In genu valgum, the mechanical patella position may be present in one or both knees and may be a
sign of either increased femoral torsion (excessive femoral
axes of the lower extremities are displaced laterally. If the extent of
anteversion) or medial tibial rotation. The Q-angle may be increased
genu valgum exceeds 30 and persists beyond 8 years of age,
in this condition, and patella tracking may be adversely affected.
structural changes may occur. As a result of the increased external
torque acting around the knee, the medial 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
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 (valgus torque). Additional
related changes may include flat foot, lateral tibial torsion, lateral
patellar subluxation, and lumbar spine contralateral rotation.

© Shamerry Adato – BSPT 2023

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). Femoral retroversion
or lateral tibial torsion may be responsible for the rotated position of
the patella. Grasshopper-eyes patella leads to abnormal patella
tracking and a decrease in the stability of the patella.
Vertebral Column
Scoliosis
© Shamerry Adato – BSPT 2023
Two terms, scoliosis and rotoscoliosis, are used to describe the lateral
curvature of the spine, which typically involves the lumbar and thoracic
regions. Scoliosis is the older term and refers to an abnormal side
bending of the spine but gives no reference to the coupled rotation that
also occurs.
Rotoscoliosis is a more detailed definition, used to describe the curve
of the spine by detailing how each vertebra is rotated and side flexed
in relation to the vertebra below. For example, with a left lumbar
convexity, the L5 vertebra would be found to be side flexed to the right
and rotated to the left in relation to the sacrum. The same would be
true with regard to the relation between L4 and L5. This rotation,
toward the convexity, continues in small increments until the apex at
L3. L2, which is above the apex, is right rotated and right side flexed
in relation to L3. The small increments of right rotation continue up until
the thoracic spine, where the side bending and rotation return to the
neutral position.
The currently accepted definition of scoliosis is a 10-degree
lateral curvature measured radiographically, with the vertebral
rotation of the spine taken with the patient standing upright. This
definition is based on the fact that a graph of lateral spinal curvature of
the general population is a smooth exponential function in which the
sharpest change in slope occurs at 10 degrees. Scoliosis can be found
in four forms: static, sciatic, idiopathic, and psychogenic. The cause of
the latter is self-explanatory. An abnormal lateral thoracic curve is
described as being static (structural) or dynamic (nonstructural):
• Static. The term static, or structural, scoliosis is used to
describe an irreversible lateral curvature with fixed rotation
of the vertebrae. With structural scoliosis, the vertebral
bodies rotate toward the convexity of the curve, producing a
prominence. The prominence, which occurs posteriorly on
the side of the spinal convexity in the thoracic spine, is called
a rib hump. The rotation of the vertebral bodies causes the
spinous processes to deviate toward the concave side,
which causes a prominence anteriorly on the side of the
concavity. The curvature results in an adaptive shortening of
the intrinsic trunk muscles on the concave side and
lengthening of the intrinsic muscles on the convex side.
Persistent scoliosis during forward bending (Adam’s sign) is
indicative of a structural curve. Structural curves may be
genetic, congenital, or idiopathic, producing a structural
change to the bone and a loss of spinal flexibility. For
example, structural scoliosis may be caused by a
hemivertebra, osteoporosis, osteomalacia, or compression
fractures.
• Dynamic. The term dynamic, or nonstructural, scoliosis is
used to describe a reversible lateral curvature that can be
change with forward or side bending and with positional
changes. Causes include poor posture, nerve root irritation
(see Sciatic), leg-length discrepancy, atrophy, or hip flexor
contracture. In the case of a leg length discrepancy, if a
platform under the heel of the shorter limb eases or even
abolishes the symptoms while standing or with lumbar
flexion or extension, a shoe lift is advised.
Other types of scoliosis to consider include:

• Sciatic. The sight of a patient with a pelvic shift or list is

relatively common in patients presenting with LBP. The
sciatic, or nonstructural, lumbar scoliosis results from sciatic
pain caused by a lumbar disk herniation and unilateral
spasm of the back muscles. Sciatic scoliosis usually occurs
with convexity to the symptomatic side of the herniated disk.
The shift is thought to result from the body finding a position
of comfort and protection, as a consequence of an irritation
of a spinal nerve or its dural sleeve, although the neuronal
mechanisms of sciatic scoliosis have not been well clarified.
These postural changes cannot be relieved by voluntary
efforts but usually disappear after alleviation of the sciatic
pain. The extent of scoliosis should be noted if it is thought
to be contributing to the patient’s symptoms and is occurring
because of pain or dysfunction. An attempt should be made
to manually correct the shift (see Chapter 28) to ascertain
whether this can be done painlessly. A compensatory shift
or scoliosis is often easy and painless to correct.

• Idiopathic. Scoliosis is never normal, although most cases

are idiopathic, manifesting in the preadolescent years. The
curve of idiopathic scoliosis differs from the tilt of the spine
associated with recent intervertebral disk (IVD) problems in
that it is accompanied by a lower thoracic or lumbar rotation
deformity. If this deformity is not obvious in the standing
posture, it should become obvious during flexion, as it is
manifested by the so-called razor back eminence of the
thoracic cage.

The curve patterns are named according to the level of the apex of the
curve. For example, a right thoracic curve has a convexity toward the
right, and the apex of the curve is in the thoracic spine. There may be
a number of curves spanning the thoracic and lumbar region, and the
clinician should determine if the curvature is contributing to the
patient’s pain as, frequently, these curves can be asymptomatic. A
slight lateral curve in the frontal plane is thought to result from right-
hand dominance or the presence of the aorta.

© Shamerry Adato – BSPT 2023

 OPTIMAL POSTURE IN SITTING AND LYING
MUSCLE ACTIVITY in the active erect sitting posture is also greater
than in both relaxed erect and slouched sitting. In relaxed erect sitting,
the LoG is only slightly anterior from its position in active erect sitting.
Posture in Sitting In the slouched posture, the LoG is posterior to the spine and hips, but
body weight is being supported by the back of the chair, and so less
muscle activity is required than in active erect posture
INTRADISCAL PRESSURE

The amount of muscle activity employed to maintain a particular

posture affects the amount of interdiskal pressure and energy
expenditure. Increases in muscle activity cause increases in interdiskal
pressures and decreases in muscle activity are accompanied by
decreases in interdiskal pressures. Upper and lower erector spinae
muscles shifted to higher levels of activity during active erect sitting
than during standing. This increase in muscle activity has been
attributed in part to the differences in the extent of lumbar lordosis
observed between sitting and standing. Sitting forces the pelvis into a
posterior tilt and, as a result, causes a reduction in the lumbar curve in
comparison with that observed in standing. In one radiographic study
of 109 patients, the average lumbar curve (L1 to S1) was 15º less in
active erect sitting than was an average lumbar curve of 49º in the
same population in standing posture. The LoG would be farther away
from the apex of the joint axes of the lumbar vertebrae in a flexed or
more kyphotic lumbar spine than in a lordotic lumbar spine. Therefore,
one would expect that more muscle activity would be required to
maintain the active erect sitting posture than to maintain standing.
However, the results of the following study raise questions about a
more kyphotic lumbar spine’s being responsible for all of the increase
in muscle activity in active erect sitting versus standing.

Posture in Lying

The overall goal for sitting posture is the same as the goal for standing
posture: to attain a stable alignment of the body that can be maintained
with the least expenditure of energy and the least stress on body
structures. In our analysis of standing posture, we saw that moments
at the spine and extremity joints were created when the LoG was at a Interdiskal Pressures
distance from either a portion of the vertebral column or the axes of
the extremity joints. The greater the distance that the LoG was from In general, interdiskal pressures are less in lying postures than in
the joint axes, the larger the moment that was created and, as a result, standing and sitting postures. Interdiskal pressures in supine lying
the more muscle activity and/or passive tension in ligaments and joint (0.10 MPa) were less than in either lying prone (0.11 MPa) or lying on
capsules that was required to maintain equilibrium and a stable the side (0.12 MPa), and in all of these postures the interdiskal
posture. The necessary increase in muscle activity resulted in more pressure was less than in sitting and standing postures.
energy expenditure and increased loads on body structures.

In a way, sitting postures are more complex than standing postures.

The same gravitational moments as in standing posture must be
considered, but, in addition, we must consider the contact forces that
are created when various portions of the body interface with various
parts of chairs, such as head, back, and foot rests, and seats. The
location and amount of support provided to various portions of the body
by the chair or stool may change the position of the body parts and
thus the magnitude of the stresses on body structures.

© Shamerry Adato – BSPT 2023

You can check on the above graph the difference in discal pressure
across different positions of the body. Note that the disc pressure is
much less when lying down and the highest when lifting an object in
front without bending the knees.

EFFECTS OF POSTURE

Age and Gender

Postural alignment in elderly people may show a more flexed posture
than in the young adult; however, many elderly individuals in their 70s
and 80s still demonstrate a close-to-optimal posture. No correlations
were found between age and kyphosis either in the thoracic region or
at the thoracolumbar junction. Only the loss of lumbar lordosis at
the proximal levels showed the strongest correlation with age.

The flexed posture observed in some elderly persons is probably due

Postural control in infants develops progressively during the first year
of life, from control of the head to control of the body in a sitting posture
and then to control of the body in a standing posture. Stability in a
posture, or the ability to fix and hold a posture in relation to gravity,
must be accomplished before the child is able to move within a
posture. The child learns to maintain a certain posture, usually through
co-contraction of antagonist and agonist muscles around a joint, and
then is able to move in and out of the posture (sitting to standing and
standing to sitting). Once stability is established, the child proceeds to
controlled mobility and skill. Controlled mobility refers to the ability to
move within the posture—for example, weight shifting in the standing
posture. Skill refers to performance of activities such as walking,
running, and hopping, which are dynamic postural activities.
to a number of factors, some of which may relate to aging processes.
Conditions such as osteoporosis may affect posture in elderly persons.
Osteoporosis (abnormal rarefaction of bone) weakens the vertebral
bodies and makes them liable to fracture. After the collapse of a series
of the anterior portions of the weakened vertebrae, the normal
posterior convexity of the thoracic curve increases (kyphosis). In
kyphosis, the anterior trunk flexor muscles shorten as the posteriorly
located trunk extensors lengthen. The ROM at the knees, hips, ankles,
and trunk may be restricted because of muscle shortening and disuse
atrophy. Furthermore, as voluntary postural response times in elderly
people appear to be longer than in young people, elderly persons may
elect to stand with a wide BoS to have a margin of safety.

The erect standing posture in infancy and early childhood differs

somewhat from postural alignment in adults, but by the time a
child reaches the age of 10 or 11 years, postural alignment in the
erect standing position should be similar to adult alignment.

© Shamerry Adato – BSPT 2023

 Pregnancy This type of injury is caused by repetitive stress that exceeds the
physiologic limits of the tissues. Muscles, ligaments, and tendons are
especially vulnerable to the effects of repetitive tensile forces, whereas
Normal pregnancies are accompanied by weight gain, an increase in weight bones and cartilage are susceptible to injury from the application of
distribution in the breasts and abdomen, and softening of the ligamentous and excessive compressive forces.
connective tissue. The location of the woman’s CoG changes because of the
increase in weight and its distribution anteriorly. Consequently, postural
changes in pregnancy include an increase in the lordotic curves in the
cervical and lumbar areas of the vertebral column, protraction of the
shoulder girdle, and hyperextension of the knees.

Occupation and Recreation

Each particular occupational and recreational activity has unique

postures and injuries associated with these postures. Bricklayers,
surgeons, carpenters, and cashiers assume and perform tasks in
standing postures for a majority of the working day. Others, such as
secretaries, accountants, computer operators, and receptionists,
assume sitting postures for a large proportion of the day. Performing
artists often assume asymmetrical postures while playing a musical
instrument, dancing, or acting. Running, jogging, and long-distance
walking are dynamic postures with which very specific injuries are
associated. Many of the injuries sustained during both occupational
and recreational activities belong to the category of “overuse injuries.”

© Shamerry Adato – BSPT 2023

 PRACTICE QUESTIONS
The line of gravity passes anterior to the earlobe False
The line of gravity passes anterior to the medial malleolus False
o Line of Appleton: Line from the earlobe to the
humeral head
o Check if head is excessively positioned anteriorly
or posteriorly
o The shoulders may be protracted or retracted

o Examine the spine for abnormalities on the

During a forward sway in which the displacement in CoG is big enough lordosis or kyphosis – cervical lordosis, thoracic
for the ankle strategy to handle, the paraspinals contract first. True or kyphosis, lumbar lordosis
False?
o Pelvic level: Check the angle between the PSIS
False. and ASIS (15 deg normal)

It is the abdominals that should contract first given that we are talking o Check if knees are hyperextended
about a hip strategy here.
- Frontal (Posterior):
Remember that in ankle strategy, the muscle opposite the direction o Check if head is rotating or leaning to one side
of the displacement (e.g. forward sway - gastrocs → hams → o While examining spine, look for lateral shifts that
paraspinals, which are all posterior muscles) should contract to may be indicative of scoliosis
counter the force in a distal to proximal direction of contraction. o Posterior reference points:
▪ Both acromion
In hip strategy, it is the opposite. The muscle on the same side as ▪ Scapular spines
the direction of the displacement (e.g forward sway - abs → quads ▪ Both inferior angle of scapula
→ tibialis anterior) should contract in a proximal to distal direction o Check how far away the medial borders of the
to prevent further displacement of the CoG. shoulder blade are at the spine

o Compare both Iliac Crests and check the PSIS.

OBSERVATION AND POSTURAL ANALYSIS The gluteal fold can also be used as a reference
point
o Identify valgus or varus positioning just like in the
Summary (from Physiotutors) frontal (anterior) plane
- Requires observation of key landmarks in the body o Compare both medial malleoli
o Depending on the number of toes that you can see
- Patient should be exposed (wearing less clothing) in the achilles tendon, one leg can be rotated more
o Take of shirt, wear shorts and remove shoes than the other.

- Advise the pt to stand upright, relax the shoulders and have Note: Not everything considered abnormal can be pathological
arms hang naturally beside the body
- Frontal (Anterior): STATIC POSTURE ASSESSMENT (iBody Academy)
o Line from tip of the nose running to the middle of
chin and the manubrium of the sternum
4 angles are used:
o Head can be rotated or leaning to one side
1. Anterior
2. Posterior
o Compare the level of the shoulders
3. Left Lateral
o Assess the angle of both clavicle
4. Right Lateral
o See if nipples are at the same height (disregarded
in female pt)
Notes for pt:
- Align the feet. Reduces the mistake of diagnosis
o Compare both iliac crests with ASIS as another
- Start from the bottom up to the head of the neck area.
landmark
o Compare spacing between trunk and arms
Posterior View
o Arm length can be examined by comparing the
1. Achilles Tendon Position: must be exactly straight in the
level of fingertips of both hands
middle of the foot
- Outward Achilles tendon – flat foot
o Check if patellas are leveled and if they are at an
2. Knee Position
outward varus position or an inward valgus
- Knees close – Valgus position
position
- Knees far – Varus position
o Check the level of both medial malleoli
3. Hip position – check if there is tilting by locating the highest
point of the ilium and comparing both sides
- Sagittal:

© Shamerry Adato – BSPT 2023

 4. Spine Position – spinous process must be exactly in a
straight line. Curves are indicative of scoliosis
- C-curve and S-shape scoliosis
- You may need to ask the client to bend over to
check for scolio – extra hump = c-curve, switching
hump = s-shape
5. Shoulder position – check if one shoulder is higher or lower,
abnormalities can be related to scoliosis, the neck area or
the cervical area
- Right-handed pt – right shoulder is a bit lower than
the left shoulder and vice versa (left handedness)
6. Neck position
- Check for tilting to the right or left by looking at the
lowest point of the earlobes (don’t focus on the
head itself) and comparing each side
- Rotation of the neck: Focus on the mandible – how
much of the chin is visible compared to the other
side?
Anterior View
1. Toe position: Both toes must be a bit outward by 10 to 25
deg
- Both needs evaluation due to possible
abnormalities of the ankles, knee or the hip
position
i. Toe in position
ii. Toe out position
2. Position of Patella – both patellas must be at the same level
and should face center to the anterior side
- Inward or outward rotation of the patella indicates
rotation of leg respectively or a tightness of thigh
muscles on one side of the patella
3. Arm position
- Check the distance of the arm from the body,
abnormal distance may indicate tightness of arm
muscles
- Check amount of rotation of both arms. Inward or
outward rotation of arms could indicate elbow or
(more commonly) shoulder abnormalities
(tightness = IR, weakness = ER)
• Check if hip is rotated forward or backward. Line
must be at the center of hip
i. Hip Rotated Forward (Anterior Tilt): line
is at the back
ii. Hip Rotated Backward (Posterior Tilt):
line is closer to the anterior point of the
hip
iii. Two landmarks are evaluated: PSIS and
the ASIS – an imaginary line between
them with an angle compared to the
horizontal line
iv. Males: 0 to 5 degrees forward
1. Less than 0 indicates
posterior rotation of the hip
v. Female: 5 to 10 degrees forward
4. Acromion
• Shoulder forwarded – anterior muscles are tight,
back muscles are weak (vice versa)
• Check each side of the shoulders
INDEPENDENTLY
5. Ear canal (External Auditory Meatus)
- Forwarded Cervical Posture – bending of the neck
(like when looking at our phones)
Spine
- Note the four natural curves of the vertebral
column.
- Lordosis: turn forward (Cervical and Lumbar)
- Kyphosis: turn backward (Thoracic and Sacral)
- Hyperkyphosis – abnormality, extra hump in the
back
- Hyperlordosis extra front curve
- Hypolordosis or alordosis = no curve, flat back
Anterior pelvic tilt – hyperlordosis
Posterior Pelvic tilt – hypolordosis

Lateral View
Check from both the left and the right. Sometimes there is difference
from the two sides.

Landmarks to consider:

1. Lateral Malleolus – starting from anterior to this structure,

trace if the line of the body is aligned to the top
- Plum Line: Compare points together with a thread
2. Knee (Middle) – Line should pass to here
• Knee forwarded position – flexed knee position,
forwarded compared to the line = tightness in the
hamstring area
• Line sitting anterior to the knee, patella is back to
the line = knee is hyperextended
i. Indication of the QF muscles
ii. Happens when standing for a long time
3. Center of the hip (Ilium)
• COG is here

© Shamerry Adato – BSPT 2023