0196-6011/86/0801-0034$02.

00/0
THEJOURNAL OF ORTHOPAED~C AND SPORTS PHYSICAL THERAPY
Copyright O 1986 by The Orthopaedic and Sports Physical Therapy Sections of the
American Physical Therapy Association

Suggestions from the Clinic

A New Musculoskeletal Assessment in a Student
Population
KEVIN P. SINGER, DipPE, NZRP*

A common finding in repetition activities (typing, running, swimming . . .), are overuse
syndromes arising from a mechanical imbalance affecting overstressed soft tissues
and joints. A more subtle corollary, occasioned by a sedentary life-style, is an
imbalance between postural and phasic muscle groups leading to joint dysfunction.
Postural and phasic muscles as defined by V Janda (New Zealand Manip Ther Assoc
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Tech Newsletter 2: 1-3, 1977) interplay in complex patterns which determine

strength and coordination for normal function. Joint pathology, and central or
peripheral nervous system impairment, all lead to compensatory changes in the
muscle function, namely the tendency for postural muscles to become tight and for
phasic muscles to weaken. Faulty posture through muscle imbalance compromises
joint mechanics predisposing to dysfunction. Appropriate management of
Copyright © 1986 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

musculoskeletal disorders should recognize the role of imbalance between postural

and phasic muscles in both the etiology and sequelae of the disorder. A
musculoskeletal examination of 35 students was undertaken to develop assessment
skills, devise a recording form, and refine a test sequence to assist data collection.
The principal finding of tightness in postural muscles is consistent with the theory
that these muscles undergo adaptive shortening. This survey provided the
opportunity to examine the incidence of muscle imbalance in a young adult
population and to prepare guidelines for future study.
Journal of Orthopaedic & Sports Physical Therapy®

The concept of "functional pathology of the
motor system" has been adopted by Jandal' to
address the emphasis on joint lesions within the
continuum of musculoskeletal disorders. Janda, a
specialist in neurology and rehabilitation medicine
(Prague), is noted for investigations into "postural"
and "phasic" muscle function. This distinction by
Janda into two functional muscle systems was
developed from electromyographic studies and
years of clinical experience, evolving a philosophy
on "muscle imbalance" integral to many joint dis-
orders. Postural muscles, those mainly responsi-
ble for maintenance of the typical upright posture,
show a tendency to become tight, whereas mus-
cles with a predominantly phasic role tend to
~eaken.'~.'~
Sedentary life-style patterns are implicated by
Janda to favor the postural muscles relative to
phasic muscles, leading to an imbalance between
'Department of Human Movement Studies, University of Western
Australia. Nedlands, WA 6009, Australia.
the two groups.12 This tendency may be progres-
sive, predisposing to inefficient posture. Janda
suggests that low back disorders provide exam-
ples of this imbalance, where tightness of the hip
flexors and lumbar erector muscles may inhibit
gluteal and abdominal muscles to compromise
lumbar spine mechanics, encouraging spinal dys-
function. Gait may also be compromised due to
limitation of hip extension in stance phase, with
symptoms focusing in the lower back. A similar
pattern may develop in the cervical region with
tight sternocleidomastoids, pectorals, and scap-
ular protractors producing a forward inclination of
the head and shoulders, with mechanical stress
affecting the cervicothoracic and craniovertebral
joints.'* Janda proposes that postural muscle
"tightness" and phasic muscle "inhibition" should
be assessed during musculoskeletal examina-
tions and that a treatment rationale include appro-
priate mobilization therapies along with improving
muscle extensibility of "tight" postural muscles
and facilitating "weakened" phasic
 JOSPT July 1986 MUSCULOSKELETAL ASSESSMENT
Muscle shortening may be due to disuse, paresis,
contracture, spasticity, spasm or postural faults.
However, it is this latter disorder which Janda
considers as a focus for muscle dysfunction. Eval-
uation of muscles commonly associated with
shortening requires consistency in choice of start-
ing position, fixation, and controlled movements
to elicit an accurate assessment of muscle exten-
sibility. Discrimination between shortened, tight
musculature and joint restriction due to patholog-
ical changes, requires sensitivity to the expected
average "normal" motion and careful technique.13
This paper presents the findings from a muscu-
loskeletal examination of 35 Physiotherapy stu-
dents, following an 18 month part-time study pro-
gram on the concept of muscle imbalance.
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METHODOLOGY
Instructional Course
The evaluation of muscle imbalance described
by Janda"~'~and reviewed by Buswell,' included
Copyright © 1986 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
both spinal and peripheral joint assessment tech-
niques. It is beyond the scope of this paper to
adequately describe the complete muscle function
test methodology; interested readers are directed
to the recent translation of Janda's work for a
comprehensivediscussion.13
Study Organization
Preliminary study reviewed assessment tech-
Journal of Orthopaedic & Sports Physical Therapy®
niques to develop and evaluate competence be-
fore the survey was initiated. A basic classification
scale (Table 1) was adopted to record muscle
weakness, tightness, and joint restriction data.
The scales are adopted from Maitland" and
Janda;13 the normal expected range of motion
was subjectively evaluated according to the as-
sessment tests described by H~ppenfield.~ Nor-
mal posture has been "idealized" as symmetrical
balance between body parts, with equal weight
distribution between the lower limbs; this concept
was used in the subjective assessment of static
posture. lnterrater reliability was assessed for
agreement during preliminary testing by the six
participants in the program and to improve con-
sistency, the assessment was divided into three
discrete sections: upper limb and neck, trunk, and
lower limb, with two examiners concentrating on
each of these areas.
Data Recording
Several draft recording forms were prepared
with the most recent presented in Figures 1 and
35
TABLE 1
Description of recording scales for muscle weakness,
tightness, and joint range tests
Muscle weakness
0 Normal muscle function
- Moderate; correspondingto Grade Illt3(p 2)
= Gross; corresponding to Grade II
Muscle tightness
0 Normal muscle function
+ Moderate limitation in expected range, with asym-
metry compared to contralateral side13(p 225).
++ Gross; where muscle tension limits the outer range of
normal motion
Joint range
0 Normal joint excursion, range complete, no pain
I Restriction to anatomical range" (p 30)
II Pathological restriction to range, with pain
! Joint pain
(--) Joint hypermobility
2. These sheets accommodated subject details:
age, sex, relevant injury history, and anthropo-
metric assessment. Observational data were de-
picted on the body outline to highlight any asym-
metry and to note queries for more detailed as-
sessment later in the examination. Muscle func-
tion tests were evaluated, recording presenting
weakness or t i g h t n e s ~ ~ (Table
~ ~ ' 1).
~ ~Joint
' ~ func-
tion was assessed with active and accessory
(passive) motion tests as described in manual
therapy t e x t ~ . ~ , ~ Restriction
.'~-'~ was noted ac-
cording to the range of motion tests and end
"feel." Peripheral and spinal joint problems were
further highlighted on the appropriate articular
diagrams for more detailed follow-up. Spinal mo-
tion ranges were depicted on the line graphs, with
active and passive ranges contrasted. Hip exten-
sor firing patterns were included in the test series
to examine the recruitment order for hamstring,
gluteal, and paravertebral muscles. In those indi-
viduals where the gluteals are inhibited (weak),
earlier activation of the hamstring and paraverte-
bra1 muscles result to stabilize the spine on the
pelvis.I2This test requires unilateral hip extension
performed with the subject lying prone, noting the
recruitment pattern by observation and palpation.
Confirmation of weakness is considered with bi-
lateral hip extension, where speed of movement,
symmetry, and end position are compared.13
Assessment Sequence
The sequential order for the assessment (Fig.
3) was coordinated to permit transition from gait
assessment, observation of static posture, to ac-
 SINGER JOSPT Vol. 8, No. 1
N A Y E: DATE: : :I0 .

ACE: P R S l D.0.R: : :I n . SEX: [ M I / [ F l OCCUPATION:

SPORE. RECREAnON:

PAST IIISTQR Y or INJUR Y:

PHYSOUE: [Mw~[ fhf01f L [Ecblf 1 DOMINANT I I A N D [ R I / [ L L DOMINANT FOOT [ R ] / L

[J.
HUCIIT: [cmL WUCHT: [Kg1 LEC LENCTII: fcmal [ L I [ c m ? -
Downloaded from www.jospt.org at on April 18, 2020. For personal use only. No other uses without permission.
Copyright © 1986 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

[KEY: l l C H T : [ M o d e m ~ e t, C m tc W E A K : [ Modemta - , C r a a --J, INCREASED SHAPE: [fW. PA'IN: [!I]

I LI POSTURAL MUSCLE [R] [L] PHASIC MUSCLE IRI

I SCALENI I
PECTORAUS MAJOR SERRATUS A n v
Journal of Orthopaedic & Sports Physical Therapy®

R HOMBOIDS
TRAPEZIUS [LowerJ

RECTUS ABDOMINUS

ERECTOR SPINAE [IlJ I OBUQUE ABDOMINUS I

ERECTQR SPINAE @urn]

muus
CASTROCNEMIUS PERONEn

RECTUS FEYORIS VASrUS M E D I A U S

HAYSTRINCS

ADDUCTORS[I I t ] CLUTEUS MAXIMUS

I U O PSOAS CLUTEUS MEDIUS

PIRIFORMIS CLUTEUS MINIMUS

UUSCLE DYSFUNCTION: JOINT DYSFUNCTION:

1
Fig. 1. Musculoskeletalassessment data recording form.
 SINGER JOSPT Vol. 8,No. I

OBSERVATIONS: ACTIVE TESTS: ACCESSORY TESTS:

GAIT :
S A N D TEST3 On bZS. h e 4
feet Irrvsrted, everted.
STAT l C POSTURE (Postedor)
heel alignment
achilles tendons
calf h r l k Solsur / G a r t m c n e m h u test
papliteal creases
odductor assymmetry
gluteal folds
pelvic levels (PSIS) lkndelcnbcrg tart
spinal alignment
-erector spinae W a l motlm. P/E. Side F, Rotntlon
-Quadmfw lumbamm
s c a p l a e asymmetry
tmpeziw
STATIC POSTURE (Antedor)
feet asymmetries
calf shape
potellae
quadricem buUc sfpat test
pelvic levels (ASIS)
u m b i l i c w - (abdomlnals)
v a i s t shape
-
nipple levels (pectomls)
sternum, SC, A C joints
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trapezius - (upper fibres)

sternocleidomastoids
head posture
a r m cam'age
STATIC POSTURE (LatemfJ
assess feet arches
-
lolee posltion (recurvotum)
Copyright © 1986 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

i l i o tibtal t m c t
spinal curves
shoulder position
head posture

SITTING
- review spinal posture i s
- assess U m m c i c W s
- upper l i m b posture
Neck m o t f o n c F/E, Side F, R o t n t i o n
Note respiratory e x c u n l o m of rib-cage 'Ihomcic m t n t i o n test
A r m motion tests:
Full mnge tests a l l joints
Apley s c m t c h tests (Shoulder) c
Abduction f i r i n g pattern s y m m e t r y

SITTING AT EDGE OF PLINTH

%mas tcsts' for:
I l i o psoas, rectus femoris, i l i o t i b ~ a lt r a c t
Journal of Orthopaedic & Sports Physical Therapy®

Hamstring f l e x i b i l i t y test

LYING SUPINE
measure leg length
abdominals and obliques
Ohserve w i t h lolees flexed t o 90°
L o v e r limb motion tests. A l l joints
S t a t i c s i t - u p test (20 second hold)
L o v e r l i m b accessory tests
Shoulder protraction test (Rhomboids)
Pectorals, Sternocleidomastoid,
Levator S c o p l a e , trapezius t~ghtness
Upper l l m b accessory tests

LYING PRONE
Soleus / Castmcnemius test
H i p extensor f i r i n g pattern
Shoulder girtile r e t m c t i o n
Socro iliac joint P-A sprlngtng
Spinous process P - A springing
(Lumbar & Thoracic spines)

SIDE LYING
Lumbar A-P glides, flexion gapping,
side glides.

ADDITIONAL TESTS:

Fig. 3. Sequential order for the musculoskeletal examination noting starting positions with appropriate observations, active then
accessory tests. Inset figures used to highlight specific aspects of assessment.

tive then accessory tests, i.e., all standing as- sented in Table 2. The majority of these students
- and Iving.
sessments before those in sitting - - participated reaularlv in sport and recreational
activities. No history-of seious illness or injuries
Subjects and Analysis were recorded and all subiects consented to the
Thirty-five Physiotherapy students were exam- assessment. The studenis were requested to
ined and normative data for this group is pre- bring swim attire for the study and a warm, well
 JOSPT July 1986 MUSCULOSKELETAL ASSESSMENT
TABLE 2 TABLE 3
Normative data for 35 students presenting for a Summary of joint restriction data recorded from the
musculoskeletal exarnination accessory motion tests on 35 students during a
musculoskeletal examination*
Number of students in survey
Males
Females
35
17
18
Extension Flexion zz:n Rotation

Age range (years) 18-35 Spinal joints

Age mean (years) 22.5 Cervical spine 2 0 5 7
Thoracic spine 0 0 1 7
Lumbar spine 8 15 3 3
lit room away from distraction was utilized
throughout. The summary findings from each as- Incidence of moderate joint restrictions
sessment were discussed with each participant
and appropriate home stretching exercises rec- Peripheral joints
ommended where indicated.'' The incidence of Ankle, subtalar, feet
Knee
muscle tightness and joint disorders was studied Hip
from the collected data and the most consistent Sacroiliac
findings presented here. A review of the literature Hand
failed to reveal other studies of this nature, there- Wrist
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Elbow
fore no comparative analysis could be considered.
Shoulder

RESULTS 'These data do not distinguish between dominant limbs. The

subjects were right handed 5.1.
Posture
Copyright © 1986 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

One-third of this student group presented with TABLE 4

Summary of muscle dysfunction data recorded during a
correctable postural asymmetries, consisting of musculoskeletalexarnination of 35 students*
increased lumbar/cervical lordosis and/or thoracic
Postural muscles Phasic muscles
kyphosis. Additionally, nine subjects presented
Sternocleidomastoid Scaleni
with a postuial scoliosis in the thoracolumbar
Pectoralis major Serratus anterior
region. Leg length inequalities (>1 cm) were re- Levator scapulae Rhomboids
corded in the majority of these cases. Scapular Trapezius (upper) Trapezius (lower)
position asymmetries and shoulder-neck profiles Quadratus lumborum Lattisimus dorsi
were generally suggestive of "handedness," with Erector spinae Abdominals
Journal of Orthopaedic & Sports Physical Therapy®

tighter postural muscles on the dominant side.
Joint Restriction
Two-thirds of this sample presented with bio-
mechanical compensations in the feet (according
to the concept of "neutral" alignment)lgthe major-
ity with either flattening of the longitudinal arches
associated with hindfoot pronation, or limitation
of joint mobility in the forefoot region. Accessory
spinal motion tests6.18(Table 3) indicated a mod-
erate reduction of lumbar flexion in one-third of
the sample, consistent with active tests where
limitation in trunk and hip flexion was also demon-
stated, as measured by the distance of fingertips
to the floor.5 This test may reflect tightness in the
spinal erector muscles and hamstrings, in addition
to possible hip or spinal joint limitation (Table 4).
Muscle Dysfunction
Postural muscle tightness in the sternocleido-
mastoid, upper fibers of trapezius and levator
lliopsoas Gluteals
Rectus femoris Vastus medialis
Tensor fascia lata
Hamstrings
Adductors
Soleus Tibialis anterior
Gastrocnemius Peroneii
Tibialis posterior
These incidence figures reflect individual students and do not
discriminate left from right side.
scapulae was demonstrable in over half of this
sample and the majority of this number exhibited
tightness in pectoralis major, presenting with for-
ward inclination of the head and shoulders com-
pared to the normal weightbearing posture.* The
lumbar erector spinae muscles were tight in three-
quarters of those assessed, with over half of this
group exhibiting tight iliopsoas and hamstring
muscles. The consistent finding in the majority of
this student group was moderate tightness in
those muscles supporting the upright posture:
soleus, hamstring, iliopsoas, quadratus lum-
 IGER
borum, and the erector spinae muscles of the
thoracolumbar region (Table 4).
DISCUSSION AND CONCLUSIONS
No articular or muscle pathologies were evident
on examination of 35 young adults and no gross
muscle weakness, tightness, or joint restrictions
recorded. Due to the diversity of subject back-
ground (life-style, sport . . .) no association be-
tween activity and muscle imbalance could be
determined. The majority of these students pre-
sented with tightness in postural muscles, pre-
dominantly those maintaining the locomotor pos-
ture, to correlate with the concept that these
muscles adaptively shorten and become tight.14
Those students showing the most accentuated
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lumbar lordosis and reduced range of active flex-
ion, exhibited corresponding tightness in ilio-
psoas, hamstrings, with weakened abdominal and
gluteal musculature.This pattern of compensation
due to muscle imbalance is implicated by Janda
Copyright © 1986 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
in back pain disorder^."^'^ The postural scoliosis
in the thoracolumbar spine, seen in one-fifth of
the sample, was attributable to leg length differ-
ences. This type of compensation may be a factor
in low back pain5 resulting from acute derange-
ment which may incriminate an intervertebral disc
pr~blem,'~ from local spasm in iliopsoas,' or due
to a structural s c o l i o ~ i s However,
.~~ no student
described low back pain at the time of the as-
Journal of Orthopaedic & Sports Physical Therapy®
sessment although previous episodes were indi-
cated in many histories. The pattern of tight scap-
ular elevators and shoulder girdle protractors with
inhibited scapular retractors, confirmed the imbal-
ance trend which Janda12attributes to cervicotho-
racic and craniovertebral joint disorders. No stu-
dent presented with neck problems; range of mo-
tion tests were pain free. The marked incidence
of functional mechanical compensations recorded
from examination of ankle, subtalar joints, and
feet is not understood as no emphasis was di-
rected to this section of the assessment. The
incidence of postural muscle tightness in an oth-
erwise healthy young adult population may reflect
the subjective nature of the test procedures and
the difficulty in establishing normative criteria from
clinical impressions. However, from these obser-
vations it may be suggested that unless general
activities encourage complete joint range mobility
and stretches for the commonly shortened pos-
tural muscles, then tightening of these muscles
may develop with the possibility of associated
joint dysfunction. Inherent in such conjecture is
JOSPT Vol. 8,No. 1
the need for careful studies on specific popula-
tions to follow trends of muscle tightness in the
commonly affected groups.
The test sequence presented, facilitated obser-
vation, active and accessory joint examinations in
an ordered way to avoid unnecessary changes in
starting positions. This further encouraged effi-
ciency during the tests and was a practical
method of evaluating the musculoskeletal system
in a student population. The data recording form
accommodated all the main findings from the as-
sessment, providing quick inspection of important
details when discussing the evaluation with each
individual.
Future study in this area would help to deter-
mine whether adaptive changes in the musculo-
skeletal system relate to life-style, Sporting or
recreational influences in specific groups. A cross-
sectional study may help to assess the onset of
postural muscle imbalance and changes in these
patterns for age/sex groups. Longitudinal studies
would be important to support cross-sectional
trends. The relationship between muscle dysfunc-
tion and low back pain is worthy of further inves-
tigation, as is the role of prophylactic stretching
advice in the management of these disorders. The
contention by Janda that subtle alteration in mus-
cle balance occurs at cost to the articular system
has a basis for continued investigation in normal
and patient populations.
Appreciation is extended to Mrs. Jean Buswell NZRP, MNZMTA,
for instruction and encouragement in this study, along with Graeme
Shaw. Celia Tan, Colin Tutchen. Kathy Vause, and Gill Webb for their
involvement and cooperation. I am particularly grateful to Drs. Jim
Taylor and Lance Twomey of the Departments of Anatomy (UWA) and
Physiotherapy (WAIT), for careful and considered comments on the
development of this paper.
REFERENCES
1. Buswell J: Normal Muscle Dysfunction:Teaching notes. Auckland:
AT1 Physiotherapy Department, 1980
2. Buswell J: Assessment and management of common postural
faults. Patient Management 8:29-46, 1984
3. Cyriax J: Textbook of Orthopaedic Medicine, Ed 7, Vol 1. London:
Bailliere Tindall. 1978
4. Daniels L, Worthingham C: Muscle Function Testing: Techniques
for Manual Examination, Ed 3. Philadelphia: WB Saunders Co.
1972
5. Giles LGF, Taylor JR: Low back pain associated with leg length
inequality. Spine 6:510-521, 1981
6. Grieve GP: Common VertebralJoint Problems. Edinburgh: Church-
ill Livingstone, 1981
7. Grieve GP: Treating backache-a topical comment. Physiotherapy
69:316, 1983
8. Hoppenfield S: Physical Examination of the Spine and Extremities.
New York: Appleton Century Crofts, 1976
9. Hoppenfield S: Orthopaedic Neurology: A Diagnostic Guide to
Neurologic Levels. Philadelphia: Appleton Century Crofts, 1977
Downloaded from www.jospt.org at on April 18, 2020. For personal use only. No other uses without permission.

JOSPT July 1986 MUSCULOSKELETAL ASSESSMENT 41

10. Janda V: The technique of therapy of postural and phasic muscles. 16. McKenzie RA: The Lumbar Spine: Mechanical Diagnosis and Ther-
Copyright © 1986 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

New Zealand Manip Ther Assoc Tech Newsletter. 2:l-3,1977
11. Janda V: Muscles, central nervous regulation and back problems.
In: Korr IM (ed), The Neurologic Mechanisms in Manipuative Ther-
apy, pp 27-41. New York: Plenum Press, 1978
12. Janda V: Muscles as a pathologic factor in back pain. In: Buswell
J, Gibson-Smith M (eds), Proceedings of the International Federa-
tion of Manipulative Therapists, Christchurch. New Zealand, Feb-
ruary 1980. pp 1-24. Auckland: York Pelorus. 1982
13. Janda V: Muscle FunctionTesting. London: Butterworths, 1983
14. Janda V: On the concept of postural muscles and posture in man.
Aust J Physiother 29:83-85, 1983
15. Kaltenborn FM: Mobilisation of the Extremity Joints: Examination
Journal of Orthopaedic & Sports Physical Therapy®
apy. Waikanae: Spinal Publications, 1981
17. MaitlandGD: Peripheral Manipulation, Ed 2. London: Butterworths,
1977
18. Maitland GD: Vertebral Manipulation, Ed 4. London: Butterworths,
1979
19. Subotnick SI: Pediatric Sports Medicine. Mountain View, CA: Fu-
tura Publ, 1977
20. Taylor JR: Scoliosis and growth: Patterns of asymmetry in normal
vertebral growth. Acta Orthop Scand 54:596-602, 1983

and Basic Treatment Techniques, Ed 3. Oslo: Olaf Norlis Obkhan-

del, Universitetsgaten, 1980
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Copyright © 1986 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Journal of Orthopaedic & Sports Physical Therapy®