4.

Lumbar vertebrae:
Plumb Line: The line falls midway between the abdomen and back and slightly
anterior to the sacroiliac Joint. Common faults include:
* Lordosis: Hyperextension of lumbar vertebrae. It may be due to:
- Anterior pelvic tilt. - Compressed vertebrae posteriorly.
- Stretched anterior longitudinal ligament and lower abdominal muscles.
- Tightness of posterior longitudinal ligaments, lower back extensor and hip
flexor muscles.
* Sway back: Flattening of the lumbar vertebrae (the pelvis is displaced
forward). It may be due to:
- Thoracic kyphosis. - Posterior pelvic tilt. - Stretched anterior hip ligaments-
hips hyperextended. - Compression of vertebrae posteriorly.
- Stretched posterior longitudinal ligaments, back extensors and hip flexors.
* Flat back: Flattening of the lumbar vertebrae. It may be due to:
- Posterior pelvic tilt. - Tightness of the hamstring muscles. - Weakness of the
hip flexor muscles. - Stretched posterior longitudinal ligaments.
5. Pelvis and hip:
Plumb Line: The line falls slightly anterior to the sacroiliac joint and posterior
to the hip joint, through the greater trochanter, creating an extension moment.
Common faults include:
* Anterior pelvic tilt. The anterior superior iliac spines lie anterior to the pubic
symphysis. It may be due to:
- Increased lumbar Lordosis and thoracic Kyphosis. - Compression of vertebrae
posteriorly. - Stretched abdominal muscles, sacro-tuberous, sacroiliac and
sacro-spinous ligaments. - Tightness of hip flexors.
* Posterior pelvic tilt. The symphysis pubis lies anterior to the anterior superior
iliac spines. It may be due to:
- Sway back with thoracic kyphosis. - Compression of vertebrae
anteriorly.
- Stretched hip flexors, lower abdominal muscles and joint capsule.
- Tightness of hamstring muscles.
 Figure 15. Anterior and posterior pelvic tilt.
6. Knee:
Plumb line: The line passes slightly anterior to the midline of the knee, creating
an extension moment. Common faults include:
* Genu recurvatum: Knee is hyperextended and the gravitational stresses lie far
forward of the joint axis (fig16). It may be due to:
- Tightness of quadriceps, gastrocnemius and soleus muscles. - Stretched
popliteus and hamstring muscles at the knee. - Compression forces anteriorly.
- Shape of tibial plateau.
* Flexed knee: The plumb line falls posterior to the joint axis (fig 17). It may be
due to: - Tightness of and hamstring muscles at the knee. - Stretched quadriceps
and tight gastrocnemius muscles. - Posterior compression forces. - Bony and
soft tissue limitations.
Figure 16. Genu recurvatum knee Figure 17. Flexed knee

7. Ankle:
Plumb line: The line lies slightly anterior to the lateral malleolus, aligned with
tuberosity of 5th metatarsal. Common faults include:
* Forward posture: The plumb line is posterior to the body; body weight is
carried on the metatarsal heads of the feet. It may be due to:
- Ankles in dorsiflexion with forward inclination of the legs; posterior
musculature stretched. - Tightness of dorsal musculature.
- Posterior muscles of the trunk remain contracted.
b) Posterior view
In a posterior view examination, the examiner’s plumb line divides the body
into equal left and right halves.
1. Head and neck:
Plumb line: The midline bisects the head through the external occipital
protuberance; head is usually positioned squarely over the shoulders so that
eyes remain level. Common faults include:
* Head tilt: Subject’s head lies more to one side of the plumb line. It may be
due to:- Tightness of lateral neck flexors on one side. - Stretched lateral neck
flexors contra-laterally. - Compression of vertebrae ipsi-laterally.
* Head rotated: The plumb line is to the right or left of the midline. It may be
due to: - Tightness of the sternocleidomastoid, upper trapezius, scalene and
intrinsic rotator muscles on one side. - Elongated contralateral rotator muscles.
- Compression and rotation of the vertebrae.
2. Shoulder and scapula:
Plumb line: It falls midway between shoulders. Common faults include:
* Dropped shoulder: One shoulder is lower than the other. It may be due to:
- Hand dominance (dominant shoulder is lower).
- Lateral trunk muscles are short and hip is high and adducted.
- Tightness of the rhomboid and latissimus dorsi muscles.
* Elevated shoulder: One shoulder is higher than the other. This may be due to:
- Tightness in the upper trapezius and levator scapulae muscles on one side;
hypertrophy may be noticed on the dominant side.
- Elongated and weak lower trapezius and pectoralis minor.
- Scoliosis of the thoracic vertebrae.
* Shoulder medial rotation: The medial epicondyle of the humerus is directed
posteriorly. It may be due to:
- Joint limitation in lateral rotation. - Tightness of the medial rotator muscles.
* Shoulder lateral rotation: Olecranon process faces posteriorly. It may be due
to: - Joint limitation in medial rotation. - Tightness of the lateral rotators.
* Adducted scapulae: The scapulae are too close to the midline of the thoracic
vertebrae. It may be due to:
- Shortened rhomboid muscles. - Stretched pectoralis major and minor muscles.
* Abducted scapulae: The scapulae have moved away from the midline of the
thoracic vertebrae. It may be due to:
- Tightness of the serratus anterior muscle. - Lengthened rhomboid and middle
trapezius muscles.

Figure 18. Shoulder and scapulae.

* Winging of the scapulae: The medial borders of the scapulae lift off ribs. It
may be due to: - Weakness of the serratus anterior.

Figure 19. Winging of the scapulae

3. Trunk:
Plumb Line: The line bisects the spinous process of the thoracic and lumbar
vertebrae. Common faults include:
* Lateral deviation (Scoliosis): The spinous processes of the vertebrae are
lateral to the midline of the trunk.
- Intrinsic trunk muscles are shortened on one side.
- Contralateral intrinsic trunk muscles are lengthened.
- Compression of vertebrae on the concave side.
- Structural changes in rips or vertebrae.
- Leg-length discrepancy and obliquity.
- Internal organ disorders.
4. Pelvis and Hip:
Plumb line: The line bisects the gluteal cleft and the posterior superior iliac
spines are on the same horizontal plane; the iliac crests, gluteal folds and greater
trochanters are level. Common faults include:
* Lateral pelvic tilt: One side of the pelvis is higher than the other due to:
- Scoliosis with ipsilateral lumbar convexity. - Leg-length discrepancies.
- Shortening of the contralateral quadrates lumborum.
- Tight ipsi-lateral hip abductor muscles on the same side and tight contralateral
hip adductor muscles. - Weakness of the contralateral abductor muscles.
* Pelvic rotation: The plumb line falls to the right or left of the gluteal cleft. It
may be due to:
- Tightness of medial rotator and hip flexor muscles on the rotated side.
- Ipsilateral lumbar rotation.

Figure 20. Lateral pelvic tilt.

 Abducted hip: The greater trochanter is higher on the involved side. It may
be due to:
- Tightness of the hip abductor muscles. - Tightness of contralateral hip
adductor muscles. - Weakness of contralateral adductors and ipsilateral
abductors.
5. Knee:
Plumb Line: The plumb line lies, equidistant between the knees. Common faults
include:
 Genu varum: The distal segment (leg) deviates toward midline in relation to
the proximal segment (thigh); the knee joint lies lateral to the mechanical axis
of the lower limb. It may be due to:
- Tightness of medial rotator muscles at the hip with hyper-extended knees,
quadriceps and foot evertor muscles. - Compression of medial joint structures.
- Femoral retroversion. - Elongated lateral hip rotator muscles, popliteus and
tibialis posterior.
 Figure 21. Bow leg and knock knee.
 Genu Valgum: The mechanical axis for the lower limbs is displaced laterally.
It may be due to:
- Tightness of ilio-tibial band and the lateral knee joint structures.
- Femoral ante-version. - Lengthened medial knee joint structures. -
Compression of lateral knee joint. - Foot pronation.
6. Ankle and Foot:
Plumb line: The line is equidistant from the
malleoli, a line (Feiss’) is drawn from the medial
malleolus to the first metatarsal bone and the
tuberosity of the navicular bone lies on the line.
Common faults include:
 Pes planus (Pronated): There is decreased
medial longitudinal arch, the Achilles tendon is
convex medially and the tuberosity of the
navicular bone lies below the Feiss line. It may be
due to:
- Shortened perennial muscles. - Elongated
posterior tibial muscle. - Stretched plantar
calcaneo-navicular (spring) ligament. - Structural
displacement of the talus, calcaneus and navicular
bones.
 Pes Cavus (supinated): The medial
longitudinal arch is high and the navicular bone
lies above Feiss’ line. It may be due to: Shortened
posterior and anterior tibial muscles. Elongated
peroneal and lateral ligaments.

Figure 22. Pes cavus and pes planus deformity.

 c) Anterior View
Relationships can be posturally assessed from the anterior view with the
plumb line bisecting the body into equal left and right halves.
1. Head and Neck:
Plume Line: The line bisects the head at the midline into equal halves. Common
faults include:
 Lateral Tilt: See section on posterior view.
 Rotation: See section on posterior view.
 Mandibular asymmetry: The upper and lower teeth are not aligned and the
mandible is deviated to one side. It may be due to: - Tightness of the
mastication muscles on one side. - Stretched mastication muscles on the
contralateral side.
- Mal-alignment of temporo-mandibular joints. - Mal-alignment of teeth.
2. Shoulders:
Plumb Line: A vertical line bisects the sternum and xiphoid process. It may be
due to:
 Dropped ore elevated shoulder: See section on posterior view.
 Clavicle and joint asymmetry: It may be due to: - Prominences secondary to
joint trauma. - Subluxation or dislocation of sterno-clavicular or acromio-
clavicular joints. - Clavicular fractures.
3. Elbows:
A line bisects the upper limbs and forms an angle of 5° to 15° laterally at
the elbow with the elbow extended. This angle is normal and is referred to as
the carrying angle. Common faults include:
 Cubitus valgus: The forearm deviates laterally from the arm at angle greater
than 15° (female) and 10° (male). It may be due to: - Elbow hyperextension.
- Distal displacement of trochlea in relation to capitulum of humerus. -
Stretched ulnar collateral ligament.
 Cubitus varus: The forearm deviates medially (adducts) from the arm, at an
angle of less than 15° for females and 10° for males. It may be due to:
- Fracture about the elbow joint. - Inferior displacement of the humeral
capitulum.
- Stretched radial collateral ligament.
 Figure 23. Cubitus varus and valgus.
4. Hip:
Plumb line: Common faults include:
 Lateral rotation: The patellae angle out. It may be due to: - Tightness of the
lateral rotators and gluteus maximus muscles. - Weakness of the medial rotator
muscles. - Femoral retroversion. - Internal tibial torsion (compensated).
 Medial rotation: The patellae face inward. It may be due to: - Tightness of
the ilio-tibial band and the medial rotator muscles. - Weakness of the lateral
rotator muscles. - Femoral ante-version. - External tibial torsion (compensated).
5. Knee:
Plumb Line: The legs are equidistant from a vertical line through the body.
Common Faults include:
 External tibial torsion: Normally, the distal end of the tibia is rotated
laterally 25° from the proximal end. Excess of 25° rotation is an increase in
torsion and is referred to as lateral tibial torsion (toeing out). It may be due to: -
Tightness of the tensor fasciae latae muscle or ilio-tibial band. - Bony mal-
alignment.
- Cruciate ligament tear. - Femoral retroversion.
 Internal tibial torsion: The feet face directly forward or inward.
- Tightness of the medial hamstring and gracilis muscles. - Structural
deformities of the tibia (traumatic or developmental). - Anterior cruciate
ligament tear.
- Femoral ante-version. - Foot pronation. - Genu valgus.
6. Ankle and Foot:
Plumb line: Common Faults include:
 Hallux valgus: Lateral deviation of the first digit at the metatarso-phalangeal
joint. It may be due to: - Excessive medial bone growth of the first metatarsal
head. - Joint dislocation. - Tight adductor hallucis muscle.
- Stretched abductor hallucis muscle.
Claw toes: Hyperextension of the metatarso-phalangeal joint and flexion of the
proximal interphalangeal joints, associated with pes cavus. It may be due to:
- Tightness of the long toe flexors. - Shortness of the toe extensor muscles.
 Hammer toes: Hyperextension of the metatarsophalangeal joints and distal
interphalangeal joints and flexion of the proximal interphalangeal joints. It may
be due to:
- Shortness of the toe extensors. - Lengthened lumbricals.

Figure 24. Hallux

valgus Figure 25.
Hammer toe .

2) Sitting Posture
Hip and Pelvis:

Observation: The pelvis assumes a posterior tilt with the posterior inferior iliac
spines in the same horizontal plane as the superior pubic ramus. Common faults
include:
 Posterior pelvic tilt: The superior pubic ramus is superior to the posterior
inferior iliac spines. It may be due to:- Lumbar vertebrae flexed excessively.
- Tightness of the hamstring muscles. - Elongated low back extensors.
 Anterior pelvic tilt: The superior pubic ramus lies inferior to the posterior
inferior iliac spine. It may be due to: - Tightness of low back extensor muscles.
- Lengthened hip extensor muscles. - Excessive lumbar lordosis.

Management of Impaired Posture

Faulty posture underlies many spinal and extremity disorders. Often by simply
correcting the underlying postural stresses the primary symptoms can be
minimized or even alleviated.

General Management Guidelines

Before developing a plan of care and selecting interventions for management,

evaluate the findings from the examination of the patient, including the history,
review of systems, and specific tests and measures, and document the findings.
 Postural alignment (sitting and standing), balance, and gait
 ROM, joint mobility, and flexibility
 Muscular strength and endurance for repetitions and holding
 Ergonomic assessment if indicated
 Body mechanics
 Cardiopulmonary endurance/aerobic capacity, breathing pattern
Postural Alignment:
Proprioception and Control
Initially, good alignment may be prevented because of restricted mobility of
muscle or connective tissue or malalignment of a vertebral segment, but
developing patient awareness of balanced posture and its effects should begin as
soon as possible in the treatment program in conjunction with stretching and
muscle-training maneuvers.
Active Control of Spinal Movement
Isolate each body segment and train the patient how to move that segment. If
one region is out of alignment, it is likely that there are compensatory deviations
in the alignment throughout the spine. Therefore, total posture correction,
including lower extremity alignment, should be emphasized. Direct the patient’s
attention to the feel of proper movement and muscle contraction and relaxation.
It may be useful to have the patient assume an extreme corrected posture, then
ease away from the extreme toward mid position, and finally hold the corrected
posture. Use reinforcement techniques such as:
Verbal reinforcement. As you interact with the patient, frequently interpret the
sensations of muscle contraction and spinal positions that he or she should be
feeling.
Visual reinforcement. Use mirrors so the patient can see how he or she looks,
what it takes to assume correct alignment, and then how it feels when properly
aligned. Verbally reinforce what the patient sees.
Tactile reinforcement. Help the patient position the head and trunk in correct
alignment and touch the muscles that need to contract to move and hold the
parts in place.
Axial Extension (Cervical Retraction) to Decrease a Forward Head Posture:
Patient position and procedure: Sitting or standing, with arms relaxed at the
side. Lightly touch above the lip under the nose and ask the patient to lift the
head up and away (Fig. 26 A). Verbally reinforce the correct movement of
tucking the chin in and straightening the spine, and draw attention to the way it
feels. Have the patient move to the extreme of the correct posture and then
return to midline.
Scapular Retraction:
Patient position and procedure: Sitting or standing. For tactile and
proprioceptive cues, gently resist movement of the inferior angle of the scapulae
and ask the patient to pinch them together (retraction). Suggest that the patient
imagine “holding a quarter between the shoulder blades.”
The patient should not extend the shoulders or elevate the scapulae (Fig. 25.B).

FIGURE (25) Training the patient to correct (A) forward-head posture and (B) protracted scapulae.

Total Spinal Movement and Control

Patient position and procedure: Sitting. Instruct the patient to curl the entire
spine by first flexing the neck, then the thorax, and then the lumbar spine. Give
cues for unrolling by first touching the lumbar spine as the patient extends it,
then the thoracic spine as he or she extends it and takes in a breath to elevate the
rib cage. Then direct attention to adducting the scapulae while you gently resist
the motion
and then lifting the head in axial extension while you give slight pressure
against the upper lip (see Fig. 9). Verbally and visually reinforce the correct
posture when it is obtained.

Relationship of Impaired Posture and Pain

Have the patient assume the faulty posture and wait. When he or she begins to
feel discomfort, point out the posture and then instruct how to correct it and
notice the feeling of relief. Many patients do not accept such a simple
relationship between stresses and pain, so draw their attention to noticing what
posture they are in (including when at work, home, driving/riding in a car, or in
bed) when their symptoms develop and how they can control the discomfort
with the techniques they have been taught.
Reinforcement: It is not possible for a person always to maintain good posture.
Therefore, to reinforce proper performance, teach the patient to use cues
throughout the day to check posture.
For example, instruct the patient to check the posture every time he or she walks
past a mirror, waits at a red traffic light while driving a car, sits down for a
meal, enters a room, or begins talking with someone. Find out what daily
routines the patient has that could be used for reinforcement or reminders;
instruct the patient to practice and report the results. Provide positive feedback
as the patient becomes actively involved in the relearning process.

Postural Support : If necessary, provide external support with a postural splint

or tape to prevent the extreme posture of round shoulders and protracted
scapulae. These supports help train correct muscle functioning by acting as a
reminder for the patient to assume correct posture when he or she slouches.
Also, by preventing the position of stretch from occurring, stretch weakness can
be corrected. These devices should be used only on a temporary basis for
training so the patient does not become dependent on them.

Joint, Muscle, and Connective Tissue Mobility Impairments: Common muscle

imbalances in length and strength should be treated using ,Stretching procedures
, joint mobilization techniques , selected manual stretching and mobilization
with movement techniques .
Impaired Muscle Performance: Typically impaired posture muscles that
support the body in sustained postures succumb to the effects of gravity,
become less active, and develop stretch weakness.
Strengthening alone does not correct this problem, so any exercises must be
done in conjunction with posture training for control.
In addition, exercises for muscular endurance are necessary to prepare the
muscles to function over an extended period of time. Finally, environmental
adaptations must be made to minimize the stresses of sustained and repetitive
postures.
Body Mechanics: Muscle strengthening for safe body mechanics includes not
only strengthening specific muscles but also functional activities that prepare
the body for specific stresses that it is required to do for a particular function.

Stress Provoking Postures and Activities: Relief and Prevention : It is critical

to help the patient adapt postures and activities that are performed on a
sustained or repetitive basis at work, at home, recreationally, or socially if they
are contributing to the postural stresses and musculoskeletal disorders.
It may be necessary to use a lumbar pillow for support or to modify the work
environment (workstation) to relieve sustained stressful postures.

Stress Management/Relaxation: A component of the educational process is to

teach the individual how to relax tense muscles and relieve postural stress.
Muscle relaxation techniques can be incorporated throughout the day to relieve
postural stress, and conscious relaxation training increases patient awareness
and control over tension in the muscles.

Muscle Relaxation Techniques: Whenever discomfort develops from

maintaining a constant posture or from sustaining muscle contractions for a
period of time, active ROM in the opposite direction aids in taking stress off
supporting structures, promoting circulation, and maintaining flexibility. All
motions are performed slowly, through the full range, with the patient paying
particular attention to the feel of the muscles. Repeat each motion several times.

Cervical and Upper Thoracic Region

Patient position and procedure: Sitting with the arms resting comfortably on
the lap, or standing. Instruct the patient to:
 Bend the neck forward and backward. (Backward bending is
contraindicated with symptoms of nerve root compression.)
 Side bend the head in each direction; then rotate the head in each
direction.
  Roll the shoulders; protract, elevate, retract, and then relax the scapulae
(in a position of good posture).
 Circle the arms (shoulder circumduction). This is accomplished with the
elbows flexed or extended, using either small or large circular motions
with the arms pointing either forward or out to the side.
Both clockwise and counterclockwise motions should be performed, but
conclude the circumduction by going forward, up, around, and then back, so the
scapulae end up in a retracted position. This has the benefit of helping retrain
proper posture.

Modalities and Massage: Once acute symptoms are under control, the use of
modalities and massage are minimized or decreased so the patient learns self-
management through exercises, relaxation, and posture retraining and does not
become dependent on external applications of interventions for comfort.

Healthy Exercise Habits : It is important to integrate a progression of postural

control into all stabilization exercises, aerobic conditioning, and functional
activities. The patient is carefully observed as greater challenges to activities are
performed; and, if necessary, reminders are provided to find the neutral spinal
position and to initiate contraction of the stabilizing muscles prior to the
activity.
For example, when reaching overhead, the patient learns to contract the
abdominal muscles to maintain a neutral spine position and not allow the spine
to extend into a painful or unstable range.

This is incorporated into body mechanics, such as when going from picking up
and lifting to placing an object on a high shelf, or into sport activities when
reaching up to block or throw a ball. Once developed under your guidance,
encourage the patient to continue with a healthy lifestyle, fitness level, and body
mechanics.
References :
1. Carolyn Kinser. Lynn Allen . Therapeutic exercise foundations and
techniques, 6. ed . Davis plus . 2012.
2. Jane Hohnsone. Postural assessment : hands on Guidesfot therapist. Human
kinetics.2012.
3. Allison, GT, Morris, SL, and Lay, B: Feedforward responses of transversus
abdominis are directionally specific and act asymmetrically: implications for
core stability theories. J Orthop Sports Phys Ther 38(5):228–237, 2008.
4. American Physical Therapy Association: Guide to Physical Therapist
Practice, ed. 2. Phys Ther 81:139, 2001.
5. Andersson E, et al: The role of the psoas and iliacus muscles for stability and
movement of the lumbar spine, pelvis, and hip. Scand J Med Sci Sports
5:10–16, 1995.
6. Basmajian, JV: Muscles Alive, ed. 4. Baltimore: Williams & Wilkins, 1979.
7. Beazell, JR: Dysfunction of the longus colli and its relationship to cervical
pain and dysfunction: a clinical case presentation. J Manual Manipulative
Ther 6(1):12–16, 1998.
8. Bo, K, Sherburn, M, and Allen, T: Transabdominal ultrasound measurement
of pelvic floor muscle activity when activated directly or via a transverse
abdominis muscle contraction.Neurourol Urodyn 22:582–588, 2003.
9. Cholewicki, J, Panjabi, MM, and Khachatryan, A: Stabilizing function of
trunk flexor-extensor muscle around a neutral spine posture. Spine
22(19):2207–2212, 1997.