Postural Analysis

Client's Postural Assessment

Before devising an intervention, it is crucial to determine the client's position. The initial assessment is the static postural assessment, which is essential for identifying potential postural deviations, muscular weaknesses, asymetry between the left and right sides of the body, and movement compensations that can lead to a variety of musculoskeletal problems (Jang et al., 2019; Kim et al., 2020; Singla and Veqar, 2014).Furthermore, it helps establish a baseline against which to compare the effectiveness of the prescribed treatment (Johnson, 2012). In addition to observational analysis using line of gravity, plumb line, and palpation (Hazar et al., 2015), photographic posture is a fundamental and valid method of observing (Do Rosario, 2014). The method used for assessment this case study was PostureScreen Mobile iOS App. Boland et al., (2016) found a moderate inter-rater reliability  (ICC>0.60) for seven measures. Contrary,  Kan et al., (2016) investigated its reliability and found less than desirable inter- and test-retest reliability and notable differences in measurement when compared to a gold standard methods (IIC=0.26- 0.93). Contrary, Szucs et al., (2018) found strong reliability ICC 0.71-0.99.

Anterior view

                            Figure 1. Visual illustration of frontal view postural assessment.

Based on figure 1, it appears that the client may be experiencing some postural imbalances and compensations. Specifically, it can be observed that the left deltoid muscle is elevated and internally rotated, while the right arm is slightly longer than the left caused by the elevated shoulder. Additionally, the client’s weight-bearing appears to be shifter to the right side, which has caused the ASIS (anterior superior iliac spine) to be unlevelled (lateral tilt). The lateral pelvic tilt (LPT) can be consequence leg length inequality, possible causing scoliosis with curvature towards the shorter limb (Raczkowski et al., 2010), muscle tightness (which can be confirmed by the leg length test); or both (Kendal et al., 2006). However, the length discrepancy can be mal diagnosed in people with LPT. Tonic muscles are quadratus lumborums, causes the opposite muscles to be tighter, and causes back pain and the affected area is higher (Dombroski, 2018; Harley et al., 2017).

Posterior view:

Figure 2. Visual illustration of client's posterior postural assessment.

My client presents a cervical rotation and small head tilt to the left (See table 1, Figure 2) caused by tightness of the muscles responsible for lateral flexion. These muscles are the levator scapulae, sternocleidomastoid, scalene, and upper trapezius muscles (Johnson, 2012; Kushner et al., 2017). In addition, the left elbow of the individual is internally rotated (IR) (olecranon rotates), indicating that the glenohumeral joint (GH) is also internally rotated. This is further confirmed by the left hand-palm, which also indicated internal rotation of the GH joint (Ekstrom et al., 2020; Johnson, 2012). Consequently, the left subscapularis, pectoral major minor, latissimus dorsi, and teres major muscles may be shortened  (Grosdent et al., 2020; Johnson, 2012).

Muscular imbalances and compensations can be caused by a variety of factors, such as inadequate posture, repetitive movements, and medical conditions (Claus et al., 2018). In this instance, the client's prolonged seating and repetitive keyboard use at his desk job have most likely contributed to his postural problems. Inadequate ergonomics at the workstation (chair and desk height may also contribute) (Ellegast et al., 2012). In addition, the internal rotation of the left elbow and hand suggests an a area of concern affecting the shoulder girdle and upper body due to muscle imbalances, joint laxity, or conditions such as rotator cuff impingement or shoulder instability (Cools et al., 2014).  IR has the potential to weaken the infraspinatus, supraspinatus, and posterior fibres (Johnson, 2016). Consequently, main left-sided muscles may be shortened (Grosdent et al., 2020; Johnson, 2012). 

  Figure 3. Visual illustration of client’s postural assessment showing head, neck tilt and cervical rotation to the left side.

Moreover, in this plane it can be observed by figure 1 shows PSIS (Posterior Superior Iliac Spine) not aligned and tilted to the right causing hip hike to the right, which could be caused by leg length discrepancy (Bangerter et al., 2018). Further leg-length test would be necessary. Additionally, the reason why the left shoulder is elevated and the right PSIS is tilted, could inform about a possible not diagnosed scoliosis (Pinto et al., 2019). Furthermore, the spine muscles are slightly bulked as consequence of compensation.

Figure 4. Visual illustration of client’s posterior static posture of buttock crease and PSIS alignment (left).

 

Lateral view:

Figure 5. Visual illustration client postural assessment showing a correct posture (Strauss Scoliosis Correction, 2022) compared to client posture (anterior pelvic tilt and kyphosis).

On this side view, it can be perceived that the client has forward head posture (FHP)(figure 5), which is associated with shortened levator scapulae, sternocleidomastoid, upper trapezius, and posterior cervical spine muscles (Ruivo et al., 2014), and is also related to the left cervical rotation (see posterior view).  Poor posture weakens the deep neck flexors and scapular retractors (lower trapezius and rhomboids) (Harman et al., 2005; Bae et al., 2016). Normal posture is characterised by the alignment of the ear lobe, acromion, anterior thoracic spine, and trochanter (figure 5) (Singla, 2017). Failure of alignment leads to protracted shoulders and increased thoracic kyphosis (Figure 5) (Singla, 2017), also known as "slouched posture'. This inadequate alignment is also characterised by protraction, internal rotation, anterior tilt, and abducted scapula (also known as winging scapula), as shown in Figure 4 (Ghambari et al, 2014; Ruivo et al, 2014). Further scapular test would be necessary to better assess winging scapula.

On the other hand, it is noticeable a slight anterior pelvic tilt (APT) which results in lumbar lordosis (Posterior Superior Iliac Spine (PSIS) not in line with Anterior Superior Iliac Spine (ASIS) (Johnson ,2016), which leads to overactive hip flexors and erector spinae; and underactive gluteus maximus and abdominal muscles (Smith et al., 2015). It is known that desk jobs led to muscle tightness, decrease in flexibility and joint ROM (Pradip et al., 2018). Specifically, prolonged sitting causes alteration in the hip flexors muscles, shortening the illipsoas and periformis, associated with lower back pain (Chaurasia et al., 2004; Pradip et al., 2018; Yoon et al., 2017). As a result, the lordotic curve increases by a constant hyperextended spine, tilting pelvis forwards and increasing the APT (Cheung et al., 2018; Al Subahi et al., 2018).

Table 2.  Movement compensation summary in the static postural assessment (Clark et al., 2016).

Static Posture Assessment Summary
Compensation	Tight/ Overactive     Muscles	Inhibited/Weak      Muscles
Cervical Rotation	Scalene muscles Levator Scapulae L Sternocleidomastoid R	Scalene muscles L Levator Scapulae R Sternocleidomastoid L -
Forward Head	Levator Scapulae Sternocleidomastoids Upper Trapezius Pectoralis major Pectoralis minor	Deep neck flexors Scapular retractors: -          Lower Trapezius Rhomboid Iliocostalis thoracis
Shoulder Elevation	Upper Trapezius Levator Scapulae	Serratus anterior Lower trapezius
Shoulder Internal Rotation	Subscapularis Anterior deltoid Pectoral Major Pectoral minor Teres Major Latissimus dorsi	-Infraspinatus -Posterior Deltoids -Teres minor Supraspinatus
Protracted Scapula	Pectoralis minor Upper trapezius short head biceps	Serratus anterior Rhomboids Middle and lower trapezius
Anterior Pelvic Tilt	Hip flexors:    - Illipsoas    - Piriformis    - Psoas Major Erector Spinae Multifidus Quadratus Lumborum Tensor Fascia Latae Sartorius	Gluteus Maximus Gluteus Minimus Gluteus Medius Rectus Abdominis Obliques Transversus abdominis Hamstrings
Lateral Pelvis Tilt	Quadratus lumborum Right Erector spinae Right e External oblique Hip Adductor Abductor	Same on the opposite side
Feet Externally Rotated		Tibilialis Anterior Posterior Tibilaies Vastus mediales Gluteus Medius Glute maximus Hip external rotators

References:

 

Bae, W.S., Lee, H.O., Shin, J.W. and Lee, K.C., (2016) ‘The effect of middle and lower trapezius strength exercises and levator scapulae and upper trapezius stretching exercises in upper crossed syndrome.’ Journal of physical therapy science, 28(5), pp.1636-1639.

Bangerter, C., Romkes, J., Lorenzetti, S., Krieg, A. H., Hasler, C.-C., Brunner, R. and Schmid, S. (2019) ‘What are the biomechanical consequences of a structural leg length discrepancy on the adolescent spine during walking?’ Gait & Posture, 68 pp. 506–513.

Boland, D. M., Neufeld, E. V., Ruddell, J., Dolezal, B. A. and Cooper, C. B. (2016) ‘Inter- and intra-rater agreement of Static Posture Analysis using a mobile application.’ Journal of Physical Therapy Science, 28(12) pp. 3398–3402.

Buyukaslan, A., Abul, K., Berk, H. and Yilmaz, H., (2022). ‘Leg length discrepancy and adolescent idiopathic scoliosis: clinical and radiological characteristics.’ Spine Deformity, pp.1-8.

Cools, A. M., Johansson, F. R., Cagnie, B., Cambier, D. C. and Witvrouw, E. E. (2012) ‘Stretching the posterior shoulder structures in subjects with internal rotation deficit: Comparison of two stretching techniques.’ Shoulder & Elbow, 4(1) pp. 56–63.

Cunha, B., Tadi, P. and Bragg, B.N. (2021) Torticollis. In StatPearls [Internet]. StatPearls Publishing.

Do Rosário, J. L. (2014) ‘Photographic analysis of human posture: A literature review.’ Journal of Bodywork and Movement Therapies, 18(1), pp. 56–61.

Dombroski, C., 2018. Leg Length Discrepancy. Clinical Practice Guidelines, p.370.

Ellegast, R.P., Kraft, K., Groenesteijn, L., Krause, F., Berger, H. and Vink, P., (2012) ‘Comparison of four specific dynamic office chairs with a conventional office chair: impact upon muscle activation, physical activity and posture.’ Applied ergonomics, 43(2), pp.296-307.

Fatima, G., Qamar, M.M., Hassan, J.U. and Basharat, A., (2017) ‘Extended sitting can cause hamstring tightness.’ Saudi Journal of Sports Medicine, 17(2), p.110.

Ghanbari, A., Ghaffarinejad, F., Mohammadi, F., Khorrami, M. and Sobhani, S., (2008)  ‘Effect of forward shoulder posture on pulmonary capacities of women.’  British journal of sports medicine, 42(7), pp.622-623.

Harman K, Hubley-Kozey CL, Butler H: Effectiveness of an exercise program to improve forward head posture in normal adults: a randomized, controlled 10-week trial. J Manual Manip Ther, 2005, 13: 163–176

Harman K, Hubley-Kozey CL, Butler H: Effectiveness of an exercise program to improve forward head posture in normal adults: a randomized, controlled 10-week trial. J Manual Manip Ther, 2005, 13: 163–176. [

Hazar, Z., Karabicak, G. O. and Tiftikci, U. (2015) ‘Reliability of Photographic Posture Analysis of adolescents.’ Journal of Physical Therapy Science, 27(10), pp. 3123–3126.

Higashihara, A., Nagano, Y., Takahashi, K., and Fukubayashi, T. (2015). ‘Effects of forward trunk lean on hamstring muscle kinematics during sprinting.’ Journal of Sports Sciences, 33(13), 1366–1375.

Hopkins, B. B., Vehrs, P. R., Fellingham, G. W., George, J. D., Hager, R., & Ridge, S. T. (2019). ‘Validity and Reliability of Standing Posture Measurements Using a Mobile Application.’ Journal of Manipulative and Physiological Therapeutics.

Hou, S., Ivanhoe, C. and Li, S. (2015) ‘Botulinum toxin injection for spastic scapular dyskinesia after stroke.’ Medicine, 94(32).

Johnson, J. (2012) Postural assessment. Champaign, IL: Human Kinetics.

Jung, S.I., Lee, N.K., Kang, K.W., Kim, K. and Do, Y.L., (2016). ‘The effect of smartphone usage time on posture and respiratory function.’ Journal of physical therapy science, 28(1), pp.186-189.

Kan, S., Fortuna, J., Nur, S. (2016) ‘Can a mobile application be used to assess postural alignment in clinic?.’ Canadian Society for Biomechanics, Hamilton, ON.

Kendall, J. C., Bird, A. R. and Azari, M. F. (2014) ‘Foot posture, leg length discrepancy and low back pain – their relationship and clinical management using Foot Orthoses – an overview.’ The Foot, 24(2) pp. 75–80.

McClure, P., Greenberg, E. and Kareha, S. (2012) ‘Evaluation and management of Scapular dysfunction.’ Sports Medicine and Arthroscopy Review, 20(1) pp. 39–48.

Mendiguchia, J., Gonzalez De la Flor, A., Mendez-Villanueva, A., Morin, J.B., Edouard, P. and Garrues, M.A., (201). ‘Training-induced changes in anterior pelvic tilt: potential implications for hamstring strain injuries management.’ Nagahara Journal of Sports Sciences, 39(7), pp.760-767.

Nasm (N.d). Overactive and underactive muscles part 2: Excessive forward lean and low back Arch. NASM. [Online] [Accessed on April 26, 2023]https://blog.nasm.org/fitness/the-nasm-cpt-podcast-ep-10.

Neumann. D.A. (2010)  Kinesiology of the Musculoskeletal System, Foundations for Rehabilitation 2nd ed. St. Louis, MO: Mosby Elsevier.

Park, J.H., Moon, J.H., Kim, H.J., Kong, M.H. and Oh, Y.H., (2020). ‘Sedentary lifestyle: overview of updated evidence of potential health risks.’ Korean journal of family medicine, 41(6), p.365.

Pinto EM, Alves J, De Castro AM et al (2019) Leg length discrepancy in adolescent idiopathic scoliosis. Coluna/Columna 18:192–195. https://doi.org/10.1590/S1808-185120191803208 752

Post, E. G., Olson, M., Trigsted, S., Hetzel, S., and Bell, D. R. (2017) ‘The Reliability and Discriminative Ability of the Overhead Squat Test for Observational Screening of Medial Knee Displacement.’ Journal of Sport Rehabilitation, 26(1).

Pradip, B., Sudhir, B. and Nidhi, B., 2018. Prevalence of tightness in hip muscles in middle aged Indian men engaging in prolonged desk jobs: A descriptive study. Int. J. Phys. Educ. Sports Health, 5(2), pp.15-21.

Raczkowski, J. W., Daniszewska, B. and Zolynski, K. (2010) “Clinical research functional scoliosis caused by leg length discrepancy.” Archives of Medical Science, 3 pp. 393–398.

Rosário, J.L.P. (2014) ‘A review of the utilization of baropodometry in postural assessment.’ Journal of bodywork and movement therapies, 18(2), pp.215-219.

Ruivo, R.M., Pezarat-Correia, P. and Carita, A.I., (2014) ‘Cervical and shoulder postural assessment of adolescents between 15 and 17 years old and association with upper quadrant pain.’ Brazilian journal of physical therapy, 18, pp.364-371.

Singla, D. and Veqar, Z., (2014). ‘Methods of postural assessment used for sports persons.’ Journal of clinical and diagnostic research: JCDR, 8(4).

Smith, L. K., Weiss, E. L., & Lehmkuhl, L. D. (2015). Brunnstrom's Clinical Kinesiology. FA Davis

Strauss Scoliosis Correction (2023) Lordosis: Guide to causes, symptoms, and treatments. Lordosis: Causes, Symptoms, and Treatments. [Online] [Accessed on March 18, 2023]https://www.hudsonvalleyscoliosis.com/what-is-scoliosis/lordosis/.

Szucs, K. A., & Brown, E. V. D. (2018). ‘Rater reliability and construct validity of a mobile application for posture analysis.’ Journal of physical therapy science, 30(1), pp.31-36.

Yadav, R. and Basista, R., (2020) ‘Effect of Prolonged Sitting on Hamstring Muscle Flexibility and Lumbar Lordosis in Collegiate Student.’ International Journal  Health Reseach, 10, pp.280-289.