Postural Assessment and Correction for Exercise Professionals

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This module is one in a continually developing series from Intelligent Fitness.

Those currently available include:

Advanced Cardiovascular Conditioning for Health and Performance

Advanced Resistance Training for Health and Performance

Analysis of Human Movement

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Applied Physiology for Exercise Professionals

Essential Anatomy

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Essential Conditioning Skills - Exercise to Music - Fitness Instruction - Water Based Exercise

Essential Nutrition

Fat Loss: The Science of Assessment, Nutrition and Exercise Prescription

Flexibility: The Art and Science of Stretching

Foundations of Anatomy

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Postural Assessment and Correction for Exercise Professionals

Programme Design: The Art and Science of Exercise Prescription

The Science of Torso Training - Part 1 - Part 2

Details of the full Intelligent Fitness portfolio can be found at www.intelligent-fitness.co.uk

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© Intelligent Fitness 2009 Postural Assessment and Correction

Dear Student Welcome to Postural Assessment and Correction for Exercise Professionals.

The purpose of this module is to provide the student with a sound understanding of the various postural faults. The essential skills necessary to accurately assess posture and plan correction strategies will enable students to safely fulfil their role in the prevention of poor posture and back pain.

Most importantly this module discusses the protocols for referral to specialists such as Chartered Physiotherapists, Osteopaths and Chiropractors.

This module has been written to provide you with a reference source and to add structure to your study, which is essential if you are to gain a thorough understanding of the subject.

This module may be used on its own, however, the best results will be achieved by also attending any corresponding Intelligent Fitness training days.

I trust you will find this module worthwhile.

David Wells

Principal Intelligent Fitness Trainer

© Intelligent Fitness 2009 Postural Assessment and Correction

Table of Contents

The Provenance of the Evidence ................................................................. 1

Getting the Most from this Resource Manual ............................................... 1

Posture ........................................................................................................ 3 Static posture ...................................................................................... 3

Dynamic posture ................................................................................. 3

Ideal Postural Alignment .............................................................................. 6

Ideal posture viewed from the side ..................................................... 6

Ideal posture viewed from the front ..................................................... 7

Ideal posture viewed from the rear ...................................................... 7

Poor Posture ............................................................................................. 10 The constancy of the postural fault ................................................... 10

Definition and prevalence of persistent low back pain ...................... 11

The Assessment of Individuals with Persistent LBP .............................. 12

Red flags – indicators of serious pathology ....................................... 13

Yellow, blue and black flags – indicators of risk of an ongoing condition .............................................................................. 14

Advice and Education for Back Self Care .............................................. 15

Exercise Guidelines for Low Back Pain ................................................. 17

The Role of the Exercise Professional ................................................... 20

Exercise preventing back pain .......................................................... 21

Postural Assessment ............................................................................... 24 Pressure distribution of weight in standing ........................................ 25

Electromyography activity in quiet standing ...................................... 25

Visual Assessment of Alignment ............................................................ 26

Conducting a visual assessment ....................................................... 27

Visual assessment – a conclusion .................................................... 31

Postural sway .................................................................................... 32

© Intelligent Fitness 2009 Postural Assessment and Correction

The Head and Cervical Spine .................................................................. 34 Faulty alignment ................................................................................ 34

Possible muscle imbalances ............................................................. 34

Causes .............................................................................................. 35

Correction ......................................................................................... 35

Muscle Length Assessments ................................................................. 36

Cervical spine flexion ROM assessment ........................................... 36

Cervical spine lateral flexion ROM assessment ................................ 36

Cervical spine rotation ROM assessment ......................................... 37

Neck Flexor Strength Test ..................................................................... 38

Active Neck Extensor Stretch ................................................................ 39

The Thoracic Spine, Shoulder Girdle and Shoulder Joint .................... 42 Faulty alignment ................................................................................ 42

Possible muscle imbalances ............................................................. 42

Possible causes ................................................................................ 43

Correction ......................................................................................... 43

Pectoralis Minor Length Assessment ..................................................... 44

Pectoralis Major Length Assessments ................................................... 46

Latissimus Dorsi Length Assessment .................................................... 48

Medial Rotators Length Assessment ..................................................... 49

Trapezius Strength Test ......................................................................... 50

Standing Serratus Anterior Strength Test .............................................. 52

Pectoralis Minor Stretch ......................................................................... 53

Upper Trapezius Active Stretch ............................................................. 54

Strengthening Serratus Anterior ............................................................ 55

Strengthening Middle and Lower Trapezius ........................................... 56

Thoracic Extension Exercise .................................................................. 57

Seated Sternal Lift ................................................................................. 58

© Intelligent Fitness 2009 Postural Assessment and Correction 7

The Pelvis, Lumbar Spine and Hips ........................................................ 60 Faulty alignment ................................................................................ 60

Anterior Pelvic Tilt ...................................................................................... 61

When viewed from the side ............................................................... 61

When viewed from the front .............................................................. 61

Possible muscle imbalances ............................................................. 62

Commonly seen in: ........................................................................... 62

Possible causes ................................................................................ 63

Correction ......................................................................................... 63

The Thomas Test ................................................................................... 64

Influence of tight tensor faciae latae and/or sartorius ........................ 66

Modified Ober Test ................................................................................ 67

The Straight Leg Raise Test .................................................................. 69

Supine Abduction Test ........................................................................... 71

Supine Trunk Flexion Test ..................................................................... 72

Upper Rectus Abdominis Test ............................................................... 73

Tripod Hamstring Stretch ....................................................................... 75

Gluteus Maximus Inner-Range Exercise................................................ 76

Learning gluteal activation ................................................................ 77

Modified Trunk Curl ............................................................................... 78

Back Flattening Drill ............................................................................... 79

© Intelligent Fitness 2009 Postural Assessment and Correction

Posterior Pelvic Tilt..................................................................................... 80

When viewed from the side ............................................................... 80

Possible muscle imbalances ............................................................. 81

Commonly seen in ............................................................................ 81

Possible causes ................................................................................ 81

Correction ......................................................................................... 81

Passive Prone Trunk Extension Test ..................................................... 82

Active Prone Trunk Extension Test ........................................................ 83

Hip Flexor Inner Range Holding Test ..................................................... 85

Passive Back Extension......................................................................... 86

Hip Flexor Shortening ............................................................................ 87

Seated Pelvic Tilt Re-education ............................................................. 88

Lateral Pelvic Tilt ........................................................................................ 89

When viewed from the front or back ................................................. 89

Possible muscle imbalance ............................................................... 90

Commonly seen in ............................................................................ 90

Possible causes ................................................................................ 90

Correction ......................................................................................... 90

Standing Trunk Lateral Flexion Test ...................................................... 91

Trunk Lateral Flexor and Hip Abductor Strength Test ............................ 93

Gluteus Medius Strength Test ............................................................... 95

Adductor Strength Test .......................................................................... 97

Gluteus Medius Activation Drills ............................................................ 98

Preferred position for outer to mid-range drill .................................... 98

Preferred position for ‘mid’ to inner range drill ................................... 99

Building functional strength ............................................................. 100

The Trendelenburg Sign Test .............................................................. 101

© Intelligent Fitness 2009 Postural Assessment and Correction 9

Anterior Displacement of the Pelvis.......................................................... 103

When viewed from the side ............................................................. 103

Possible muscle imbalances ........................................................... 104

Commonly seen in: ......................................................................... 104

Possible causes .............................................................................. 105

Correction ....................................................................................... 105

Stretching the Upper Abdominals and Intercostals .............................. 105

Strengthening the External Obliques ................................................... 106

Spinal Lengthening .............................................................................. 107

Misalignments of the Lower Limbs ....................................................... 110 Postural Bow Legs ............................................................................... 110

Hip medial rotation .......................................................................... 110

Knee hyperextension ...................................................................... 110

Foot pronation ................................................................................. 110

Postural Knock Knees ......................................................................... 111

Hip lateral rotation ........................................................................... 111

Knee flexion .................................................................................... 111

Foot supination ............................................................................... 111

Scoliosis and Handedness Patterns ..................................................... 113 Scoliosis ................................................................................................... 114

The prevalence and detection of scoliosis ...................................... 114

Causes of scoliosis ......................................................................... 114

Symptoms ....................................................................................... 115

Treatment and correction ................................................................ 115

Handedness Patterns ............................................................................... 116

A typical right handed pattern ......................................................... 117

Correction and prevention ............................................................... 117

Selected Bibliography ............................................................................ 118

42 Postural Assessment and Correction © Intelligent Fitness 2009

The Thoracic Spine, Shoulder Girdle and Shoulder Joint

In ‘ideal’ alignment the thoracic spine should exhibit a smooth curvature that is slightly convex posteriorly.

The shoulder girdle should be level anteriorly/posteriorly and not protracted or retracted.

The scapulae should be stabilised (lie flat) against the rib cage. The medial borders of each scapula should be vertical and no more than 7– 10 cm from the spinous processes. The spine and inferior angle of each scapula should align with T3/T4 and T7 respectively.

The centre of the shoulder joint, whose resting position is largely determined by the shoulder girdle, should lie on the LOG. No more than ⅓ of the humeral head should be anterior to the acromion process.

The humerus should hang with the cubital fossa (elbow crease) at 45° to the sagittal plane.

Faulty alignment

Anterior deviations of the shoulder complex and thoracic spine are often referred to as ‘round shouldered'. When significant, the term kyphotic is more commonly used.

Tightness of the anterior shoulder muscles will pull the shoulder forward of the LOG. The further forward the arm lies the greater the leverage force on the posterior structures, which in turn lengthen through ‘creep’.

As previously discussed, increased flexion of the thoracic spine results in a compensatory extension movement in the cervical spine.

Possible muscle imbalances

The following muscle tightness and weakness may be present and should be confirmed by more relevant testing.

Possibly Weak Effect

•• Lower trapezius •• Serratus anterior

•• Allows excessive abduction & downward rotation of the scapula

•• Thoracic erectors •• Allows excessive flexion

•• Infraspinatus •• Teres minor

•• Allows excessive medial rotation of the shoulder

© Intelligent Fitness 2009 Postural Assessment and Correction 43

Possible causes

•• Pattern overload

•• Prolonged poor sitting/working positions

•• Postural stress

•• Advanced osteoporosis

•• Tuberculosis of the spine

•• Degeneration of the intervertebral discs

•• Scheuermann’s disease Correction

Whether a kyphotic posture is correctable depends upon the flexibility of the thoracic spine.

•• If the individual is younger and the thoracic spine is mobile, stretching and strengthening of the relevant muscles and simple re-positioning drills may suffice.

•• If the kyphosis appears fixed and thoracic spine movement is grossly reduced, an assessment and possibly mobilisation by a Chartered Physiotherapist, Osteopath or Chiropractor is recommended.

•• Repositioning drills to master shoulder girdle alignment.

Possibly Tight Effect

•• Pectoralis minor •• Tilts forward and

downwardly rotates the scapula

•• Pectoralis major •• Anterior deltoid

•• Anterior displacement of the humeral head and medial rotation of the shoulder

•• Latissimus dorsi •• Teres major

•• Medial rotation of the shoulder

•• Upper trapezius •• Elevation and upward

rotation of the shoulder girdle

•• Intercostal muscles •• Internal obliques (upper

lateral fibres)

•• Reduces intercostal spaces and pulls ribs to pelvis

44 Postural Assessment and Correction © Intelligent Fitness 2009

Pectoralis Minor Length Assessment

The aim of this assessment is to assess the degree of any tightness in pectoralis minor. Preferred position

•• Lying supine with the hips and knees flexed and the lower back flat on the table

•• The arms at the sides, elbows extended and palms upward.

Action

•• Relax the shoulder muscles to allow the posterior border of the acromion process to move towards the surface of the table.

•• Assess the position of the shoulder girdle by palpating the posterior border of the acromion process.

Results Unlike the measurement of other muscles, such as the hamstrings, the literature does not indicate the desired length of pectoralis minor in degrees of motion available. Rather, it suggests comparing the distance between the posterior border of the acromion process to the table surface, bilateraly.

Length of pectoralis minor may also be noted by observing an individual’s posture, as tightness in this muscle may cause the scapula to appear anteriorly tilted (coracoid process forward and downward), excessively protracted and perhaps medially (downwardly) rotated. This may result in the shoulder/s appearing to be pulled forward from the LOG if the individual were standing.

Berryman Reese and Bandy (2002)

© Intelligent Fitness 2009 Postural Assessment and Correction 45

If the shoulder/s appear to be pulled forward, assess the amount of tightness in pectoralis minor by placing your hand against the anterior aspect of the shoulder and GENTLY apply downward pressure.

Eliminating / identifying tightness in biceps brachii and coracobrachialis

If the shoulder is held forward, before assuming tightness in pectoralis minor, tightness in the other two muscles that can depress the coracoid process should be eliminated.

Whilst applying gentle pressure to the shoulder, passively flex the elbow fully, taking biceps brachii off stretch. If the tension in the shoulder remains, biceps brachii is not responsible for the misalignment.

With the elbow still flexed, passively flex the shoulder approximately 20 – 30°, taking coracobrachialis off stretch. If the tension in the shoulder still remains, pectoralis minor is the cause.

64 Postural Assessment and Correction © Intelligent Fitness 2009

The Thomas Test

The aim of this test is to assess the length of the hip flexors; distinguishing between the one-joint and the two-joint muscles

Preferred position

•• The individual should lie supine on the table with both knees towards the chest thus ensuring the lower back and sacrum are flat to the table. The greater trochanters should be level with the end of the table.

Action

•• Hold one leg close to the chest to stabilise the pelvis in its posterior tilt.

•• Relax the opposite leg and allow it to lower to its resting length.

Normal value

Optimal length is indicated by the femur lying horizontally with the knee flexed to 90°.

© Intelligent Fitness 2009 Postural Assessment and Correction 65

Tightness is indicated by the femur remaining above the horizontal and/or the knee flexing to less than 90°.

To determine which of the hip flexors is exhibiting the tightness, extend the knee.

•• If the femur drops to horizontal, the tightness lies in rectus femoris, the length of the one-joint hip flexors is ideal.

•• If, with the knee extended, the femur remains above horizontal the one-joint hip flexors are tight (and possibly rectus femoris as well).

If, on passive flexion of the knee to 90°, the thigh raises slightly, this indicates that both the one-joint hip flexors and rectus femoris are tight.

66 Postural Assessment and Correction © Intelligent Fitness 2009

•• Lengthening of the one-joint hip flexors is indicated by the femur dropping below the horizontal either on the initial part of the assessment or once the knee has been extended.

Influence of tight tensor faciae latae and/or sartorius

If tight, TFL will abduct the hip as the leg is lowered. If abduction is prevented the patella may be drawn laterally and/or the knee may be extended slightly.

Tightness is sartorius will also abduct the hip but will also externally rotate the hip as the leg is lowered.

Main Actions of Tensor Fasciae Latae and Sartorius

Joint TFL Sartorius

Hip Abducts Abducts

Hip Flexes Flexes

Hip Internally rotates Externally rotates

Knee Extends Flexes

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Selected Bibliography

Berryman Reese N., and Bandy W., 2009 Joint Range of Motion and Muscle Length Testing 2nd edition, W.B. Saunders Company, Philadelphia

Bigos, S.J., Holland, J., Holland, C., Webster, J.S., Battie, M., Malmgren, J.A., High-quality controlled trials on preventing episodes of back problems: systematic literature review in working-age adults. Spine Journal 2009, Feb; 9(2), pp. 147-168

Chartered Society of Physiotherapy (2006) Clinical guidelines for the physiotherapy management of persistent Low Back Pain (LBP) London

Clark, M.A., 2001 A Scientific Approach to Understanding Kinetic Chain Dysfunction National Academy of Sports Medicine Thousand Oaks CA

Jull. G (1994) cited by Bullock-Saxton, J., Murphy, D., Norris, C., Richardson, C., and Tunnell, P (2000). The muscle designation debate: the experts respond. Journal of Bodywork and Movement Therapies 4(4), pp. 225-227

Kendall, F. P., 2005 Muscles Testing and Function 5th edition, Lippincott, Williams and Wilkins, Baltimore, Maryland

McGill, S. 2006 Ultimate Back Fitness and Performance, 3rd edition, Backfitpro Inc, Waterloo, Ontario

McGill, S. 2007 Low Back Disorders, Evidence-based Prevention and Rehabilitation, 2nd edition, Human Kinetics, Champaign, Illinois

NICE (2009) Low back pain: early management of persistent non-specific low back pain Royal College of general Practitioners, London

Norris, C. M., 2000 Back Stability, Human Kinetics, Champaign, Illinois

Norris, C. M., 2008 Back Stability – Integrating Science and Therapy, 2nd edition, Human Kinetics, Champaign, Illinois

Norris, C. M., 2009, Personal correspondence, April 2009