Example of a postural assessment

Posted on February 6, 2013

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For an update on Jeremy click here.

A couple notes before getting into this:

  • Along with my in-person clientele I also help people out online. With the latter I have to rely more on pictures and videos. I thought going through a person’s standing photos (assessing posture and alignment) illustrating what I look for would make a good post. Jeremy was cool enough to let me use him as an example. 
  • Please remember as I go through the assessment I’m speaking in generalities. Nothing is set in stone until the person moves. What the posture assessment does (for me) is give an idea of what movements I want to attempt along with indicators for why the person has the history they do.
  • I know some people are going to think, “Is it really necessary to look at this many different variables???” The answer is a resounding yes. Every thing I’m going to go over is important. Plus…
  • While this took me a while to write and will probably take the reader a while to go through, this comprises maybe 90 seconds of a person’s session. After doing this a thousand or so times you get good at spotting these things immediately. Again, posture is just an indicator of what may happen during movement. Movement is king though.
  • Don’t get too caught up in the anatomy involved. While it’s important and good to know, at the end of the day you don’t think about correcting one muscle; you think about correcting movements. It’s not plausible to expect a client to know all their anatomy and have to think about it. It IS plausible to be able to coach them to move differently. E.g. you don’t teach someone to “contract their external obliques, relax their lumbar spinal erectors, posteriorly tilt the pelvis, etc.” you teach them to “pull their stomach in.”

History

The first thing I do with anyone I work with is talk to them. First, what has bothered them in the past; second, what currently bothers them.

Here is Jeremy’s pertinent history as detailed by him:

-Lots of lumbosacral (lower back) injuries, sometimes resulting in “pinched nerve” / leg numbness down both legs

-Left groin injuries

-Right hip popping

-Right shoulder stiffness / issues with bench pressing

-Plantar fasciitis on the left foot

Other things worth mentioning:

-During deadlifting the weights hit the ground on the left side before the right side

-Groin “tightness” preventing wide, powerlifting style, squatting

-Gets more lower back issues on left side than right

-Left leg ends up much higher in the air than right leg when doing a butterfly type stretch

-Lower back feels better when toddler squattingsleeping on back with legs up, laying flat on incline bench

-Powerlifting style bench press (with an arch) bothers the low back

-Right shoulder has felt better since cutting down volume of bench pressing

-Tough time elevating arms in something like an overhead squat

Based off Jeremy’s history, the first things I’m going to look at are 1) His hips / pelvis / lower back and 2) His shoulders. The majority of issues seem to revolve around the pelvis, so I start there and then move on. (This is typically a good place to start with anyone as the hips control a lot.)

Standing photos

I start by looking at three angles:

Looking at the hips

The most glaring aspect of the hips is the lateral pelvic tilt.

It’s pretty clear the right hip is being held higher than the left. So, now we have a plausible explanation for Jeremy experiencing the weights hitting the ground on the left side before the right during a deadlift i.e. the left hip is closer to the ground than the right.

Looking at the lower back

If you look (very) closely at Jeremy’s lower back, you can see the left spinal erectors are more developed than the right.

jeremy-back 2

jeremy-back-spinal-erectors 2

This is almost always a sign of issues at the lower back. Namely, the lower back is rotating too often in one direction. (The lateral tilt confirms rotation as well.) Hence, one side of the spinal erectors are more developed. We’re pretty much guaranteed there is an imbalance between the obliques too.

We have our next (potential) explanation for Jeremy experiencing more issues with the left side of his lower back: His left side is doing more work than the right, thus, it’s pissed off.

The things that give Jeremy’s lower back relief make sense now. That list again is: Toddler squat, lower back flat on ground with feet up, lower back flat against incline bench – One of the commonalities here is the lower back is 1) Flat and 2) Not moving.

It makes sense things like bench pressing with an arch, squatting, deadlifting would bother his back as these are all things where the spinal erectors are working heavily. And, for Jeremy, his spinal erectors are pulling on his back in an asymmetric fashion = discomfort / pain.

It’s worth mentioning here Jeremy also noted relief during things such as walking or jogging. I don’t read much into this though because he works as a computer scientist and is thus sitting a lot. It’s been my experience simply getting people to get out of a chair will give them some relief strictly because they are up and moving.

So far we have Jeremy’s hips laterally tillted with one side of the lower back appearing to be working more than the other. My train of thought at this point is “This guy is twisting too much during the day and or when working out.”

The shoulders

When someone mentions shoulder pain during bench pressing it’s nearly always 1) At the bottom of the movement (bar is on chest) and 2) Indicative the humerus is excessively gliding forward. That is, the humerus is extending too much / the elbow is traveling too far behind the shoulder.

Tight lats

Humeral anterior glide. (Right picture is bad, left is better.) From: http://www.manualtherapymentor.com

We can see this excessively humeral extension and anterior glide pretty quickly on Jeremy:

jeremy-side-arm-lines 2

jeremy-side-anterior-glide-lines 2

You can see some forward head posture / thoracic kyphosis / anteriorly tilted scapulae here too.

The line of thinking at this point -for the shoulders- is “We are getting rid of anything where the elbows drift behind the shoulders / torso.”

There’s more going on with Jeremy’s shoulders though. Looking at things from the back we can see his shoulders are downwardly rotated and depressed:

jeremy-back-downward-rotation-lines-1 2

rough sketch of the scapulae (they’re tough to see in the photos) gives another illustration of the downward rotation:

jeremy-back-downward-rotation-lines-2 2

All of this makes sense. Jeremy has trouble with something like an overhead press because the movement requires a great deal of humeral flexion and upward rotation of the scapula. Jeremy is constantly in downward rotation and humeral extension. No wonder lifting his arms overhead is tough.

Looking closer at the shoulders we can see the right shoulder is hanging a bit lower than the left,

jeremy-front-with-shoulder-line 2

I typically wouldn’t give much thought to a difference this small. However, the fact his right shoulder has a history of pain causes me to take this into consideration and look closer.

One of the downward rotators is the rhomboids,

Rhomboids

If you look closely at the rhomboids you can see Jeremy more developed on the right side than left. (Evidenced by the indentations on the right side.)

jeremy-back-rhomboid-lines 2

And now there’s a possible explanation for why his right shoulder gives him more trouble: The rhomboids appear to more dominant on that side, making it more likely the right shoulder is even more restricted than the left.

The reason it’s important to note the downward rotation is because humeral glide is secondary to downward rotation. You can try and correct humeral glide but not end up correcting downward rotation. However, correcting downward rotation you can concurrently correct humeral anterior glide.

I rarely see humeral anterior glide by itself. There’s pretty much always something going on at the scapula first. Doesn’t mean you don’t worry about the anterior glide; it’s just not the primary concern.

This is one reason why just pulling on a bunch of tubes, doing the sleeper stretch, and working the hell out of your glenohumeral internal rotation deficit (GIRD) gets so many people no where. They’re going after the symptom (humeral anterior glide), not the cause (downward rotation).

Looking at the feet and knees

The feet look pretty good. They’re nice and straight with no aberrant alignment at the ankles. The left ankle may have a tad of pronation to it, but I’m being pretty damn picky.

jeremy-feet-front 2

At the knees there is a dramatic impairment. They are internally rotated, especially the left.

jeremy-front-knee-lines 2

We now have a likely explanation for Jeremy’s groin issues: The adductors can play a role with internal rotation of the femur, which Jeremy has in excess. Thus, when he tries something requiring a great deal of femoral external rotation, like a squat (think “knees out”) or butterfly stretch, he feels restricted.

This also causes me to think back to that slight pronation at the left ankle. Because there is a very strong chance if Jeremy were to stand with his knee caps facing straight ahead his feet would become overpronated / significantly everted. That is, his femurs are internally rotated relative to his tibias, OR you could say his tibia is laterally rotated relative to the femur. With this being more signifcant on the left side.

A lot of anatomy has just been revealed. The femoral internal rotators, such as the adductors and tensor fascia latae, as well as the tibial lateral rotators, such as the biceps femoris (hamstring) and TFL again, are likely working too much. While the femoral lateral rotators, such as the gluteus max and posterior gluteus medius, are likely working too little.

If Jeremy does in fact overpronate the foot there is a good chance we’ve found a possible culprit for his plantar fasciitis history.

There is another possible culprit though. Looking at things from the side we can see the knees are excessively flexed:

jeremy-side-knee-lines 2

This is important to note because when the knees are this flexed two other things are typically going on 1) The hips are flexed and or 2) The ankles are dorsiflexed.

Jeremy’s hips don’t look too flexed (there isn’t much anterior tilt) but he definitely has some dorsiflexion. This could be another reason why he’s had issues at the feet i.e. his plantar is constantly on stretch. Although, because his fasciitis history is only on the left -even though both knees are flexed- my hunch is the pronation is a bigger concern.

It’s also worth mentioning here just because his ankles are dorsiflexed does not mean his calves are not tight. While the soleus only acts at the ankle (plantarflexor), the gastroc acts at the ankle and knee (plantar AND knee flexor).

Calves

So, the ankle might be dorsiflexed -stretching the gastroc distally- but the knee is simultaneously flexed -tightening the gastroc proximally- thus, the gastroc is not fully on stretch (while the soleus is).

Therefore, something that works on knee extension AND dorsiflexion -stretching the hamstrings and gastroc- would probably be beneficial for Jeremy.

Simplifying things

Again, the anatomy isn’t as important as the movements. Overall, here’s where my thought process with Jeremy is after these photos:

He needs more:

  • Overhead / upward rotation at the arms
  • Humeral posterior glide
  • External rotation of the femurs
  • Knee extension
  • Extension at the thoracic spine

He needs less:

  • Humeral extension / anterior glide
  • Downward rotation / depression at the arms (anything that pulls the arms down)
  • Femoral internal rotation
  • Tibia external rotation
  • Rotation / mobility / movement at the lumbar spine

And that’s really how I’ll go forward with him. Not just “we need to work and X, Y, Z etc. muscles,” but we need to work on the above movement issues. This will set the stage for what exercises he does, how he does them, which exercises he does not do, as well as how we adjust his daily activities -which is just as important.

From there, the muscles tend to take care of themselves.

To see Jeremy’s progress after a month click here. 

 

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