Another example of a postural evaluation

Posted on February 20, 2013

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For an update on Jennifer, click here.

The first one of these can be found here: Example of a postural assessment.

Preface:

  • Along with my in-person clientele I also help people out remotely. 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. Jennifer was cool enough to let me use her 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 their current issues.
  • 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. Everything 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.
  • 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.”
  • For those interested, I talk a bit about Jennifer (before ever seeing pictures of her) in this post as well: Can foot pain and hip pain be related?

History

One thing I didn’t talk about in the first postural assessment is how I typically digests someone’s history. First, I actually start out with their current issues. After that, I’ll ask them about their history to see if there’s anything I think might help form a connection. So,

Current issues and information

-“Always” has some degree of lower back / hip pain.

-Consistent right shoulder soreness / pain / fatigue.

-Suffers occasionally from right foot pain. Most recently diagnosed as Morton’s neuroma and told no treatment was necessary.

-When hip pain is alleviated, foot pain tends to be too.

-Foot pain is better when barefoot.

-Foot pain described as “hot foot” by an orthopedist she saw.

-Recently rode 23 miles on her bike with no foot issues, so, foot seems to be getting better.

Pertinent history

-2004 developed pain in left butt cheek. Initially diagnosed as herniated disc but MRI showed no herniation. Later a physical therapist diagnosed condition as piriformis syndrome. “It’s fine” as long as she stretches it.

-2006 Left knee sprain. Went to physical therapy for 6 weeks and no issues since.

-Foot issue started in August of 2012.

-Recalls “years ago” right arm really acting up after a very busy day working at a tattoo removal clinic.

Things about Jennifer I think are important

-Occupation as Physician’s Assistant

-Does a lot of writing in the form of “charting”

-Performs minor surgeries, laser work, etc.

-Right arm and shoulder feel the worst after days consisting of many injectables

To give you an idea how my arm is positioned, I would liken it to a teacher writing on a chalk board. Shoulder abducted, internally rotated, forearm flexed. My left shoulder never bothers me, and by Sunday night, my right arm feels great!

I’ve actually given up a favotite hobby of mine, cross stitching, because that now also gives me shoulder fatigue, which I’m fearful will in turn will affect my work. As a side note, my other favorite hobby, skeet/clay shoots, do not bother my arm.

writing-arm-position 2

Think of Jennifer’s arm positioning as something like this.

Jennifer’s exercise routine:

-Runs/walks on treadmill Monday through Friday for up to 60 minutes

-Monday, Tuesday, Thursday, Friday: Bikes ~23 miles totaling ~60 minutes

-Weight lifting routine (as described by her):

-Bicep Curls and Tricep Extensions 2-3x a week

-Shoulders 2x a week

-Front Raises

-Lateral Raises

-Chest Press and Row Machine 2x a week

-Legs 6 days a week:

-Hip bridges

-Leg Extensions

-Side Leg Lifts

Jennifer’s goals:

My main goals are to work on this right sided yuckiness, stay healthy, get stronger. I’m not really looking to lose weight, just maintain, and if I put on some muscle weight that would be cool.

What I’m looking for

Alright, so based off all of that I’m going to first be looking at Jennifer’s shoulders. She does have some hip / lower back / lower body history, but this doesn’t seem to be too severe and not as big of a concern to her as her shoulders. The fact she mentions adjusting her hobbies to accommodate her arm, but is still bike riding 23 miles with no real issues, is indicative of her priorities and how she’s feeling.

Her photos

Shoulders

The first thing I’m going to go over is a common mistake I often see in shoulder assessment. By looking at Jennifer’s hands we can see the palms are turned pretty far inward, almost facing backward.

jennifer-front-zoomed-in-hands 2

Many will immediately go “Oh, her shoulders are internally rotated.” Not necessarily. It’s important to understand while the hands can be turned in, that doesn’t mean the shoulders are too. Because the forearms can rotate on the humerus.

pronator teres

It’s possible the forearm can be pronated (palms turned in) but the humerus neutral. You need to look at the humerus itself to judge if it’s internally rotated. An easy way to discern this subtle difference is to look at the olecranon.

olecranon

Back of the elbow.

If this is also medially rotated then the humerus is probably internally rotated. (The humerus CAN be internally rotated and the forearm laterally / supinated, but this is pretty damn unusual.)

Looking at Jennifer,

jennifer-olecranon-fossa-close 2

We can see the olecranon are pointing out indicating the humerus is probably rotated medially. Right now I can be pretty sure Jennifer’s humeral internal rotators -such as the lat, pec major, pec minor- are working on overdrive. This is no surprise based off of Jennifer’s ADLs (activities of daily living). The most relevant one being the arm position she writes and works in.

Next, Jennifer’s right humerus is abducted (flaring out).

jennifer-s-front-abducted-humerus 2

The left line is flaring out but the right line is pretty straight.

Again, really no surprise here. Keep in mind the writing / working position Jennifer described earlier, “Shoulder abducted, internally rotated.” She, as mentioned, is clearly doing this movement a lot.

When the shoulder is held in abduction like this it’s indicative the shoulder abductors are over active. There are only two humeral abductors: The middle deltoid and supraspinatus.

shoulder abduction

Note: This is a GREAT opportunity to corroborate my post on the rotator cuff where I mention it’s typical for some muscle(s) of the cuff to be overworked and other muscle(s) of the cuff needing to be calmed down. Jennifer is a perfect illustration of having a cuff muscle (supraspinatus) that needs to be calmed down.

When the humerus is constantly abducted like this it’s common for the humerus to excessively glide upward, aka humeral superior glide.

jennifer-front-humeral-superior-glide-arrow 2

See how the pointy bone (humeral head) is going upward?

You can see the difference in contour between Jennifer’s two shoulders:

jennifer-front-humeral-superior-glide-arrow-comparison

And when the humeral head is excessively gliding in one direction it is concurrently not gliding enough in a different direction. (Typically the opposite e.g. Jennifer has too much superior glide and needs more inferior glide.)

For those familiar with Jeremy’s postural assessment, you can discern the difference between anterior glide and superior glide pretty well by noticing how much more extended Jeremy’s humerus is:

jeremy-side-anterior-glide-lines 2

Jennifer’s humerus is more vertical but still has the prominent humeral head = more superior glide.

Again, not only is the supraspinatus overactive but so is the middle deltoid. Looking back at Jennifer’s weightlifting routine you can see the mention of front and lateral raises. Along with these, there is the chest press and row machine. While I haven’t seen her perform these exercises, I just about guarantee Jennifer’s arms are abducted during nearly all of her upper body exercises.

Here’s some examples after a quick google search for “Chest press” and “Row machine.” See how the arms are flared out in this chest press?

chest pressAnd a row machine:

rear view row machine with abduction lines

A lot of these exercises are going to have to either be modified or canned, at least for a while. Jennifer is already performing a ton of humeral abduction during her job; she needs some other things in her exercise routine to even things out. Not to mention these exercises are typically done with the hands pronated / humerus medially rotated. More movements she already is doing plenty of.

This is a common thought process I see people run into. Whatever activity they are trying to improve they immediately try and simulate in the weight room. Another example would be golfers who go in the weight room and do every twisting exercise they can think of. More often than not people are better off using exercise / the weight room as a means of balancing all the movements inherent in their ADLs as opposed to simulating their ADLs. You can’t just keep piling on the same movement over the same movement just because you added resistance to it.

It’s great to get stronger in a specific movement, but you can’t do anything if you’re not healthy (balanced) enough to perform that movement well.

Finally, I’m going to need to talk to her about how much she leans on her elbows. This is pretty simple, lean on your elbow and it pushes your elbow up, which then pushes your humerus up.

Shoulder pain

Notice the right shoulder protruding

She’ll need to look for this leaning during her bike riding too.

Next, Jennifer’s left scapula is abducted. An abducted scapula is classified as a scapula that’s more than 3 inches from the spine. I can’t measure her, this is just something I’ve learned to eyeball:

jennifer-back-smaller-with-good-color-scapular-abduction-left1 2

You can see the difference in length from the spine between the two scaps:

jennifer-back-smaller-with-good-color-scapular-abduction-comparison1 2

Looking closely at that area it appears the right rhomboid muscles are overdeveloped as well, holding the scapula in a bit of downward rotation, which is likely a sign Jennifer is having issues with upward rotation. Something that typically accompanies humeral superior glide.

These dysfunctions are actually a little more obvious from the zoomed out picture:

jennifer-s-back 2

As I’ve mentioned before, it’s very common for a scapular issue to accompany a humeral issue, and you always attack the scapular issue first. Here is an example of why: On Jennifer’s left shoulder we’ve deduced the scapula is a bit abducted and the humerus is a bit internally rotated. Typically when a scapula abducts the humerus medially rotates, and when the scapula adducts the humerus laterally rotates. See below:

Now, this isn’t a guarantee; it’s typical. For instance, the scapulae are adducted and humeri internally rotated here:

scapular retraction humeri internally rotated

The takeaway is Jennifer likely can correct a lot, if not all, of her internal rotation issues on the left shoulder by simply adducting (retracting) the left scapulae. That is, the left humerus might not actually be internally rotated relative to the scapula, it very well may just appear that way due to the position of the left scapula. However, she won’t correct her scapular issue by simply laterally rotating the humerus.

Improve the position of the scapula and you improve the position of the humerus. Improve the position of the humerus and you don’t necessarily improve the scapula.

For those interested, Jennifer’s shoulder tilt is a likely explanation for her shoulder issues.

jennifer-s-front-shoulder-horizontal-line1 2

A shoulder tilt is indicative of an imbalance at the abdominals. Notice how her bra strap is higher on one side than the other? If you look closely you can see the ribs lower on the left side (right in picture ) than the right.

jennifer-front-close-shoulder-and-ab-line 2

In other words, Jennifer is a bit tilted to the left. So, instead of gravity acting on her muscles just in an up and down manner, with her tilt gravity is actually now encouraging her to tilt further to the left. Gravity isn’t just acting on her in a vertical direction, it is also acting (on her muscles) in a horizontal manner. Something akin to,

jennifer-s-front-abdominal-line-with-gravity-arrows 2

From the front we can see the body getting pushed to the right; Jennifer is leaning to her left. Thus, from the back the arrows would go,

jennifer-back-smaller-with-good-color-tilt-arrows 2

Her right shoulder blade is getting pushed to the left (adduction), and her left shoulder blade is getting pushed to the left (abduction for that shoulder). And as we just went over, her left scapula is abducted and her right scapula appears to have overactive adductors (rhomboids).

In other words, her shoulder blades are getting pushed to the left.

Lastly, because the right arm can only go so far left -it will eventually touch her body- as the shoulders tilt more to the left her right arm flares out MORE. That is, it abducts.

jennifer-s-front-abdominal-line-with-gravity-arrows-abduction-too 2

The crucial point here is the solution for Jennifer’s humeral ABduction issue is NOT to only focus on doing the opposite i.e. humeral ADduction; she needs to also focus on correcting the tilt of her shoulders. Once she does that, her shoulders are then able to hang down straight. Then, and only then, if her arm is still abducted does she need to also focus on adducting it (keeping it close to her side). Because as of right now, in standing, she can’t bring her arm any closer to her side; it’s already touching her side.

Going along with that, instead of her having to think about “My left scapula needs to be adducted some, my right scapula abducted some, I need to adduct my right arm, etc. etc.” A lot of correction will likely come from “Stop leaning to the left.”

The simpler the cue the better.

It’s like when someone has issues with their knees caving in during a squat. Rather than say “Externally rotate your femur, internally rotate your tibias, plant your feet flat, etc. etc.” You simply say, “Feet straight, knees out.” Done.

Lower back / Hips

I already went over the lateral tilting Jennifer’s exhibiting in the shoulder section,

jennifer-front-close-shoulder-and-ab-line 2

This is a sign Jennifer is likely having some rotational issues at the lower back as well. Typically, excessive lower back extension will accompany excessive rotation. However, looking at Jennifer from the side she looks pretty good.

She has some swayback posture, but it’s not much. You can see her thoracic spine is a bit kyphotic and her hips a bit extended:

jennifer-left-side-less-quality-swayback 2

That doesn’t mean once she starts moving, or once she gets fatigued, this posture doesn’t get exaggerated; it very well could. However, initially this isn’t going to be much of a priority.

In terms of anatomy, when the thoracic spine has an exaggerated hunch there’s a good chance the rectus adominus is tight / stiff, especially proximally (where it attaches to the ribs). The RA is pulling the ribs down.

(Credit kctcs.edu)

Distally -by the pelvis- the RA may be weak / elongated along with the external obliques. If you look closely at Jennifer’s stomach you can see how by her ribs she appears to be nice and sucked in but by her pelvis she seems pushed out.

An exercise which loosens up the rectus abdominus proximally but concurrently tightens the RA and external obliques distally would be a nice addition to her routine. The Backward Rocking stretch is one example:

And for those wondering it’s doubtful the outline above is from where Jennifer stores her fat. 1) Jennifer is pretty lean 2) Women tend to not store their fat in the lower stomach and 3) More than likely if she were to stand nice and tall, chest out / stomach in, the “pot belly” look would go away.

Knees

The most obvious thing going on the knees is the internal rotation, with the left knee being more pronounced. You can see this by the medial orientation of the patella i.e. they are turned inward:

jennifer-front-less-quality-internal-rotation-knees 2

As well as the prominent medial hamstring crease relative to the lateral,

jennifer-back-hamstring-crease 2

As I went over in the hips section, the hips are a bit extended, Jennifer’s knees come along for the ride with a bit of hyperextension as well,

jennifer-knee-hyperextension 2

These two impairments -internal rotation and hyperextension- are two clear indicators the posterior glutes could be working better. As far the internal rotation, the glutes help to externally rotate the femur, so if the femur is locked in internal rotation the posterior glutes likely are too long / weak.

The hyperextension is a bit more complicated. As far as hip extensors (we’ll get to knee extensors in a second) we primarily have the gluteus maximus and hamstrings,

The posterior gluteus medius can act as a hip extensor too,

posterior gluteus medius muscle

As can the adductor magnus,

adductor magnus

(Credit Washington U. Radiology.)

When the hip extensor muscles that attach higher up on the femur -the glutes- aren’t performing well the hip extensors that connect further down towards the knee -hamstrings and adductor magnus- pick up the slack. Hence, the knee comes along for the hip extension ride = hyperextended knees.

Now there’s definitely some stiffness going on at the knee extensors (quadriceps) too, but it’s important to understand the need for proper gluteal exercises here as well. “Stretch the quads” is not a full solution.

Finally, it’s worth mentioning Jennifer’s knee sprain history is on the left knee, the one which is more significantly internally rotated. An excessively rotated knee makes a sprain more likely, but, it’s also possible her sprain made her more susceptible to an internally rotated knee. Hard to say which came first in this scenario. Either way, it should be worked on to either help prevent another future sprain or to correct the impairments that came along with the last one.

Feet

Because Jennifer’s feet are straight in the picture but her knees are internally rotated, her tibias are actually laterally rotated relative to the femur.

jennifer-front-less-quality-internal-rotation-knees 2

Therefore, there is a very good chance if Jennifer stood with her knee caps facing straight her feet would become everted and or overpronated. They would turn out.

jennifer-front-less-quality-internal-rotation-knees-tibias-too 2

You can see some of this even with the feet straight in the curvature of the right ankle,

jennifer-pronation-curvature 2

Right now my hunch with Jennifer is once she moves (walks / runs) this pronation is going to get exacerbated.

Also, you can’t see it in Jennifer’s photos, but when the hips and knees are hyperextended the ankles tend to be plantarflexed,

(Original image credit (without markings) to Kingdom of Style.)

I’ve mentioned before how these impairments are more common in women primarily due to wearing higher heeled shoes.

hyperextended knee

Look at the hyperextension of the left knee and the plantarflexion of the left ankle.

Anatomy wise, here’s one thing going on: The tibialis anterior is often talked about as an ankle dorsiflexor. It pulls the foot up.

tibialis anteriorThis muscle is often talked about because many people lack dorisflexion as things like high heeled footwear locks their foot down (plantarflexion).

But, and this is less talked about, the tibialis anterior also supinates the foot.

Supinated foot

It turns the foot inward as it dorsiflexes the ankle. So, when training the tibialis anterior and dorsiflexion in someone like Jennifer it also crucial to train supination. You can’t let the foot dorisflex but also pronate.

dorsifleion with supination

Good. (Dorsiflexion with supination.)

dorsiflexion with pronation

Bad. (Dorsiflexion with pronation.)

Summarizing and simplifying

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

She needs more:

  • Humeral inferior glide (probably posterior too)
  • Left scapular adduction
  • Right scapular abduction / upward rotation
  • Femoral external rotation / Wake up those posterior glute muscles

She needs less:

And that’s how I’ll approach things moving forward with her. It will be a combination of just a couple of exercises (to start) along with modifications of her ADLs, all intended at improving what she needs more and less of.

Based off how she looks, feels, and handles these modifications, we’ll progress from there.

For an update on Jennifer, click here.

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