How to Look at Posture

~::-':vc ::nts for Evaluation

We have a couple of options for looking at the body to 'read' the story behind the problem. Place the body in an anatomically neutral or symmetrical stance. This reveis core imbalances responsible for postural misalignments. 2. Allow the body to unselfconsciously assume its habitual posture, and also observe its movement patterns. This reveis patterns of compensation for core issues that are often at the root of joint problems. To observe the second case scenario, it can be helpful to have the student walk in place, or walk away from
you and back again, so that when he comes to a stop, you can see him fall into his more habitual posture, f only for a moment. In the process, you can often see the compensations that take place, such as throw> more weight to the outer heel of the foot to avoid pronation. You can observe how the feet are placed - whether one is turned out more than the other, or one is forward of the other the orientation of the hips and so on. This reveis the kind of stress that is habitually placed on the body or joints. For instance, if the student has chronic knee pain after walking, the outwardly turned foot (of the leg that is in pain) shows you the kind of rotational stress being placed upon the knee. This approach shows us the compensations the rotations, distribution of weight and so on but only suggests clues as to the core issues, and often masks them. Our habitual (usually asymmetrical) stance is the product of the body's attempt to diffuse problems that lie at a deeper level. Misalignments at the core are uncomfortable. We stand asymmetrically whether consciously or unconsciously as a way of decreas:he discomfort by adjusting at the periphery. When a student stands with a symmetrical foundation, the true postural deviations of the spine show themselves, as well the imbalances in muscle tone in the legs, > u JJj

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Zich form of observation has its purpose. Our habitual stance reveis the compensations that are most likely to be the immediate cause of pain or wear upon the body. A neutral stance and the discomfort it brings reveis the deeper causes behind the compensations. We'll explore each of these forms of observation in turn, starting with the neutral stance.

Neutral Foundation for Evaluation

A neutral or symmetrical stance will include the following:13 1. Feet hip distance (acetabular) apart i.e. vertically in line with the center of the ball-and-socket space of the hip joint. 2. Rotation of the feet: typically in yoga the placement of the feet in Tadasana is parallel, which is used as the stance in evaluation as well. But for the sake of providing a neutral basis for evaluation (rather than an attempt at approximating an ideal of anatomically neutral), it is more often recommended in the field of bodywork that there be approximately 15 degrees of equal external rotation of both feet.14 3. Feet evenly positioned one foot should not be in front of the other.
13 Integrative Manual Therapy volumc III, Thomas Giammatteo, p. 11 14 Ibid.,p. 11
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4. Knees equally flexed/extended if one knee is hyperextended, it should be brought to neutral (with a 'microbend') to match the posture of the other knee.

Sagttal Plae Evaluation Tilting Forward and Back, as Seen from the Side
The 'Sagittal Plae' provides a 'side view' of the body. Evaluation of the body from this 'side view' usually involves an imaginary or real 'plumb line' that touches the curve of the upper back (thoracic kyphosis) and also in normal posture touches or is very cise to the base of the head (occiput) and buttocks. The crner of a wall can be used for this, though the student has to resist the 5.5 cm temptation to lean or press into it. Healthy spinal curves typically give 5-6 cm of space between the plumb line and the deepest part of the cervical curve and lumbar curve.

Typical Misalignments on the Sagittal Plae15

The following are typical deviations of posture that we find in the sagittal plae. 5-6 cm These deviations can be either of a pair of opposites in each rea of the spine: Head and Neck: Forward Head and Neck the head is forward of the center of gravity through the spine. The vertebrae are 'stuck' forward of this plumb line. Fat Neck loss of cervical curve in which the head and particularly the jaw/chin is drawn back strongly, straightening the spine like a ballerina. Upper Back Fat Upper Back loss of thoracic curve by vertebrae that are 'stuck' forward. The reason for this can sometimes be traced to dysfunction of the organs within the rib cage lungs, heart, etc. Excessive Curve in Upper Back excessive thoracic kyphosis because thoracic vertebrae are stuck in a flexed or forward-bending position, which can involve osteoporosis. Often this is a protective mode of posture, especially protecting the heart. In general, this is also a protective posture when the arteries are put under stress from standing up straight particularly if there is a problem with the femoral artery. Lower Back We will be looking at basic postural types, all of which are categorized basically according to the alignment of the pelvis. The distinctions as seen in the sagittal plae have to do with whether the pelvis is tilted too far forward, has a deficient tilt or is forward of the line of gravity causing a flattened lumbar spine, or is 'tucked' causing a rounded lumbar spine. The remaining types have to do with rotations or torsions of the pelvis observed in the coronal and transverse planes.
15 The points and informational points here are paraphrased from Integrative Manual Therapy volume III, Giammatteo, p. 11
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Other Deviatons Protruding Chin from hyperextension of the neck (between occiput and atlas). Headaches can result from the compression of the back of the neck at the space beneath the head. Dowager's hump a dysfunction at the junction between the cervical and thoracic vertebrae.

Misalignments at the Extremities

Misalignments in the Sagittal Plae can also show up in the limbs: 1. Forward (anterior) Shoulders most often from shortness of pectoralis minor and subscapularis. 2. Hyperextension of the Knees
3. Posterior Glide of the base of the tibia limitation of the ability to 'flex' the foot (dorsiflexion) because the tibia is stuck 'back' (posterior) on the talus bone. This is a very common problem, a limitation of movement quite often associated with hyper-

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Coronal Plae Evaluation Highs and Lows, as Seen from Front and Back
Evaluation in the Coronal plae looks at the body from trie front and back, taking note of differences in elevation between right and left sides of the body highs and lows that indcate either 'bends' (in the spine side to side) or 'shifts' (such as a shift of the head or chest to one side, or a sideward shift of the pelvis). A useful grid is suggested by Pete Egoscue in which we Une up the key joints: ankles, knees, hips and shoulders. The point here is largely to determine whether the joints on the two sides of the body are level with each other, or whether one side is higher or lower. Vertical alignrnent of the joints is an added and desirable bonus. The shoulders, of course, vary a great deal in width among various body types (measured at the axis of the joint, or head of the armbone). Thus we look more to the chest at the hollow space just beneath the collarbone, to the outside of the rib cage. The point is that the shoulders be 'level' across the collarbones, and parallel to the horizontal lines of the rest of the joints notably the hips.

Because of the variety of shoulder widths, the shoulder joints themselves may not une up vertically with the hips, knees and ankles. Nevertheless, the joint levis (horizontal lines) should ideally be parallel with each other.

The level of the hips is ideally measured at the joint itself. This s usually rather hard for most of us to determine, so a sood indicator is to find your 'hip points' with your thumbs, and check whether they are level' in a mirror.

The knee joints are meant to bend at right ansies, and so ideal placement is vertically below the hip joints. Wide hip joints that crate a greater 'Q' angle from hip bone to knee will place uneven pressure on the knee as well as affect the tone of the four muscles of the quadriceps, with greater chance of knee problems The quality of the arches whether the feet pronate (fallen arches, arches turning in) or supnate (high arches, ankles turning out) will affect how well the ankles bend in une with the knee and hip.
Redrawn from The Egoscue Method of Heang Through Motion, p. 12

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The hips are measured at the hip joint itself, where the head of the thighbone fits in the socket. This is of course very hard to observe, so a helpful and more accessible indicator would be the 'hip points,' which can easily be found by touch. This gives a fair indication of whether one hip is higher than the other, and also tells you of rotations in the pelvis: when one hip point is higher than the other, it is often rotated more posteriorly ('back') than the other, indicating that the hip bone itself is rotated back. The other hip point which is lower is often tipped anteriorly, indicating that the hip bone is rotated forward. This is one of the most accessible and important bits of information you can fmd for figuring out sacral and hip problems.

The Most Common Problem Observed at the Hip Points

The most common problem you will observe in the Coronal plae is a discrepancy in the level of the hip points one hip point (quite often the left) is observed to be higher (toward the head) than the other. This can be due to a real discrepancy in leg length causing a sideward tilt to the hips or much more commonly an apparent discrepancy in leg length arising from the habit of putting more weight on one leg than the other, usually with pronation of the foot on the more weight-bearing side. This makes the other leg seem to be shorter, since it struggles to reach the ground usually supinating the foot. In this case there is not so much a tilt to the side, but rather a torsin, in which the hip bones are rotated in opposite directions the 'low' hip point rotated forward and down on the more weight-bearing and collapsed side; the 'high' hip rotated up and back on the lighter side. This discrepancy in hip height has consequences for the knees and shoulders. Knees There will be rotations in the bones of the legs that will cause wear and tear on the knees largely because the hip joints and feet will be 'pointing' in different directions, causing twisting or uneven pressure in the knees. The single most important principie at work for motion in the lower body is that the lower leg joints knee and ankle are meant to move at right angles both in line with each other and in line with the hip. If we are walking forward, the hip joint 'points' us forward, and the knee and ankle should also 'point' straight forward as they bend and extend in the process of walking. But all too often they don't. When there is a discrepancy in the hip joints because of rotations in the hip bones. the hips 'point' the legs in different directions: one thigh is rotated inwardly, pointing the thighbone/ knee inward toward the midline as it bends; the other is rotated more externally, pointing the thighbone/ knee outward. The inward rotation is on the side of the hip point that is 'down;' the external rotation is on the side of the 'high' hip point. On the high side, the hip is doing the walking rather than the core hip exors (psoas), and the leg and hip get stifF. Usually, as we'll see in cases of rotated and twisted postures, the foot will be turned out (externally rotated) on the leg in which the thigh is turned in (medially rotated) meaning that the thighbone and shins are turned in opposite directions at the knee, twisting the knee. On the side of the 'high' hip, the stifhess and external rotation of the hip will cause more jamming at the outer knee. Many knee problems arise from the fact that the knee essentially tries to do whatever the hip and foot tell it to do. When it receives opposing messages, it suffers! The first clue to the cause of problems in the knee, foot and hip thus can be found in the Coronal plae - from observing the relative 'height' of the hip points and arches of the feet (pronation or supination), and from observing the rotations of the thighbone and shin relative to each other at the knee.

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Shoulders The shoulder is often though not always elevated on the same side as the 'high' hip. The shoulder generally acts as a counterweight to the hips, and can be involved in the effort of hoisting up the stiff leg and swinging it around to bring it forward. This is dramatized by actors playing the role of a hunchback in horror films. With most of the weight shifted to one side of the body, they throw the opposite hip and leg forward with the help of the lifted or 'hunched' shoulder, as if that side of the body were half paralyzed. In some cases that's not far from the mark, minus the hammy theatricality.16 Postural dysfunctions that show up in the Coronal plae thus include shifts, bends and tilts to the side: a shift in weight (via a shift in the hips to one side, along with a tilt) can crate a side-bend in the spine, and a tilt (and even a shift) of the head to the opposite side as a counterbalance. But at least in this case, the problem lies not in the architecture; it lies in the unbalanced use to which it is being put in a word, ftmction. And form our physical form most often follows function.

The'Shorter Leg Syndrome'which s Observable n the Coronal Plae

Habitually shifting the weight to one side s like carrying a heavy bucket; the heavy side is compressed downward, while the light side is pulled upward Lower Hip Greater weightbearing Increased stress on hip joint, knee and ankle As the pelvis shifts to the weight-bearing side, the lium of the weight-bearing side tips downward (anteriorly) from pressure, especially as the weight-bearing muscles of the hip tire. This can cause pinching or compression in the groin at the hip joint. Lighter Load: Muscles and Bones pulled up away from floor To get a sense of this, imagine carrying a heavy bucket: the compressed leg is on the side of the bucket. The other leg is lighter: the ilium puls upward and usuaily tips back (posteriorly) as the energy of the entire leg (and shoulder) puls upward to maintain balance. Thus the 'hip points' are noticeably uneven. Foot Pronates under the weight: pressure from walking rebounds nto the ankle and knee Usually foot of the 'short' weight-bearing leg will be pronated (weight on the inner edge; fat foot) while the foot of the long' leg will be supinated (weight on the outer edge; high arch). Since the supinated foot seems to struggle to reach the ground and has less weight on itbecause the hip is pulled up higher the leg seems to be shorter and will even appear to be so if you have the person lie down, and look at the apparent leg length.

Shoulders and Hips Move and Work as aUnit

Elevated Hip

Right Leg Stiffens

Foot supinates (high arch) as it 'reaches' for the floor while bearing less weight

Redrawn from The Egoscue Method of Healing Through Motion, p. 32

16

The Egoscue Method of Healing Through Motion, p. 36

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Lateral Shift of Neck Shoulder Girdle Inferior angle of scapula 12th Ribs (lateral) Space between lower ribs and liui (top of hip bone)

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There are of course more elabrate and precise points for checking difFerences in elevation on either side of the body.17 These can include lateral shifts in the bones, such as in the head of the shin bone, or in the bones of the ankles. In the legs and arms, coronal deviations show up as the following: 1. Lateral (sideways) shift or compression at the hips (greater trochanters). Checking the level of the 'hip points' tips us offon this. 2. Lateral glide of the head of the shin (tibial plateau) at the knee joint. Here we can check the 'bump of the tibia below the kneecap. 3. Pronation or Supination of the foot and anide. Here we look to the inner ankle (inferior medial malleolus) 4. The angle of the elbow (as well as the level), and the turn or 'ulnar deviation' of the wrist. Here we can tell especially by noting how much of the back of the hand is showing.
Integrativc Manual Therapy volume III, Thomas Giammatteo, p. 21
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Transverse Plae Posture Evaluaton: Rotations around the Center

Transverse Plae evaluation has to do with rotational dysfunctions of the spine, and the checking is done for the most part from the back body by looking at the tone and prominence of the muscles at either side of the spine, and at the transverse processes.18 These kinds of rotations are obviously related to 'outer body' rotations seen in the Coronal Plae evaluation, especially when there is scoliosis. Transverse Plae evaluation looks closer to the spine in the back body, noticing prominences around the vertebrae, which are more 'in' or 'out' rather than high or low. At the front body, we can look at the shoulders for transverse dysfunction. We look for whether a shoulder is 'forward.' This will bring limitations in movement: if the right shoulder is forward (protracted, with the shoulder blade moving away from the spine), then the arm will be limited in its ability to lift out to the side (horizontal abduction) as well as limitations in the ability to draw back (retract) the shoulder. The most important landmarks at the front body are the 'hip points,' which can give a clue to rotations of the spine at the sacrum. Because of their connection to the Spiral Sutra, rotations of the pelvic bones that appear at the hip points will be closely allied with misalignments and rotations that appear in the arches of the feet, the knees, spine, shoulders and neck. Transverse evaluation looks 'around' the central axis of the body to see rotations that appear as combinations of 'tilts' (anterior or 'forward,' and posterior or 'back') that appear in the sagittal plae, and highs and lows that appear in the coronal plae. The transverse plae makes these observations 'three-dimensional' by noting rotations in three-dimensional space.

18

Integrative Manual Therapy volume III, Thomas Giammatteo, p. 24

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Basic Types of Posture

Classification of Types of Posture can be based essentially upon what the hips are doing, from a forward tilt to the pelvis causing excessive lumbar curve, to a backward tilt in the extreme, a 'tuck' causing a flat or even rounded lumbar spine. Each postural type will carry with it specific problems, particularly for the low back, which we'll explore.

Tilted'

Forward Hips/ Swayback

'Fat'

Tucked'

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Forward Pelvic Tilt

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Backward Pelvic Tilt

Backward Pelvic Tilt and Shift

Basic Postural Types can be distinguished according to:

'Rotated'

1. The 'tilt' of the pelvis, which is relative to 1. The 'shift' of the pelvis relative to the center of gravity. It is far more common that the basic postural type is combined with some degree of rotation in the pelvis, whether it s 1. A 'rotation' of the pelvis around the central axis of the body, with one side of the body hip and shoulder forward of the other. 1. A 'twist' or torsin in the pelvis itself, most often from uneven weight bearing on the feet or greater pronation and outward rotation of one foot; also accompanied by the opposite shoulder being pulled toward the 'low' hip, causing twisting in the upper body.

Twisted'

Rotated around central axis, with some discrepancy in hip ~eght from rotation of torso

Pelvis Twisted from opposins pul of shoulders and feet: greater discrepancy in hip height

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