Overall Vertical Alignment of Landmarks
Are the following skeletal landmarks in vertical alignment with, or slightly anterior to, the lateral malleolus?
Auditory meatus
Forward head posture is noted when the auditory meatus is forward of the coronal line. Muscles responsible for forward placement of the head might include sternocleidomastoid, suboccipitals, posterior cervical muscles, pectoralis minors, upper rectus abdominis and diaphragm.
Excessive or reduced spinal curvatures could induce compensations by the cervical region which would place the head forward of the coronal line.
Poor sitting postures, especially noted with computer usage, bookkeeping and while studying, lead to forward placement of the head.
Failing eyesight and hearing loss result in forward head placement in an attempt to see or hear better.
The head is rarely seen to be posterior to the coronal line.
Head of the humerus
The head of the humerus may be noted as forward of the coronal line due to tight pectoral muscles, internal rotation of the upper extremity (either humerus or pronation of forearms) or as compensation for altered spinal curvatures.
Greater trochanter
The greater trochanter (and pelvis in general) may be seen as forward of the coronal line in leaning postures where weight bearing is more toward the forefoot (metatarsal heads). Usually noted in this posture will be tight hamstrings and erector spinae, weak rectus abdominis, shortened dorsiflexors of the feet and hammer toes (as the toes attempt to ‘grip the ground’).
When the greater trochanter is posterior to the coronal line, the result is usually for weight bearing to be more calcaneal, lumbar curvature more flattened, shortened upper rectus abdominis and diaphragm, excessive kyphosis and a forward-placed head.
Head of the fibula
Sling mechanism involving biceps femoris and tibialis anticus which might alter the position of the head of the fibula if dysfunctional.
Feet and Ankle
Because the foot represents the only fixed point in standing postural assessment, the location of the gravity line must be such that it descends immediately anterior to the lateral malleolus, bisecting the calcaneocuboid joint. Alteration of this reference point will proportionately alter findings at all points.
Lower Extremity
Knees
Are the knees flexed or hyperextended?
The plumb line should hang slightly anterior to the center of the knee.
Hyperextended knees are commonly found with hyperlordosis of the lumbar spine and anterior pelvic tilt.
Flexed knees are common in the patient with reduced lumbar lordosis. This may be seen in the antalgic posture as a mechanism to open the lumbar neural foramina.
Sacroiliac joint
Lumbo-Pelvic Hip Complex
ASIS and PSIS Positioning
When the tips of your index fingers are placed one each onto the PSIS and the ASIS, with the fingers pointed directly toward each other, the positions of these pelvic landmarks can be assessed and recorded on both the right and left sides.
The tips of the anteriorly and posteriorly placed fingers should be approximately level with each other, with a slightly lower ASIS being acceptable (especially in women due to anatomical development).
When the ASIS is more than slightly lower than the PSIS, this implies that the innominate is anteriorly rotated, which increases the load on the SIJ, as well as anterior tilting of the sacrum on that side. If bilaterally present, this contributes to increased lumbar lordosis.
When the PSIS is lower than the ASIS, this implies that the innominate is posteriorly rotated on that side. If bilaterally present, this contributes to a loss of lumbar lordosis.
When one innominate is anteriorly rotated and the second is posteriorly rotated, this usually results in a pelvic torsion with a resultant rotation and side bend of the sacrum and rotational scoliosis of (at least) the lumbar region.
Ideally, the gravity line should pass slightly posterior to the center of the hip joint, or through the approximate center of the trochanter of the femur.
Determining pelvic tilt: As stated above, anatomical neutral of the pelvis is the state in which the anterior superior iliac spine and pubic symphysis lie in the same vertical plane indicates that this is correct for males, while a decline of “/” from posterior to anterior superior iliac spine, is normal for females. This will give a goniometric measurement of approximately 5°, with the stationary arm placed between posterior (PSIS) and anterior superior iliac spines (ASIS). It is commenly accepted that goniometric measurements of 3-6° for males, and 5-10° for females, PSIS to ASIS, are well tolerated, and in general coincide with a normal lordosis on x-ray.
Anterior pelvic tilt, brings the center of gravity of the body forward, requiring compensatory extension of the trunk. This is most often the origin of lumbar hyperlordosis.
Posterior pelvic tilt, may be found in association with a trunk flexed posture as well as the sway back posture. In the sway back posture, it may appear as though the pelvis is anteriorly tilted when in some cases it is posteriorly tilted.
Spine
Thoracic Spinal Curvature
Lumbar Spinal Curvature
Upper Extremity
Arm Hang
In the standing posture, the arms should hang in the middle of the body, as divided anterior to posterior.
Shoulder Complex
Shoulder Positioning
The gravity line should bisect the shoulder joint, providing the arm hang is normal.
When the shoulder is behind the line, reduced thoracic kyphosis is often found. If the shoulder is in front of the line, forward head posture is most often found.
Head & Cervical Spine
Head Positioning
Does the gravity line bisect the auditory meatus and the ear lobe?
The forward head posture is almost a universal postural fault. Its magnitude can be measured by utilizing the extended coronal plane. In ideal posture, the tip of the zygomatic arch, the sternal notch, and the pubic symphysis, should all lie in the same plane. The forward head posture then can be measured by holding a ruler horizontal at the level of the sternal notch, and dropping an imaginary plumb line to the ruler.
When the head position is found to be posterior, (similar to that of the shoulder) reduced thoracic kyphosis is common. This condition is infrequent.
NOTE: It is important to stand back and visualize the misalignment between the head, pelvis, and feet, when present. It is helpful in developing insight into treatment approach, to make manual postural adjustments at this time, taking note of what improves alignment.
The angle formed by the SCM, as it passes from origin to insertion, is helpful in determining the degree of forward head. Normal angulation is 45-60°, progressing toward 90° as the FHP develops.
Cervical Spinal Curvature