There are many examples of poor posture (Figure 15-5). Some of the causes are postural (positional), and some are structural.

Lordosis is an anterior curvature of the spine (Figure 15-6).^5–9 Pathologically, it is an exaggeration of the normal curves found in the cervical and lumbar spines. Causes of increased lordosis include (1) postural or functional deformity; (2) lax muscles, especially the abdominal muscles, in combination with tight muscles, especially hip flexors or lumbar extensors (Table 15-1); (3) a heavy abdomen, resulting from excess weight or pregnancy; (4) compensatory mechanisms that result from another deformity, such as kyphosis (Figure 15-7); (5) tight and commonly strong muscles (see Table 15-1); (6) spondylolisthesis; (7) congenital problems, such as bilateral congenital dislocation of the hip; (8) failure of segmentation of the neural arch of a facet joint segment; or (9) fashion (e.g., wearing high-heeled shoes). There are two types of exaggerated lordosis, pathological lordosis and swayback deformity.

Pathological Lordosis.

In the patient with pathological lordosis, one may often observe sagging shoulders (scapulae are protracted and arms are medially rotated), medial rotation of the legs, and poking forward of the head so that it is in front of the center of gravity (Figure 15-8). This posture is adopted in an attempt to keep the center of gravity where it should be. Deviation in one part of the body often leads to deviation in another part of the body in an attempt to maintain the correct center of gravity and the correct visual plane. This type of exaggerated lordosis is the most common postural deviation seen.

The pelvic angle, normally approximately 30°, is increased with lordosis. With excessive or pathological lordosis, there is an increase in the pelvic angle to approximately 40°, accompanied by a mobile spine and an anterior pelvic tilt. Exaggerated lumbar lordosis is usually accompanied by weakness of the deep lumbar extensors and tightness of the hip flexors and tensor fasciae latae combined with weak abdominals (see Table 15-1).¹⁰

Swayback Deformity.

With a swayback deformity, there is increased pelvic inclination to approximately 40°, and the thoracolumbar spine exhibits a kyphosis (Figure 15-9). A swayback deformity results in the spine’s bending back rather sharply at the lumbosacral angle. With this postural deformity, the entire pelvis shifts anteriorly, causing the hips to move into extension. To maintain the center of gravity in its normal position, the thoracic spine flexes on the lumbar spine. The result is an increase in the lumbar and thoracic curves. Such a deformity may be associated with tightness of the hip extensors, lower lumbar extensors, and upper abdominals, along with weakness of the hip flexors, lower abdominals, and lower thoracic extensors (Table 15-2).¹

TABLE 15-2

Changes Associated with Swayback

Body segment alignment	Long kyphosis with pelvis the most anterior body segment, hip joint moves forwards of posture line (thoracic spine mobile to compensate) Lower lumbar area flattens Pelvis neutral or in posterior tilt Hip and knee joints hyperextended Where subject stands predominantly on one leg, pelvis is tilted down to non-favored side Favored leg appears longer in standing only
Muscles commonly elongated and weak	One joint hip flexors External obliques Lower thoracic extensors Lower abdominals Neck flexors Where one leg is favored, gluteus medius (especially posterior fibers) on favored side
Muscles commonly short and strong	Hamstrings Hip extensors Upper fibers of internal obliques Internal intercostals Low back musculature short but not strong Where one leg is favored, tensor fascia lata is strong and iliotibial band is tight on favored side
Joints commonly affected	Lumbar spine Pelvic joints Thoracic spine Hip joints Thoracic spine Scapulothoracic joints Glenohumeral joints Cervical spine Atlanto-occipital joints Temporomandibular joints

Adapted from Kendall FP, McCreary EK: Muscles: testing and function, Baltimore, 1983, Williams & Wilkins; Giallonardo LM: Posture. In Myers RS, editor: Saunders manual of physical therapy practice, Philadelphia, 1995, WB Saunders.

Kyphosis is a posterior curvature of the spine (Figures 15-10 and 15-11).^7,9,11–15 Pathologically, it is an exaggeration of the normal curve found in the thoracic spine. There are several causes of kyphosis, including tuberculosis, vertebral compression fractures, Scheuermann disease, ankylosing spondylitis, senile osteoporosis, tumors, compensation in conjunction with lordosis, and congenital anomalies.¹¹ The congenital anomalies include a partial segmental defect, as seen in osseous metaplasia, or centrum hypoplasia and aplasia.^14,16,17 In addition, paralysis may lead to a kyphosis because of the loss of muscle action needed to maintain the correct posture combined with the forces of gravity.

Pathological conditions, such as Scheuermann vertebral osteochondritis, may also result in a structural kyphosis (Figure 15-12 ). In this condition, inflammation of the bone and cartilage occurs around the ring epiphysis of the vertebral body. The condition often leads to an anterior wedging of the vertebra. It is a growth disorder that affects approximately 10% of the population, and in most cases several vertebrae are affected. The most common area for the disease to occur is between T10 and L2.

The four types of kyphosis are round back, humpback, flat back, and dowager’s hump.

Round Back.

The patient with a round back has a long, rounded curve with decreased pelvic inclination (less than 30°) and thoracolumbar kyphosis. The patient often presents with the trunk flexed forward and a decreased lumbar curve (Figure 15-13). On examination, there are tight hip extensors and trunk flexors with weak hip flexors and lumbar extensors (Table 15-3).

TABLE 15-3

Changes Associated with a Round Back Form of Kyphosis

Body segment alignment	Head held forward with cervical spine hyperextended Scapulae may be protracted Increased thoracic kyphosis Hips flexed, knees hyperextended Head is usually most anteriorly placed body segment
Muscles commonly elongated and weak	Neck flexors Upper erector spinae External obliques If scapulae are protracted, middle and lower trapezius Thoracic erector spinae Rhomboids
Muscles commonly short and strong	Neck extensors Hip flexors If scapulae are protracted, serratus anterior, pectoralis major and/or minor, upper trapezius, levator scapulae Upper abdominal muscles Intercostales
Joints commonly affected	Thoracic spine Scapulothoracic joints Glenohumeral joints

Adapted from Kendall FP, McCreary EK: Muscles: testing and function, Baltimore, 1983, Williams & Wilkins; Giallonardo LM: Posture. In Myers RS, editor: Saunders manual of physical therapy practice, Philadelphia, 1995, WB Saunders.

Humpback or Gibbus.

With humpback, there is a localized, sharp posterior angulation in the thoracic spine (Figure 15-14). This is commonly a structural deformity as the result of a fracture or pathology.

Flat Back.

A patient with flat back has decreased pelvic inclination to 20° and a mobile lumbar spine (Figure 15-15). Table 15-4 outlines the structures affected.

TABLE 15-4

Changes Associated with a Flat Back Form of Kyphosis

Body segment alignment	Loss of lordosis with pelvis in posterior tilt Hip and knee joints hyperextended Forward head posture with increased flexion to upper thoracic spine
Muscles commonly elongated and weak	One joint hip flexors Lumbar extensors Local stabilizers (multifidus, rotatores) Scapular protractors (?) Anterior intercostals
Muscles commonly short and strong	Hamstrings Abdominals may be strong with back muscles slightly elongated Hip extensors Scapular retractors (?) Thoracic erector spinae
Joints commonly affected	Lumbar spine Pelvic joints Scapulothoracic joints (?) Thoracic spine (?) Cervical spine (?)

Adapted from Kendall FP, McCreary EK: Muscles: testing and function, Baltimore, 1983, Williams & Wilkins; Giallonardo LM: Posture. In Myers RS, editor: Saunders manual of physical therapy practice, Philadelphia, 1995, WB Saunders.

Dowager’s Hump.

Dowager’s hump is often seen in older patients, especially women. The deformity commonly is caused by osteoporosis, in which the thoracic vertebral bodies begin to degenerate and wedge in an anterior direction, resulting in a kyphosis (Figure 15-16).

Kypholordotic Posture.

In some cases, both the thoracic and lumbar spine may be affected. Figure 15-17 and Table 15-5 outline the changes seen with this posture.

TABLE 15-5

Changes Associated with Kypholordotic Posture

Body segment alignment	Head held forward with cervical spine hyperextended Scapulae may be protracted Increased lumbar lordosis, and increased thoracic kyphosis Pelvis anteriorly tilted Hip flexed, knee hyperextended Head is usually most anteriorly placed body segment
Muscles commonly elongated and weak	Neck flexors Upper erector spinae External obliques If scapulae are protracted, middle and lower trapezius Thoracic erector spinae Middle and lower trapezius Rhomboids
Muscles commonly short and strong	Neck extensors Hip flexors If scapulae are protracted, serratus anterior, pectoralis major and/or minor, upper trapezius Intercostales
Joints commonly affected	Thoracic spine Lumbar spine Scapulothoracic joints Glenohumeral joints

Adapted from Kendall FP, McCreary EK: Muscles: testing and function, Baltimore, 1983, Williams & Wilkins; Giallonardo LM: Posture. In Myers RS, editor: Saunders manual of physical therapy practice, Philadelphia, 1995, WB Saunders.

Scoliosis is a lateral curvature of the spine.11,13,18–24 This type of deformity is often the most visible spinal deformity, especially in its severe forms. The most famous example of scoliosis is the “hunchback of Notre Dame.” In the cervical spine, a scoliosis is called a torticollis. There are several types of scoliosis, some of which are nonstructural (Figure 15-18) and some of which are structural. Nonstructural or functional scoliosis may be caused by postural problems, hysteria, nerve root irritation, inflammation, or compensation caused by leg length discrepancy or contracture (in the lumbar spine) (Table 15-6).²³ Structural scoliosis primarily involves bony deformity, which may be congenital or acquired, or excessive muscle weakness, as seen in a person with long-term quadriplegia. This type of scoliosis may be caused by wedge vertebra, hemivertebra (Figure 15-19), or failure of segmentation. It may be idiopathic (genetic) (Figure 15-20); neuromuscular, resulting from an upper or lower motor neuron lesion; or myopathic, resulting from muscular disease; or it may be caused by arthrogryposis, resulting from persistent joint contracture,¹⁷ or by conditions such as neurofibromatosis, mesenchymal disorders, or trauma. It may accompany infection, tumors, and inflammatory conditions that result in bone destruction. Torticollis may occur because of neuromuscular problems, because of congenital problems (abnormal sternocleidomastoid muscle), or in conjunction with malocclusion of the temporomandibular joints or with ear problems (referred to the cervical spine).

With structural scoliosis, the patient lacks normal flexibility, and side bending becomes asymmetrical. This type of scoliosis may be progressive, and the curve does not disappear on forward flexion. It is most commonly seen in the thoracic or thoracolumbar spine. With nonstructural scoliosis, there is no bony deformity; this type of scoliosis is not progressive. The spine shows segmental limitation, and side bending is usually symmetrical. The nonstructural scoliotic curve disappears on forward flexion. This type of scoliosis is usually found in the cervical, lumbar, or thoracolumbar area.

Idiopathic scoliosis accounts for 75% to 85% of all cases of structural scoliosis. The vertebral bodies rotate into the convexity of the curve with the spinous processes going toward the concavity of the curve. There is a fixed rotational prominence on the convex side, which is best seen on forward flexion from the skyline view. This prominence is sometimes called a “razorback spine.” The disc spaces are narrowed on the concave side and widened on the convex side. There is distortion of the vertebral body, and vital capacity is considerably lowered if the lateral curvature exceeds 60°; compression and malposition of the organs within the rib cage also occur. Examples of scoliotic curves are shown in Figure 15-21.

The examiner should first determine the patient’s body type (Figure 15-24).²⁵ The three body types are ectomorphic, mesomorphic, and endomorphic. The ectomorph is a person who has a thin body build characterized by a relative prominence of structures developed from the embryonic ectoderm. The mesomorph has a muscular or sturdy body build characterized by relative prominence of structures developed by the embryonic mesoderm. The endomorph has a heavy or fat body build characterized by relative prominence of structures developed from the embryonic endoderm.

In addition to body type, the examiner should note the emotional attitude of the patient. Is the patient tense, bored, or lethargic? Does the patient appear to be healthy, emaciated, or overweight? Answers to these questions can help the examiner determine how much must be done to correct any problems. For example, if the patient is lethargic, it may take longer to correct the problem than if he or she appears truly interested in correcting the problem. The examiner must remember that posture is in many ways an expression of one’s personality, sense of well-being, and self-esteem.

Anterior View

When observing the patient from the front (Table 15-7; see Figure 15-1, A), the examiner should note whether the following conditions hold true:

1. The head is straight on the shoulders (in midline). The examiner should note whether the head is habitually tilted to one side or rotated (e.g., torticollis) (Figure 15-25). The cause of altered head position must be established. For example, it may be the result of weak muscles, trauma, a hearing loss, temporomandibular joint problems, or the wearing of bifocal glasses.

2. The posture of the jaw is normal. In the resting position, normal jaw posture is when the lips are gently pressed together, the teeth are slightly apart (freeway space), and the tip of the tongue is behind the upper teeth in the roof of the mouth. This position maintains the mandible in a good posture (i.e., slight negative pressure in the mouth reduces the work of the muscles). It also enables respiration through the nose and diaphragmatic breathing.

3. The tip of the nose is in line with the manubrium sternum, xiphisternum, and umbilicus. This line is the anterior line of reference used to divide the body into right and left halves (see Figure 15-1, A). If the umbilicus is used as a reference point, the examiner should remember that the umbilicus is almost always slightly off center.

4. The upper trapezius neck line is equal on both sides. The muscle bulk of the trapezius muscles should be equal, and the slope of the muscles should be approximately equal. Because the dominant arm usually shows greater laxity by being slightly lower, the slope on the dominant side may be slightly greater.

5. The shoulders are level. In most cases, the dominant side is slightly lower.

6.  The clavicles and acromioclavicular joints are level and equal. They should be symmetrical; any deviation should be noted. Deviations may be caused by subluxations or dislocations of the acromioclavicular or sternoclavicular joints, fractures, or clavicular rotation.

7. There is no protrusion, depression, or lateralization of the sternum, ribs, or costal cartilage. If there are changes, they should be noted.

8. The waist angles are equal, and the arms are equidistant from the waist. If a scoliosis is present, one arm hangs closer to the body than the other arm. The examiner should also note whether the arms are equally rotated medially or laterally.

9. The carrying angles at each elbow are equal. Any deviation should be noted. The normal carrying angle varies from 5° to 15°.

10. The palms of both hands face the body in the relaxed standing position. Any differences should be noted and may give an indication of rotation in the upper limb.

11. The “high points” of the iliac crest are the same height on each side (Figure 15-26). With a scoliosis, the patient may feel that one hip is “higher” than the other. This apparent high pelvis results from the lateral shift of the trunk; the pelvis is usually level. The same condition can cause the patient to feel that one leg is shorter than the other.

12. The anterior superior iliac spines (ASISs) are level. If one ASIS is higher than the other, there is a possibility that one leg is shorter than the other or that the pelvis is rotated more or shifted up or down more on one side.

13. The pubic bones are level at the symphysis pubis. Any deviation should be noted.

14. The patellae of the knees point straight ahead. Sometimes the patellae face outward (“frog eyes” patellae) or inward (“squinting” patellae). The position of the patella may also be altered by torsion of the femoral neck (anteversion-retroversion), femoral shaft, or tibial shaft.

15. The knees are straight. The knees may be in genu varum or genu valgum. If the ankles are together and the knees are more than two finger-widths apart, the patient has some genu varum. If the knees are touching and the feet are apart, the patient has some genu valgum. Genu valgum is more likely to be seen in females. The examiner should note whether the deformity results from the femur, tibia, or both. In children, the knees go through a progression of being straight, going into genu varum (Figure 15-27), being straight, going into genu valgum (Figure 15-28), and finally being straight again during the first 6 years of life (see Figure 15-4).¹³

16. The heads of the fibulae are level.

17. The medial and lateral malleoli of the ankles are level. Normally, the medial malleoli are slightly anterior to the lateral malleoli, but the lateral malleoli extend farther distally.

18. Two arches are present in the feet and equal on the two sides. In this position, only the medial longitudinal arch is visible. The examiner should note any pes planus (flatfoot) or pronated foot, pes cavus (“hollow” foot) or supinated foot, or other deformities.

19. The feet angle out equally (this Fick angle is usually 5° to 18° [see Figure 14-14]; Figure 15-29). This finding means that the tibias are normally slightly laterally rotated (lateral tibial torsion). The presence of pigeon toes usually indicates medial rotation of the tibias (medial tibial torsion), especially if the patellae face straight ahead. If the patellae face inward (squinting patellae) in the presence of “pigeon toes” or outward, the problem may be in the femur (abnormal femoral torsion or hip retroversion-anteversion problems).

20. There is no bowing of bone. Any bowing may indicate diseases, such as osteomalacia or osteoporosis.

21. The bony and soft-tissue contours are equally symmetrical on the two halves of the body. Any indication of muscle wasting, muscle hypertrophy on one side, or bony asymmetry should be noted. Such a finding may indicate muscle or nerve pathology, or it may simply be related to the patient’s job or recreational pursuits. For example, a rodeo bull rider will show hypertrophy of the muscles and bones on one side. (The arm that he uses to hang on!)

TABLE 15-7

Alignment in the Standing Posture: Anterior View

Body Segment	Line of Gravity Location	Observation
Head	Passes through middle of the forehead, nose and chin	Eyes and ears should be level and symmetrical
Neck/shoulders		Right and left angles between shoulders and neck should be symmetrical; clavicles also should be symmetrical
Chest	Passes through the middle of the xyphoid process	Ribs on each side should be symmetrical
Abdomen/hips	Passes through the umbilicus (navel)	Right and left waist angles should be symmetrical
Hips/pelvis	Passes on a line equidistant from the right and left ASISs; passes through the symphysis pubis	ASISs should be level
Knees	Passes between knees equidistant from medial femoral condyles	Patella should be symmetrical and facing straight ahead
Ankles/feet	Passes between ankles equidistant from the medial malleoli	Malleoli should be symmetrical, and feet should be parallel; toes should not be curled, overlapping, or deviated to one side

ASIS, Anterior superior iliac spine.

From Levangie PK, Norkin CC: Joint structures and function—a comprehensive analysis, Philadelphia, 2005, FA Davis, p. 498.

In addition, the patient’s skin is observed for abnormalities, such as hairy patches (e.g., diastematomyelia), pigmented lesions (e.g., café au lait spots, neurofibromatosis), subcutaneous tumors, and scars (e.g., Ehlers-Danlos syndrome), all of which may lead to or contribute to postural problems (Figure 15-30). Table 15-8 shows some of the malalignment postures and their effect.^2,13,27,28 Changes in one body segment cause changes in other segments as the body attempts to compensate or adjust for the malignment.² Compensatory postures are those that represent the body’s attempt to normalize appearance or improve function.²

TABLE 15-8

Malalignments Viewed Anteriorly2,13,27,28

Malalignment	Possible Correlated Motions or Postures	Possible Compensatory Motions or Postures
Torticollis	Rotation to same side limited Side flexion to opposite side limited
Scoliosis	Side flexion to convex side limited Rotation to convex side limited Rib hump on convex side
Lateral pelvic tilt (pelvic drop—right leg stance)	Right hip adduction Weak right abductors (positive Trendelenberg)	Right lumbar lateral flexion Tight left adductors
Lateral pelvic tilt (pelvic hitch— right leg stance)	Right hip abduction Weak left adductors	Left lumbar lateral flexion Tight right abductors
Forward rotation of one ilium on sacrum (right leg stance)	Right hip medial rotation Medial facing patella In-toeing Pronation of foot Long leg	Left lumbar rotation Scoliosis—concavity to left Knee flexion
Excessive anteversion	Toeing-in Subtalar pronation Lateral patellar subluxation Medial tibial torsion Medial femoral torsion	Lateral tibial torsion Lateral rotation at knee Lateral rotation of tibia, femur, and/or pelvis Lumbar rotation on same side
Excessive retroversion	Toeing-out Subtalar supination Lateral tibial torsion Lateral femoral torsion	Medial rotation at knee Medial rotation of tibia, femur, and/or pelvis Lumbar rotation on opposite side
Coxa vara	Pronated subtalar joint Medial rotation of leg Short ipsilateral leg Anterior pelvic rotation	Ipsilateral subtalar supination Contralateral subtalar pronation Ipsilateral plantar flexion Contralateral genu recurvatum Contralateral hip and/or knee flexion Ipsilateral posterior pelvic rotation and ipsilateral lumbar rotation
Coxa valga	Supinated subtalar joint Lateral rotation of leg Long ipsilateral leg Posterior pelvic tilt	Ipsilateral subtalar pronation Contralateral subtalar supination Contralateral plantar flexion Ipsilateral genu recurvatum Ipsilateral hip and/or knee flexion Ipsilateral anterior pelvic rotation and contralateral lumbar rotation
Medial femoral torsion	Excessive subtalar pronation In-toeing Medial facing or tilted patella (“squinting patella”)	Excessive subtalar supination Functional forefoot valgus
Lateral femoral torsion	Excessive subtalar supination Out-toeing Lateral facing or tilted patella (“grasshopper eyes patella”)	Excessive subtalar pronation Functional forefoot varus
Genu valgum	Pes planus Excessive subtalar pronation Lateral tibial torsion Lateral patellar subluxation Excessive hip adduction Ipsilateral hip excessive medial rotation Lumbar spine contralateral rotation	Forefoot varus Excessive subtalar supination to allow the lateral heel to contact the ground In-toeing to decrease lateral pelvic sway during gait Ipsilateral pelvic lateral rotation
Genu varum	Excessive lateral angulation of the tibia in the frontal plane; tibial varum Medial tibial torsion Ipsilateral hip lateral rotation Excessive hip abduction	Forefoot valgus Excessive subtalar pronation to allow the medial heel to contact the ground Ipsilateral pelvic medial rotation
Lateral tibial (malleolar) torsion	Out-toeing Excessive subtalar supination with related rotation along the lower quarter	Functional forefoot varus Excessive subtalar pronation with relaxed rotation along the lower quarter
Medial tibial (malleolar) torsion	In-toeing Metatarsus adductus Excessive subtalar pronation with related rotation along the lower quarter	Functional forefoot valgus Excessive subtalar supination with relaxed rotation along the lower quarter
Inadequate tibial retroflexion (bowing of the tibia)	Altered alignment of Achilles tendon causing altered associated joint motion
Bowleg deformity of the tibia (tibial varum)	Medial tibial torsion	Forefoot valgus Excessive subtalar pronation
Ankle equinus		Hypermobile first ray Subtalar or midtarsal excessive pronation Hip or knee flexion Genu recurvation
Forefoot valgus	Hallux valgus Subtalar pronation and related rotation along the lower quarter	Excessive midtarsal or subtalar supination Excessive tibial; tibial and femoral; or tibial, femoral, and pelvic lateral rotation, or all with ipsilateral lumbar spine rotation
Metatarsus adductus	Hallus valgus Medial tibial torsion Flatfoot Toeing-in
Hallus valgus	Forefoot valgus Subtalar pronation and related rotation along the lower quarter	Excessive tibial; tibial and femoral; or tibial, femoral, and pelvic lateral rotation, or all with ipsilateral lumbar spine rotation
In-toeing	Pronated foot Medial tibial torsion Metatarsus varus Talipes varus or equinovarus Tibia or genu varum Medial femoral torsion Excessive femoral anteversion Tight medial hip rotators Acetabular dysplasia (facing anteriorly)
Out-toeing	Tight Achilles Talipes calcaneovalgus Convex pes planovarus Lateral tibial torsion Hypoplastic (absence) of fibula Lateral femoral torsion Abnormal femoral retroversion Tight lateral rotators Flaccid medial rotators Acetabular dysplasia (facing posteriorly)
Rearfoot valgus (calcaneal eversion)	Tibial; tibial and femoral; or tibial, femoral, and pelvic rotation Hallux valgus

Lateral View

From the side (Table 15-9; see Figure 15-1, B), the examiner should note whether the following conditions hold true:

1. The earlobe is in line with the tip of the shoulder (acromion process) and the “high point” of the iliac crest. This line is the lateral line of reference dividing the body into front and back halves (see Figure 15-1, B). If the chin pokes forward, an excessive lumbar lordosis may also be present. This compensatory change is caused by the body’s attempt to maintain the center of gravity in the normal position.

2. Each spinal segment has a normal curve (Figure 15-31). Large gluteus maximus muscles or excessive fat may give the appearance of an exaggerated lordosis. The examiner should look at the spine in relation to the sacrum, not the gluteal muscles. Likewise, the scapulae may give the illusion of an increased kyphosis in the thoracic spine, especially if they are flat and the patient has rounded shoulders.

3. The shoulders are in proper alignment. If the shoulders droop forward (i.e., the scapulae protract), “rounded shoulders” are indicated. This improper alignment may be caused by habit or by tight pectoral muscles or weak scapular stabilizers.

4. The chest, abdominal, and back muscles have proper tone. Weakness or spasm of any of these muscles can lead to postural alterations.

5. There are no chest deformities, such as pectus carinatum (undue prominence of the sternum) or pectus excavatum (undue depression of the sternum).

6. The pelvic angle is normal (30°; Figure 15-32). The posterior superior iliac spine (PSIS) should be slightly higher than the ASIS.

7. The knees are straight, flexed, or in recurvatum (hyperextended). Usually, in the normal standing position, the knees are slightly flexed (0° to 5°). Hyperextension of the knees may cause an increase in lordosis in the lumbar spine. Tight hamstrings or gastrocnemius muscles can also cause knee flexion.

TABLE 15-9

Alignment in the Standing Posture: Side View

Joints	Line of Gravity	External Moment	Passive Opposing Forces	Active Opposing Forces
Atlanto-occipital	Anterior (anterior-to-transverse axis for flexion and extension)	Flexion	Ligamentum nuchae and alar ligaments; the tectorial, atlanto-axial, and posterior atlanto-occipital membranes	Rectus capitus posterior major and minor, semispinalis capitus and cervicis, splenius capitis and cervicis, and inferior and superior oblique muscles
Cervical	Posterior	Extension	Anterior longitudinal ligament, anterior anulus fibrosus fibers, and anterior zygapophyseal joint capsules	Anterior scalene, longus capitis and colli
Thoracic	Anterior	Flexion	Posterior longitudinal, supraspinous, and interspinous ligaments; posterior zygapophyseal joint capsules and posterior anulus fibrosus fibers	Ligamentum flavum, longissimus thoracis, iliocostalis thoracis, spinalis thoracis, and semispinalis thoracis
Lumbar	Posterior	Extension	Anterior longitudinal and iliolumbar ligaments, anterior fibers of the anulus fibrosus, and anterior zygapophyseal joint capsules	Rectus abdominis and external and internal oblique muscles
Sacroiliac joint	Anterior	Nutation	Sacrotuberous, sacrospinous, iliolumbar, and anterior sacroiliac ligaments	Transversus abdominis
Hip joint	Posterior	Extension	Iliofemoral ligament	Iliopsoas
Knee joint	Anterior	Extension	Posterior joint capsule	Hamstrings, gastrocnemius
Ankle joint	Anterior	Dorsiflexion		Soleus, gastrocnemius

From Levangie PK, Norkin CC: Joint structures and function—a comprehensive analysis, Philadelphia, 2005, FA Davis, p. 493.

Figure 15-33 illustrates normal posture and some of the abnormal deviations seen when viewing the patient from the side. Table 15-10 shows some of the malalignment postures and their effect.^2,27–29

TABLE 15-10

Malalignments Viewed Laterally2,27–29

Malalignment	Possible Correlated Motions or Postures	Possible Compensatory Motions or Postures
Forward head posture	Extension of cervical spine Protracted scapula	Increased kyphosis in thoracic spine Increased lordosis in lumbar spine Medially rotated humerus
Round back	Extension of cervical spine Protracted scapula	Forward head posture Hips flexed Knees extended
Flat back	Posterior pelvic tilt	Hips extended Knees extended Forward head posture
Swayback	Pelvic neutral or posterior tilt	Pelvis slides anterior Kyphosis Hips extended Knees extended
Pathological lordosis	Pelvis anteriorly tilted Tight hip flexors	Knees extended Ankles plantar flexed
Anterior pelvic tilt	Hip flexion (tight hip flexors)	Lumbar extension (increased lordosis) Hyperextended knees Poking chin (cervical extension) Rounded shoulders (protracted scapula) Thoracic kyphosis Ankles plantar flexed
Posterior pelvic tilt	Hip extension	Lumbar flexion (flat back) Hips extended Knees extended Forward head posture
Backward rotation of one ilium on sacrum (right leg stance)	Right hip lateral rotation Lateral facing patella Out-toeing Supination of foot Short leg	Right lumbar rotation Scoliosis—concavity to right Knee extension
Genu recurvatum	Ankle plantar flexion Excessive anterior pelvic tilt	Posterior pelvic tilt Flexed trunk posture Excessive thoracic kyphosis
Excessive tibial retroversion (posterior slant of tibial plateaus)	Genu recurvatum
Inadequate tibial retrotorsion (posterior deflection of proximal tibia due to hamstrings pull)	Flexed knee posture
Rearfoot valgus (calcaneal eversion)	Forward pelvic tilt (bilateral) Lateral pelvic tilt (unilateral)

Posterior View

When viewing from behind (Table 15-11; see Figure 15-1, C), the examiner should note whether the following conditions hold true:

1. The shoulders are level, and the head is in midline. These findings should be compared with those from the anterior view.

2. The spines and inferior angles of the scapulae are level (Figure 15-34), and the medial borders of the scapulae are equidistant from the spine. If not, is there a rotational or winging deformity of one of the scapulae? Defects, such as Sprengel’s deformity, should be noted (Figure 15-35).

3. The spine is straight or curved laterally, indicating scoliosis. A plumb line may be dropped from the spinous process of the seventh cervical vertebra (Figure 15-36).³⁰ Normally, the line passes through the gluteal cleft. This line is the posterior line of reference used to divide the body into right and left halves posteriorly (see Figure 15-1, C). The distance from the vertical string to the gluteal cleft can be measured. This distance is sometimes used as a measurement of spinal imbalance, and it is noted whether the deviation is to the left or right. If a torticollis or cervicothoracic scoliosis is present, the plumb line should be dropped from the occipital protuberance.¹¹

4. The ribs protrude or are symmetrical on both sides.

5. The waist angles are level.

6. The arms are equidistant from the body and equally rotated.

7. The PSISs are level (Figure 15-37). If one is higher than the other, one leg may be shorter or rotation of the pelvis may be present. The examiner should note how the PSISs relate to the ASISs. If the ASIS on one side and the PSIS on the other side are higher, there is a torsion deformity (anterior or posterior) at the sacroiliac joint. If the ASIS and PSIS on one side are higher than the ASIS and PSIS on the other side, there may be an up-slip at the sacroiliac joint on the high side.

8. The gluteal folds are level. Muscle weakness, nerve root problems, or nerve palsy may lead to asymmetry.

9.  The knee joints are level. If they are not, it may indicate that one leg is shorter than the other (Figure 15-38).

10. Both of the Achilles tendons descend straight to the calcanei. If the tendons angle out, it may indicate a flatfoot deformity (pes planus).

11. The heels are straight or are angled in (rear-foot varus) or out (rear-foot valgus).

12. Bowing of femur or tibia is present or absent.

TABLE 15-11

Alignment in the Standing Posture: Posterior View

Body Segment	Line of Gravity Location	Observation
Head	Passes through middle of head	Head should be straight with no lateral tilting; angles between shoulders and neck should be equal
Arms		Arms should hang naturally so that the palms of the hands are facing the sides of the body
Shoulders/spine	Passes along vertebral column in a straight line, which should bisect the back into two symmetrical halves	Scapulae should lie flat against the rib cage, be equidistant from the line of gravity and be separated by about 4 inches in the adult
Hips/pelvis	Passes through gluteal cleft of buttocks and should be equidistant from PSISs	The PSISs should be level; the gluteal folds should be level and symmetrical
Knees	Passes between knees equidistant from medial joint aspects	Look to see that the knees are level
Ankles/feet	Passes between ankles equidistant from the medial malleoli	The heel cords should be vertical and the malleoli should be level and symmetrical

PSIS, Posterior superior iliac spine.

From Levangie PK, Norkin CC: Joint structures and function—a comprehensive analysis, Philadelphia, 2005, FA Davis, p. 499.

Figure 15-39 illustrates the normal posture and some of the abnormal deviations seen when viewing from behind. Table 15-12 highlights some of the malalignment postures and their effect.^2,13,27,28

TABLE 15-12

Malalignments Viewed Posteriorly*^2,13,27,28

Malalignment	Possible Correlated Motions or Postures	Possible Compensatory Motions or Postures
Scoliosis	Side flexion to convex side limited Rotation to convex side limited Rib hump on convex side
Rearfoot varus Excessive subtalar supination (calcaneal varus)	Tibial; tibial and femoral; or tibial, femoral, and pelvic lateral rotation	Excessive medial rotation along the lower quarter chain Hallux valgus Plantar flexed first ray Functional forefoot valgus Excessive or prolonged midtarsal pronation
Rearfoot valgus Excessive subtalar pronation (calcaneal valgus)	Tibial; tibial and femoral; or tibial, femoral, and pelvic medial rotation Hallus valgus	Excessive lateral rotation along the lower quarter chain Functional forefoot varus
Forefoot varus	Subtalar supination and related rotation along the lower quarter	Plantar flexed first ray Hallux valgus Excessive midtarsal or subtalar pronation or prolonged pronation Excessive tibial; tibial and femoral; or tibial, femoral, and pelvic medial rotation, or all with contralateral lumbar spine rotation

*Many of the posterior malalignments are also seen anteriorly.

When viewing posture, the examiner should remember that the pelvis is usually the key to proper back posture. The normal pelvic angle is 30°, and the pelvis is held or balanced in this position by muscles. For the pelvis to “sit properly” on the femur, the following muscles must be strong, supple (mobile), and balanced: abdominals, hip flexors, hip extensors, superficial and deep back extensors, hip rotators, and hip abductors and adductors.

If the height of the patient is measured, especially in a child, the focal height of the child may be estimated by the use of a chart, such as the one shown in Table 15-13.³¹

TABLE 15-13

Percentage of Mature Height Attained at Different Ages

Chronological Age (Years)	PERCENTAGE OF EVENTUAL HEIGHT
	Boys	Girls
1	42.2	44.7
2	49.5	52.8
3	53.8	57.0
4	58.0	61.8
5	61.8	66.2
6	65.2	70.3
7	69.0	74.0
8	72.0	77.5
9	75.0	80.7
10	78.0	84.4
11	81.1	88.4
12	84.2	92.9
13	87.3	96.5
14	91.5	98.3
15	96.1	99.1
16	98.3	99.6
17	99.3	100.0
18	99.8	100.0

From Bayley N: The accurate prediction of growth and adult height. Mod Probl Pediatr 7:234–255, 1954.

After the standing posture has been assessed, the examiner may decide to assess some additional postures (e.g., positional, sustained, or repetitive), especially if the patient has stated in the history that these different positions have caused problems or symptoms.

Having completed the assessment of normal standing, the examiner asks the patient to flex forward at the hips with the fingertips of both hands together so that the arms drop vertically (Figure 15-40). The feet should be together, and both knees should be straight. Any alteration from this posture will cause the spine to rotate, giving a false view.

From this position, using the anterior and posterior skyline views, the examiner can note the following:

If, in the history, the patient said that sustained forward flexion caused symptoms, the examiner should ask the patient to assume the symptom-causing posture and maintain it for 15 to 30 seconds to determine whether symptoms arise or increase. Flexion has been found to decrease the stress on the facet joints, but it can increase the pressure in the nucleus pulposus.^32,33 Likewise, if repetitive forward flexion or combined movements (e.g., extension and rotation) have caused symptoms, the patient should be asked to do the repetitive or combined movements. Loading the spine by lifting an object may also cause symptoms and may be investigated if symptoms are not too great.

With the patient seated on a stool so that the feet are on the ground and the back is unsupported, the examiner looks at the patient’s posture (Figure 15-44). Sitting without a back support causes the patient to support his or her own posture and increases the amount of muscle activity needed to maintain the posture.³² This observation is carried out, as in the standing position, from the front, back, and side. If any anteroposterior or lateral deviations of the spine are observed, the examiner should recall whether they were present when the patient was examined while standing. It should be noted whether the spinal curves increase or decrease when the patient is in the sitting position and how the curves change with different sitting postures.³⁴ From the front, it can be noted whether the knees are the same distance from the floor. If they are not, this may indicate a shortened tibia. From the side, it can be noted whether one knee protrudes farther than the other. If it does, this may indicate a shortened femur on the other side.

If the patient has stated in the history that going from standing to sitting or sitting to standing resulted in symptoms, the patient should be asked to repeat these maneuvers, provided the movements do not exacerbate the symptoms too much.

With the patient lying prone, the examiner notes the position of the head, neck, and shoulder girdle, as previously described. The head should be positioned so that it is not rotated, side flexed, or extended. Any condition, such as Sprengel’s deformity or rib hump, should be noted, as should any spinal deviations. The examiner should determine whether the PSISs are level and should ensure that the musculature of the buttocks, posterior thighs, and calves is normal (Figure 15-45).

As with supine lying, if assuming the position or recovering from the position causes symptoms, the patient should be asked to repeat these movements, as long as symptoms are not made worse.