Lecture 2: Postural Deviations

In ideal posture (lateral view), where is the plumb line in relation to the lateral malleolus?

anterior to the lateral malleolus (foot neutral)

Where is the plumb line in relation to the knee joint in an ideal lateral view?

anterior to the midline of the knee joint

Where is the plumb line in relation to the hip in an ideal lateral view?

through the greater trochanter (slightly posterior to the hip)

Which vertebral level does the plumb line pass through in an ideal lateral view?

through the body of L5

Where does the plumb line pass at the shoulder in an ideal lateral view?

through the lateral acromion

Where does the plumb line pass at the head in an ideal lateral view?

through the earlobe or external auditory meatus

What spinal curvatures are seen in ideal lateral view of posture?

normal cervical and lumbar lordosis and thoracic kyphosis

What should the position of the calcaneus and Achilles tendon be in the posterior view of an ideal posture?

vertical and straight

What should be observed at the level of the knees and glutes in an ideal posterior of posture?

level popliteal and gluteal folds

In ideal posterior posture, which pelvic landmark should be level?

trochanters, PSIS, and iliac crest

Where should the inferior angles of the scapula be in an ideal posterior view of posture?

level and symmetrical

How far apart should the medial borders of the scapula be in an ideal posterior view of posture?

3-4 inches apart

What should the shoulder alignment look like from a posterior view?

shoulders should be level

How should the spine and head appear in the posterior view of ideal posture?

spine and head should be straight and centered

How is the head positioned in kyphosis-lordosis posture?

forward

What happens to the cervical spine in kyphosis-lordosis posture?

cervical hyperextension

What change occurs in the thoracic spine with kyphosis-lordosis posture?

increased thoracic kyphosis

What happens to the lumbar spine in kyphosis-lordosis posture?

increased lumbar lordosis

What is the position of the pelvis in kyphosis-lordosis posture?

anterior pelvic tilt

What is the typical hip position in kyphosis-lordosis posture?

flexed

How are the knees affected in kyphosis-lordosis posture?

slight hyperextension

What happens at the ankles in kyphosis-lordosis posture?

slight plantarflexion

What muscles in a kyphosis-lordosis posture would be shortened and strong?

• neck extensors

• hip flexors

What muscles in a kyphosis-lordosis posture would be lengthened and weak?

• neck flexors

• erector spinae of the thoracic region

• external oblique

• hamstrings (slightly but may or may not be weak)

Where is the head positioned in flat back posture?

forward

What happens to the cervical spine in flat back posture?

slight extension

How is the thoracic spine positioned in flat back posture?

• upper thoracic: increased flexion

• lower thoracic: straight

How is the pelvic positioned in flat back posture?

posterior pelvic tilt

How is the hip positioned in flat back posture?

extended

How are the knees positioned in flat back posture?

extended

What is the ankle position in flat back posture?

slight plantarflexion

What muscles are lengthened and weak in a flat back posture?

one joint hip flexors: iliopsoas

What muscles are shortened and strong in a flat back position?

hamstrings

Where is the head positioned in a sway back posture?

forward

What happens to the cervical spine in sway back posture?

slight extension

How is the thoracic spine affected in sway back posture?

increased flexion with a long kyphosis

What is the lumbar spine position in sway back posture?

flexed (low back appears flat)

What is the pelvic position in sway back posture?

posterior tilt

How are the hips positioned in sway back posture?

hyperextended with anterior displaced pelvis

What is the ankle position in sway back posture?

neutral

What muscles are shortened and strong in a sway back posture?

hamstrings and internal obliques

What muscles are lengthened and weak in a sway back posture?

one joint hip flexors: iliopsoas, external obliques, upper back extensors, neck flexors

What is the thoracic outlet?

the space between the clavicle and first rib

What structures run through the thoracic outlet?

brachial plexus and subclavian artery and vein

What can lead to having thoracic outlet syndrome?

• 1st rib (elevated)

• scalenes (tight or hypertrophied)

• pec minor (tight or hypertrophied)

• congenital cervical rib

• trauma

• poor posture

• repetitive stress injury

Where does pressure from thoracic outlet syndrome occur at?

anywhere between the interscalene triangle and the inferior border of the axilla

what types of symptoms can Thoracic Outlet Syndrome cause?

neurological, vascular, or both

What percentage of Thoracic Outlet Syndrome cases are vascular?

at most only 6%

What are possible vascular symptoms of Thoracic Outlet Syndrome?

coldness, swelling, and Raynaud’s phenomenon

In TOS, what areas may pain from C5-C7 nerve roots radiate to?

face, ear, anterior chest, and scapula

In TOS, what areas are affected by C7-T1 nerve root involvement?

posterior neck, shoulder, medial arm, and areas of ulnar nerve innervation in the hand

What activities commonly aggravate Thoracic Outlet Syndrome symptoms?

poor posture and overhead activities

What does conservative treatment for Thoracic Outlet Syndrome address?

tightness, muscle imbalance, posture, and nerve entrapment

What are the two most common provocation tests for Thoracic Outlet Syndrome?

Roos’ test and Adson’s Test

What does Roos’ test provoke and what does it indicate?

provokes pain indicating neurovascular compromise (mainly nerulogical)

What does Adson’s test provoke and what does it indicate?

provokes absent or decreased pulse (vascular compromise); may also provoke pain

Adson’s test is specifically aimed at assessing issues with which muscle group?

the scalenes

What is the starting position for Roos’ Test?

90° shoulder and elbow flexion, shoulder externally rotated

What is the movement performed during Roos’ test?

patient open sand closes their hands while keeping arms up for up to 3 mins

What indicates a positive Roos’ test?

reproduction of the patient’s symptoms (ex: pain, tingling, fatigue)

What indicates a positive Roos’ test?

reproduction of the patient’s symptoms (ex: pain, tingling, fatigue)

What is a criticism of Roos’ test?

reproduction of the patient’s symptoms (ex: pain, tingling, fatigue)

What is a criticism of Roos’ test?

high rate of flase positives: may be better performed for 30-90 secs

What is the first step in performing Adson’s Test?

palpate the patient’s radial pulse and keep your fingers on it throughout the test

What position should the arm be moved into during Adson’s test?

passive extension and slight external rotation

What should the patient do with their head and breath during Adson’s Test?

turn head toward teh test arm, take a deep breath and hold it

What indicates a positive Adson’s test?

diminished or absent radial pulse and/or reproduction or increase in pain

What muscle is primarily tested in Adson’s test?

scalenes

What does specificity measure in a clinical test?

how good a test is at accurately ruling IN people who do have the condition

What does a positive result in a high-specificity test tell us?

we can trust the patient likely does have the condition with low risk of false positives

How does specificty help with diagnosis confirmation?

high specificity makes a test good for confirming a diagnosis when the result is positive

What does sensitivity measure in a clinlcal test?

how good a test is at accurately ruling OUT people who don’t have the condition

What does sensitivity measure in a clinical test?

How good a test is at accurately ruling OUT people who don’t have the condition

What does a negative result in a high-sensitivity test tell us?

we can trust the patient likely doesn’t have the condition with low risk of false negatives

What does a false negative mean in the context of sensitivity?

a patient test negative but actually has the condition

How does sensitivity help with screening tests?

high sensitivity makes a test good for ruling out a condition when the result is negative

What does a negative result in a high-sensitivity test tell us?

we can trust the patient likely does not the condition with low risk of false negatives

What does a false negative mean in the context of sensitivity?

a patient tests negative but actually has the condition

How does sensitivty helpl with screening tests?

high sensitivity makes a test good for ruling out a condition when the result is negative

Which thoracic outlet test has good specificity?

Adson’s test - good at ruling in the condition

Which thoracic outlet test has good sensitivity?

Roos Test - good at ruling out the condition

Should you rely on only one test for thoracic outlet syndrome?

No, most PTs use multiple tests to combine strengths of sensitivity and specificity

Why combine Adson’s and Roos tests?

to increase diagnostic accuracy by using both a test with good specificity and one with good sensitivity