Child With Overdeveloped Muscles

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Ideal Alignment: In ideal alignment, the hips are neutral in rotation, as evidenced by the position of the patellae facing directly forward. The axis of the knee joint is in the coronal plane, and flexion and extension occur in the sagittal plane. The feet are in good alignment.

Postural Bowlegs: Postural bowlegs results from a combination of medial rotation of the femurs, pronation of the feet and hyperextension of the knees. When femurs medially rotate, the axis of motion for flexion and extension is oblique to the coronal plane. From this axis, hyperextension occurs in a posterolateral direction, resulting in a separation at the knees and apparent bowing of the legs.

Postural Knock-Knees: Postural knock-knees results from a combination of lateral rotation of the femurs, supination of the feet and hyperextension of the knees. With lateral rotation, the axis of the knee joint is oblique to the coronal plane, and hyperextension results in adduction at the knees.

Postural Knock Knee

POSTURAL BOWING COMPENSATORY FOR KNOCK-KNEES

Swayback External Knee Rotation

Mechanism of Postural Bowing Compensatory for Knock-Knees: Figure A shows the position of knock-knees that the subject exhibits when the knees are in good anteroposterior alignment.

Figure B shows that by hyperextending her knees, the subject is able to produce enough postural bowing to accommodate for the 4-inch separation of her feet shown in Figure A.

See center figure on the previous page for the extent of postural bowing that can be produced by hyperextension in an individual without knock-knees.

Children are often embarrassed by the appearance of knock-knees, and it is not uncommon for them to compensate if the condition persists. Sometimes, they

"hide" the knock-knee position by flexing one knee and hyperextending the other so that the knees can be close together. Rotation faults may result if the same knee is habitually flexed while the other is hyperextended.

The appearance of postural bowlegs and postural knock-knees may also result from the combination of knee flexion with rotation (not illustrated). With lateral rotation and slight flexion, the legs will appear to be slightly bowed, and with medial rotation and slight flexion, there will appear to be a position of knock-knees. These variations associated with flexion are of less concern than those associated with hyperextension because flexion is a normal movement but hyperextension is an abnormal movement.

Knock Knee Ray Pronated Feet

For each of the figures above, a beaded metal plumb line was suspended beside the subject when the radiograph was taken. Two radiographic films were in position for the single exposure. The above illustration shows the relationship of the plumb line to the bones of the foot and lower leg, with the subject standing in a position of good alignment.

This radiograph shows a subject who had a habit of standing in hyperextension. The plumb line was suspended in line with the standard base point while the radiograph was obtained. Note the change in position of the patella and the anterior compression of the knee joint.

This radiograph shows the same subject depicted by the center figure. As an adult, she attempted to correct her hyperextension fault. The alignment through the knee joint and femur are very good, but the tibia and fibula show evidence of posterior bowing; 1 (Compare with the good alignment? of these bones as seen in the figure at far left.)

Overdeveloped Child

Maintaining good alignment of the body in the sitting position can reduce or even prevent pain associated with posture-related problems. Figure A shows good alignment, requiring the least expenditure of muscle energy. Figure B shows the low back in a lordosis. This posture is mistakenly regarded as a correct position. The back muscles fatigue because it takes effort to maintain this position. Figure C is a familiar slumped position that results in strain from lack of support for the low back and results in very faulty positions of the upper back, neck and head.

People are usually advised to sit with their feet flat on the floor. If the knees are crossed, they should alternate so that they are not always crossed in the same manner. Some people, especially those with poor circulation in the legs, should avoid sitting with their knees crossed.

Some people may be comfortable in a chair with a pad in the lumbar area. Others may experience discomfort and even pain from such a lumbar support. Certain people find that a contoured pad in the sacroiliac area, or a chair that is rounded to conform to the body in that area, will enable them to sit comfortably.

There is no one correct chair. The height and depth of the chair must be appropriate to the individual. The chair should be of a height that allows the feet to rest comfortably on the floor and, thereby, avoid pressure on the back of the thighs. In a chair that is too deep from front to back, either the individual's back will be unsupported or undue pressure will be placed against the lower leg. Hips and knees should be approximately at a 90 de gree angle and the back of the chair should incline approximately 10 degrees. The sitting position can be comfortable if the chair and additional props maintain the body in good alignment.

Not all chairs are conducive to good sitting position. So-called "posture chairs," which support the back only in the lumbar region, tend to increase the lumbar curve and are often undesirable. Sitting for long periods of time in a swivel chair that tilts back at too great an angle may contribute to a very faulty position of the upper back and head.

If the chair has armrests that are too high, the shoulders will be pushed upward. If the armrests are too low, the arms will not have adequate support. With proper armrests it should be possible to pull the chair close to the desk. Whenever practical, tools and desk equipment should be placed within reach to avoid undue stretch or torsion.

Light of adequate intensity should be provided. It should fall correctly on the workspace, and should be free from glare, bright reflections, or unnecessary shadows.

When sitting for hours at a time, it is necessary to shift positions since a sitting position keeps the hips, the knees, and usually the back in flexion. Simple extension movements and occasionally standing up can alleviate the stress and strain associated with prolonged sitting positions.

In an automobile, it is important that the seat be comfortable. Pain and fatigue in the neck and shoulder region can often be traced to the need to hold the head in a forward or tilted position while driving.

EQUIPMENT

The equipment used by the Kendalls (see facing page) consists of the following:

Posture Boards

These are boards on which footprints have been drawn. Footprints may be painted on the floor of the examining room, but the posture boards have the advantage of being portable. (See the lower photograph on the facing page.)

Plumb Line

This line is suspended from an overhead bar, and the plumb bob is hung in line with the point on the posture board that indicates the standard base point (i.e., anterior to the lateral malleolus in side view, midway between the heels in back view).

Folding Ruler with Spirit Level

This is used to measure the difference in level of the posterior iliac spines. It also may be used to detect any differences in shoulder level. A background with squares (as shown in many of the photographs) is a more practical aid in detecting differences in shoulder level.

Set of Six Blocks

These blocks measure 4 inches by 10 inches and are of the following thicknesses: Vs, 'A, 3/s, '/2, 3A and 1 inch. They are used for determining the amount of lift needed to level the pelvis laterally. (See also leg-length measurements, p. 438.)

Marking Pencil

This is used for marking the spinous processes to observe the position of the spine in cases of lateral deviation.

ALIGNMENT IN STANDING

Subjects stand on the posture boards with their feet in the position indicated by the footprints.

Anterior View

Observe the position of the feet, knees, and legs. Toe positions, appearance of the longitudinal arch, alignment in regard to pronation or supination of the foot, rotation of the femur as indicated by position of the patella, knock-knees, or bowlegs should be noted. Any rotation of the head or abnormal appearance of the ribs should also be noted. Findings are recorded on the chart under the heading "Segmental Alignment."

Lateral View

With the plumb line hung in line with a point just anterior to the lateral malleolus, the relationship of the body as a whole to the plumb line is noted and recorded under the heading "Plumb Alignment." It should be observed from both the right and left sides for the purpose of detecting rotation faults. Descriptions such as the following may be used in recording findings: "Body anterior fom ankles up," "Pelvis and head anterior," "Good except lordosis," or "Upper trunk and head posterior."

Segmental alignment faults may be noted with or without the plumb line. Observe whether the knees are in good alignment, hyperextended, or flexed. Note the position of the pelvis as seen from the side view and whether the anteroposterior curves of the spine are normal or exaggerated. Also note the head position (forward or tilted up or down), the chest position (whether normal, depressed, or elevated), and the contour of the abdominal wall. Findings are recorded on the chart under the heading "Segmental Alignment."

Tape Measure

Posterior View

This may be used for measuring leg length and forward bending in reaching the Fingertips toward or beyond the toes.

Chart for Recording Examination Findings

Appropriate Clothing

Clothing, such as a two-piece bathing suit for girls or swim trunks for boys, should be worn by subjects for a postural examination. Such an examination of schoolchildren is unsatisfactory when children are clothed in ordinary gym suits.

In hospital clinics, gowns or other suitable garb should be provided.

With the plumb line hung in line with a point midway between the heels, the relationship of the body or parts of the body to the plumb line are expressed as good or as deviations toward the right or left. These findings are recorded on the chart on page 89, under the heading "Note."

From the standpoint of segmental alignment, one should note the alignment of the tendo calcaneus, postural adduction or abduction of the hips, relative height of the posterior iliac spines, lateral pelvic tilt, lateral deviations of the spine and positions of the shoulders and the scapulae. For example, a lateral pelvic tilt may result from one foot being pronated or one knee being habitually flexed (see p. 448), allowing a dropping of the pelvis on that side in standing.

Ilium Foot Boards

The equipment above consists of {left to right) protractor and caliper, folding ruler with spirit level, set of blocks, plumh line and marking pencil.

The above illustration shows the posture boards with foot prints on which the subject stands for alignment tests: A) Side view, B) Back view, C) Front view.

TEST FOR FLEXIBILITY AND MUSCLE LENGTH

Findings regarding flexibility and muscle length are recorded on the chart in the space provided. (See facing page.) Forward bending is designated as "Normal," "Limited," or "Normal+," with the number of inches from or beyond the toes also being recorded. (See p. 101 and charts on pp. 102, 103 regarding normal for various ages.) On the Postural Examination chart, "Bk" indicates back, "H.S." indicates hamstrings, and "G.S." indicates Gastroc-soleus.

Forward bending may be checked in the standing or sitting position, but the authors consider the test in the sitting position to be more indicative of flexibility. If flexibility is normal when sitting and limited when standing, there is usually some rotation or lateral tilt of the pelvis, resulting in rotation of the lumbar spine that in turn restricts the flexion in the standing position.

Findings regarding the arm overhead elevation tests may be recorded as normal or limited. If limited, findings may be further recorded as slight, moderate, or marked.

Trunk extension is the movement of backward bending, and it may be done in the standing position to help differentiate the flexibility of the back from the strength of the back muscles as done in the prone position. (See discussion. Chapter 5.) Normally, the back should arch in the lumbar region. If hyperextension is limited, the subject may try to simulate backward bending by flexing the knees and leaning backward. Knees should be kept straight during this test.

Lateral flexion movements are used to test the lateral flexibility of the trunk. The length of the left lateral trunk muscles permit range of motion for trunk bending toward the right, and vice versa. In other words, if flexibility of the trunk toward the right is limited, it should be interpreted as some muscle tightness of the left lateral trunk muscles—unless, of course, there is the element of limited spinal motion because of ligamentous or joint tightness.

Among other things, variations among individuals in length of the torso and in space between the ribs and iliac crest make for differences in flexibility. It is impractical to try to measure the degree of lateral flexion. Range of motion is considered to be normal when the rib cage and iliac crest are closely approximated in side bending. Most people can bring their fingertips to about the level of the knee when bending directly sideways. (See discussion, Chapter 5.)

MUSCLE STRENGTH TESTS

The essential muscle tests during postural examinations are described in Chapters 5, 6, and 7. They include tests of the upper, lower, and oblique abdominals as well as the lateral trunk flexors, back extensors, middle and lower trapezius, serratus anterior, gluteus medius, glu-teus maximus, hamstrings, hip flexors, soleus and toe flexors.

With problems of anteroposterior deviations in postural alignment, it is especially important to test the abdominal muscles, back muscles, hip flexors and extensors, and soleus. With problems of lateral deviation of the spine or lateral tilt of the pelvis, it is especially important to test the oblique abdominal muscles, lateral trunk flexors and gluteus medius.

INTERPRETATION OF TEST FINDINGS

In the usual case of faulty posture, the pattern of faul body mechanics as determined by the alignment test wi be confirmed by the muscle tests if both procedures have been accurate. At times, however, there may be an apparent discrepancy in test findings. This inconsiste: may be based on such things as the following: The fects of an old injury or disease may have altered t alignment pattern, particularly as related to handedne patterns; the effects of a recent illness or injury m have been superimposed on an established pattern of i balance; or a child with a lateral curvature of the spine may be in a transition stage between a C-curve and a S-curve.

Except in flexible children, postural faults see the time of examination will usually correspond with habitual faults of the given individual. With children, is necessary and advisable to do repeated tests of alig ment and to obtain information regarding their habit posture from the parents and teachers who see them f quently. It is also advisable to keep photographic reco of posture to attain a really worthwhile evaluation postural changes in growing children.

Name

Diagnosis...

Onset

Occupation..

Handedness Age

Doctor

..Date of 1st Ex... ..Date of 2nd Ex.. Height.. Weight.. Leg length: Left Right

Side view Back view

Deviated It

PLUMB ALIGNMENT Rt

Deviated rt.

SEGMENTAL ALIGNMENT

Hammer toes

Hallux valgus

Low ant. arch

Ant. foot varus

Feet

Pronated

Supmated

Flat long, arch

Pigeon toes

Knees

Med rotat.

Lat. rotat

Knock-knees

Tibial torsion

Hyperext

Flexed

Bowlegs

Pelvis

Leg in postural add

Rotation

Tilt

Deviation

Low back

Lordosis

Flat

Kyphosis

Operation

Up back

Kyphosis

Flat

Scap abducted

Scap. elevated

Thorax

Depressed chest

Elevated chest

Rotation

Deviation

Spine

Total curve

Lumbar

Thoracic

Cervical

Abdomen

Protruding

Scars

Shoulder

Low

High

Forward

Med rotated

Head

Forward

Torticollis

Lateral Tilt

Rotation

TESTS FOR FLEXIBILITY AND MUSCLE

TESTS FOR FLEXIBILITY AND MUSCLE

Forward bending. . Arm overhead elevation: Lt Hip flexors: Lt... Tensor fas. lata Lt. . Trunk extension: Trunk lat. flex.: To It

HS Rt

LENGTH GS

Rt Rt

To rt

TREATMENT

To rt

L MUSCLE STRENGTH TESTS R « L

Mid trapezius

1 ^

Low trapezius

\ 1

Back extensors

\ /

Glut medws

Glut maximus

Hamstrings

L

Hip flexors

Tib posterior

LEO lowering

Toe flexors

Left

SHOE CORRECTION

Right

Exercises: Bk. Lying

Sd. Lying Sitting

Left

SHOE CORRECTION

Right

(Wide Heel) Inner wedge (Narrow heel)

Level heel raise

Metatarsal support

Longitudinal support

Standing

Pel. tilt and breath. Pel tilt and leg si Head and sh. raising Shoulder add. stretch Straight leg-raise Hip flex stretch Stretch .. .. tensor

Forward bending To stretch low bk. To stretch h. s. Wall-sitting

Middle trapezius Lower trapezius Foot and knee ex. Wall-standing

Other Exercises:

NOTES:

Support:

)D AND FAULTY POSTUF SUMMARY CHART

Chart 2-1

Good Posture

Part

Faulty Posture

In standing, the longitudinal arch has the shape of a half-dome.

Barefoot or in shoes without heels, the feet out-toe slightly.

In shoes with heels, the feet are parallel. In walking with or without heels, the feet are parallel, and the weight is transferred from the heel along the outer border to the ball of the foot. In sprinting, the feet are parallel or in-toe slightly. The weight is on the balls of the feet and toes, because the heels do not come in contact with the ground.

Feet

Low longitudinal arch or flat foot.

Low metatarsal arch, usually indicated by calluses under the ball of the foot.

Weight borne on the inner side of the foot (pronation). "Ankle rolls in."

Weight borne on the outer border of the foot (supination). "Ankle rolls out"

Out-toeing while walking or while standing in shoes with heels ("slue-footed").

In-toeing while walking or standing ("pigeon-toed").

Toes should be straight (i.e., neither curled downward nor bent upward). They should extend forward in line with the foot and not be squeezed together or overlap.

Toes

Toes bend up at the first joint and down at middle joints so that the weight rests on the tips of the toes (hammer toes). This fault is often associated with wearing shoes that are too short.

Big toe slants inward toward the mid-line of the foot (hallux valgus) "Bunion." This fault is often associated with wearing shoes that are too narrow and pointed at the toes.

Legs are straight up and down. Kneecaps face straight ahead when feet are in good position. In side view, the knees are straight (i.e., neither bent forward nor locked backward).

Knees and legs

Knees touch when feet are apart (knock-knees).

Knees are apart when feet touch (bowlegs).

Knee curves slightly backward (hyper-extended knee). "Back-knee."

Knee bends slightly forward; that is, it is not as straight as it should be (flexed knee).

Kneecaps face slightly toward each other (medially rotated femurs).

Kneecaps face slightly outward (laterally rotated femurs).

Ideally, the body weight is borne evenly on both feet, and the hips are level. One side is not more prominent than the other as seen from front or back, nor is one hip more forward or backward than the other as seen from the side. The spine does not curve toward the left or toward the right. (A slight deviation to the left in right-handed individuals and to the right in left-handed individuals is not uncommon. Also, a tendency toward a slightly low right shoulder and slightly high right hip is frequently found in right-handed people, and vice versa in left-handed people.)

Hips, pelvis, and spine (back view)

One hip is higher than the other (lateral pelvic tilt). Sometimes, it is not really much higher but only appears to be so, because a sideways sway of the body has made it more prominent. (Tailors and dressmakers often notice a lateral tilt, because the hemline of skirts or the length of trousers must be adjusted to the difference.)

The hips are rotated so that one is more forward than the other (clockwise or counterclockwise rotation).

GOOD AND FAULTY POSTURE: SUMMARY CHART

Good Posture

The front of the pelvis and the thighs are in a straight line. The buttocks are not prominent in the back but slope slightly downward.

The spine has four natural curves. In the neck and lower back, the curves are forward; in the upper back and lowest part of the spine (sacral region), they are backward. The sacral curve is a fixed curve, whereas the other three are flexible.

Part

Spine and pelvis (side view)

In children up to approximately 10 years of age, the abdomen normally protrudes somewhat.

In older children and adults, the abdomen should be flat.

A good position of the chest is one in which it is slightly up and slightly forward (with the back remaining in good alignment).

The chest appears to be in a position approximately halfway between that of a full inspiration and a forced expiration

Abdomen

Chest

Faulty Posture

The lower back arches forward too much (lordosis). The pelvis tilts forward too much. The front of the thigh forms an angle with the pelvis when this tilt is present.

The normal forward curve in the lower back has straightened. The pelvis tips backward as in sway-back and flat-back postures.

Increased backward curve in the upper back (kyphosis or round upper back).

Increased forward curve in the neck. Almost always accompanied by round upper back and seen as a forward head.

Lateral curve of the spine (scoliosis) toward one side (C-curve) or both sides (S-curve).

Entire abdomen protrudes.

Lower part of the abdomen protrudes; the upper part is pulled in.

Depressed ("hollow-chest") position.

Lifted and held up too high, brought about by arching the back.

Ribs more prominent on one side than on the other.

Lower ribs flaring out or protruding.

Arms hang relaxed at the sides with palms facing toward the body. Elbows are slightly bent, so the forearms hang slightly forward. Shoulders are level, and neither one is more forward or backward than the other when seen from the side.

Shoulder blades lie flat against the rib cage. They are neither too close together nor too wide apart. In adults, a separation of about 4 inches is average.

Head is held erect, in a position of good balance.

Arms and shoulders

Head

Holding the arms stiffly in any position forward, backward, or out from the body. Arms turned so that palms face backward.

One shoulder higher than the other. Both shoulders hiked-up. One or both shoulders drooping forward or sloping. Shoulders rotated either clockwise or counterclockwise.

Shoulder blades pulled back too hard. Shoulder blades too far apart. Shoulder blades too prominent, standing out from the rib cage (winged scapulae).

Chin up too high.

Head protruding forward. Head tilted or rotated to one side.

FAULTY POSTURE: ANALYSIS AND TREATMENT

Postural Fault

Anatomical Position of Joints

Muscles in Shortened Position

Muscles in Lengthened Position

Treatment Procedures

Forward head

Cervical spine hyperextension

Cervical spine extensors

Upper trapezius and levator

Cervical spine flexors

Stretch cervical spine extensors, if short, by trying to flatten the cervical spine. Strengthen cervical spine flexors, if weak. A forward head position is usually the result of a faulty upper back posture. If neck muscles are not tight posteriorly, the head position will usually correct as the upper back is corrected. Strengthen the thoracic spine extensors.

Do deep breathing exercises to help stretch the intercostals and the upper parts of abdominal muscles. Stretch the pectoralis minor. Stretch the shoulder adductors and internal rotators, if short. Strengthen the middle and lower trapezius. Use shoulder support when indicated to help stretch the pectoralis minor and relieve strain on the middle and lower trapezius. (See exercises and supports, pp. 116, 163, and 343.

Kyphosis and depressed chest

Thoracic spine flexion

Intercostal spaces diminished

Upper and lateral fibers of Internal oblique

Shoulder adductors Pectoralis minor Intercostals

Thoracic spine extensors

Middle trapezius

Lower trapezius

Forward shoulders

Scapulae abducted and (usually) elevated

Serratus anterior Pectoralis minor Upper trapezius

Middle trapezius Lower trapezius

Lordotic posture

Lumbar spine hyperextension

Pelvis, anterior tilt

Hip joint flexion

Lower back erector spinae

Internal oblique (upper)

Hip flexors

Abdominals, especially external oblique (lateral)

Hip extensors

Stretch low back muscles, if tight. Strengthen abdominals by posterior pelvic tilt exercises and, if indicated, by trunk curl. Avoid sit-ups, because they shorten hip flexors. Stretch hip flexors, when short. Strengthen hip extensors, if weak.

Instruct regarding proper body alignment. Depending on the degree of lordosis and extent of muscle weakness and pain, use support (corset) to relieve strain on abdominals and help correct the lordosis.

Flat-back posture

Lumbar spine flexion

Pelvis, posterior tilt

Hip joint extension

Anterior abdominals

Hip extensors

Lower back erector spinae

Low back muscles are seldom weak, but if they are, do exercises to strengthen them and restore the normal anterior curve. Tilt the pelvis forward, bringing the low back into an anterior curve. Avoid prone hyperextension, because it increases posterior pelvic tilt and stretches hip flexors. (See p. 228.)

Instruct in proper body alignment. If the back is painful and in need of support, apply a corset that holds the back in a normal anterior lumbar curve.

Strengthen hip flexors to help produce a normal anterior lumbar curve. Stretch hamstrings, if tight.

Postural Fault

Anatomical Position of Joints

Muscles in Shortened Position

| Muscles in Lengthened Position

Treatment Procedures

Sway-back posture

(pelvis displaced forward, upper trunk backward)

Lumbar spine position depends on level of posterior displacement of upper trunk Pelvis, posterior tilt

Hip joint extension

Upper anterior » abdominals, especially upper I rectus and internal oblique

Hip extensors

Lower anterior abdominals, especially external oblique

Hip flexors (one-joint)

Strengthen lower abdominals (stress external oblique). Stretch arms overhead and do deep breathing to stretch tight intercostals and upper abdominals. Instruct in proper body alignment. Wallstanding exercise is particularly useful. Stretch hamstrings, if tight. Strengthen hip flexors, if weak, using alternate hip flexion in the sitting position or alternate leg raising from the supine position. Avoid double leg-raising exercises because of strain on the abdominals.

Slight left C-curve, thoracolumbar scoliosis

Thoracolumbar spine: lateral flexion, convex toward left

Right lateral trunk J muscles

Left lateral trunk muscles

If present without lateral pelvic tilt, stretch the right lateral trunk muscles, if short, and strengthen the left lateral trunk muscles, if weak If present with lateral pelvis tilt, see below for additional treatment procedures.

Correct faulty habits that tend to increase the lateral curve: Avoid sitting on left foot in manner that thrusts the spine toward the left; Avoid lying on the left side, propped up on an elbow, to read or write.

If weak, exercise the right iliopsoas in sitting position. (See p. 113.)

Opposite for right C-curve.

Left psoas major

Right psoas major

Prominent or high right hip

Pelvis, lateral tilt,high on right

Right hip joint, adducted

Left hip joint, abducted

Right lateral trunk muscles

Left hip abductors and fascia lata

Right hip adductors

Left lateral trunk muscles

Right hip abductors, especially the gluteus medius

Left hip adductors

Stretch the right lateral trunk muscles, if short. Strengthen the left lateral trunk muscles, if weak.

Stretch the left lateral thigh muscles and fascia, if short. Specific exercises to strengthen the right gluteus medius are not required to correct slight postural weakness; functional activity will suffice if the alignment is corrected and maintained. The subject should: Stand with weight evenly distributed over both feet, with the pelvis level. Avoid standing with weight on the

Opposite for posture with right C-curve and high left hip.|

right leg, causing the right hip to be in postural adduction. Temporarily use a straight raise on the heel of the left shoe (usually 3/i6 inch) or a pad on the inside heel of the shoe and in bedroom slippers.

FAULTY LEG, KNEE, AND FOOT POSITIONS: ANALYSIS AND TREATMENT

Postural Fault

Anatomical Position of Joints

Muscles in Shortened Position

Muscles in Lengthened Position

Treatment Procedures

Hyperextended knee

Knee hyperextension

Ankle plantar flexion

Quadriceps Soleus

Popliteus

Hamstrings at knee, short head

Instruct regarding overall postural correction, with emphasis on avoiding knee hyperextension. In those with hemiplegia, use a short leg brace with a right-angle stop.

Flexed knee

Knee Hexion Ankle dorsiflexion

Popliteus

Hamstrings at knee

Quadriceps Soleus

Stretch the knee flexors, if tight Perform overall postural correction. Knee flexion may be secondary to hip flexor shortness. Check length of the hip flexors; stretch, if short.

Medially rotated femur (often associated with pronation of foot, see below)

Hip joint, medial rotation

Hip medial rotators

Hip lateral rotators

Stretch the hip medial rotators, H tight. Strengthen the hip lateral rotators, if weak. Young children should avoid sitting in reverse tar lor fashion (i.e., W position). See below for correction of any accompanying pronation.)

Knock-knee (Genu valgum)

Hip joint adduction

Lateral knee joint structures

Medial knee joint structures

Use an inner wedge on heels, if feet are pronated. Stretch the fascia lata, if indicated

Postural bowlegs

Hip joint medial rotation

Knee joint hyperextension

Foot pronation

Hip medial rotators Quadriceps Foot everters

Hip lateral rotators

Popliteus

Tibialis posterior and long toe flexors

Perform exercises for overall correction of foot, knee, and hip po- 1 sitions. Avoid knee hyperextension. Strengthen the hip lateral rotators. Use inner wedges on heels to correct foot pronation.

Stand with feet straight ahead and about 2 inches apart. Relax the knees into 1 an "easy" position (i.e., neither stiff nor ben t). Tighten the muscles that lift the 1 arches of the feet, rolling the weight slight y toward the outer borders of the 1 feet. Tighten the buttocks muscles to rotate the legs slightly outward (until the 1 kneecaps face directly forward).

Pronation

Foot eversion

Peroneals and toe extensors

Tibialis posterior and long toe flexors

Use inner wedges on heels. (USui ally Ve inch on wide heels, and V* inch on medium heels.) Perform 1 overall correction of posture of feet and knees. Use exercises to 1 strengthen the inverters. Instruct in proper standing and walking.

Supination

Foot inversion

Tibialis

Peroneals

Use outer wedge on heels. Perform exercise for peroneals.

Hammer toes and low metatarsal arch

Metatarsophalangeal joint hyperextension

Proximal inter-phalangeal joint flexion

Toe extensors

Lumbricales

Stretch metatarsophalangeal joints by flexion; stretch interpha-langeal joints by extension. Strengthen lumbricales by metatarsophalangeal joint flexion

Use a metatarsal pad or bar.

The following muscles tend to show evidence of acquired postural weakness:

Toe flexors (brevis and lumbricales) Middle and lower trapezius Upper back extensors Anterior abdominal muscles (as tested by leg-lowering test) Anterior neck muscles

Right-handed individuals:

Left lateral trunk muscles Right hip abductors Right hip lateral rotators Right peroneus longus and brevis Left tibialis posterior Left flexor hallucis longus Left flexor digitorum longus

Left-handed individuals, but the pattern is not as common as that occurring in right-handed individuals:

Right lateral trunk muscles

Left hip abductors

Left hip lateral rotators

Left peroneus longus and brevis

Right tibialis posterior

Right flexor hallucis longus

Right flexor digitorum longus

FAULTY LEG, KNEE, AND FOOT POSITIONS: ANALYSIS AND TREATMENT

Postural Fault

Anatomical Position of Joints

Muscles in Shortened Position

Muscles in Lengthened Position

Treatment Procedures

Hyperextended knee

Knee hyperextension

Ankle plantar flexion

Quadriceps Soleus

Popliteus

Hamstrings at knee, short head

Instruct regarding overall postural correction, with emphasis on avoiding knee hyperextension. In those with hemiplegia, use a short leg brace with a right-angle stop.

Flexed knee

Knee flexion Ankle dorsiflexion

Popliteus

Hamstrings at knee

Quadriceps Soleus

Stretch the knee flexors, if tight. Perform overall postural correction. Knee flexion may be secondary to hip flexor shortness. Check length of the hip flexors; stretch, if short.

Medially rotated femur (often associated with pronation of foot, see below)

Hip joint, medial rotation

Hip medial rotators

Hip lateral rotators

Stretch the hip medial rotators, if tight. Strengthen the hip lateral rotators, if weak. Young children should avoid sitting in reverse tailor fashion (i.e., W position). (See below for correction of any accompanying pronation.)

Knock-knee (Genu valgum)

Hip joint adduction

Lateral knee joint structures

Medial knee joint structures

Use an inner wedge on heels, if feet are pronated. Stretch the fascia lata, if indicated

Postural bowlegs

Hip joint medial rotation

Knee joint hyperextension

Foot pronation

Hip medial rotators Quadriceps Foot everters

Hip lateral rotators

Popliteus

Tibialis posterior and long toe flexors

Perform exercises for overall correction of foot, knee, and hip positions. Avoid knee hyperextension. Strengthen the hip lateral rotators. Use inner wedges on heels to correct foot pronation.

Stand with feet straight ahead and about 2 inches apart. Relax the knees into an "easy" position (i.e., neither stiff nor berW). Tighten the muscles that lift the arches of the feet raffing the weight slight y toward the outer borders of the feet. Tighten the buttocks muscles to rotate the legs slightly outward (until the kneecaps face directly forward).

Pronation

Foot eversion

Peroneals and toe extensors

Tibialis posterior and long toe flexors

Use inner wedges on heels. (Usually Vs inch on wide heels, and Vie inch on medium heels.) Perform overall correction of posture of feet and knees. Use exercises to strengthen the inverters. Instruct in proper standing and walking.

Supination

Foot inversion

Tibialis

Peroneals

Use outer wedge on heels. Perform exercise for peroneals.

Hammer toes and low metatarsal arch

Metatarsophalangeal joint hyperextension

Proximal inter-phalangeal joint flexion

Toe extensors

Lumbricales

Stretch metatarsophalangeal joints by flexion; stretch interpha-langeal joints by extension. Strengthen lumbricales by metatarsophalangeal joint flexion. Use a metatarsal pad or bar.

The following muscles tend to show evidence of acquired postural weakness:

Toe flexors (brevis and lumbricales) Middle and lower trapezius Upper back extensors Anterior abdominal muscles (as tested by leg-lowering test) Anterior neck muscles

Right-handed individuals: Left lateral trunk muscles Right hip abductors Right hip lateral rotators Right peroneus longus and brevis Left tibialis posterior Left flexor hallucis longus Left flexor digitorum longus

Left-handed individuals, but the pattern is not as common as that occurring in right-handed individuals:

Right lateral trunk muscles Left hip abductors Left hip lateral rotators Left peroneus longus and brevis Right tibialis posterior Right flexor hallucis longus Right flexor digitorum longus

INTRODUCTION

The preceding section dealt with posture primarily in relation to the adult. This section introduces a variety of concepts dealing with the development of postural habits in the growing individual and a variety of influences that affect such development. No attempt is made to give the various concepts either exhaustive or equal treatment. The authors hope that this material will be useful from the standpoint of prevention and that it will create, through a recognition of the factors involved in postural development, a more positive approach toward providing, within available limits, the best possible environment for good posture.

Good posture is not an end in itself; it is a part of general well-being. Ideally, posture instruction and training should be a part of general experience rather than a separate discipline. To the extent that parents and teachers are able to recognize the influences and habits that help to develop good or faulty posture, they will be able to contribute to this aspect of well-being in the daily life of growing individuals. Nevertheless, posture instruction and training should not be neglected in a good program of health education; attention should be paid to observable faults. When instruction is given, it should be simple and accurate; while it must not be neglected, neither should it be overemphasized. It should be given in such a manner as to capture the interest and cooperation of the child.

NUTRITIONAL FACTORS

Good postural development is dependent on good structural and functional development of the body, which in turn is highly dependent on adequate nutrition. The influence of nutrition on the proper structural development of skeletal and muscular tissues is particularly significant. Rickets, for example, which is often responsible for severe skeletal deformities in children, is a disease of vitamin D deficiency.

After growth is completed, poor nutrition is less likely to cause structural faults that directly affect posture. At this stage, deficiencies are more likely to interfere with physiological function and to be represented posturally in a position of fatigue. The body uses food not only for growth but also for fuel, transforming it into heat and energy. If the fuel is insufficient, energy output decreases, and so does general physiological efficiency. Nutritional deficiencies in the adult are most likely to occur when unusual physiological demands are made on the individual over a period of time.

DEFECTS, DISEASES, AND DISABILITIES

Certain physical defects, diseases, and disabilities have associated postural problems. These conditions can be roughly divided into three groups regarding the importance of attention to posture in their treatment.

The first group consists largely of physical defects in which the postural aspects are more potential than actual during the initial stages, then become a problem only if the defect cannot be completely corrected by medical or surgical means. These defects may be visual, auditory, skeletal (e.g., clubfoot or dislocation of the hip), neuromuscular (e.g., brachial plexus injury), or muscular (e.g.. wry neck).

The second group includes conditions that are in themselves potentially disabling but in which continuing attention to posture from the early stages can minimize the disabling effects. In an arthritic condition of the spine (e.g., Marie-Striimpell), if the body can be kept in good functional alignment during the time that fusion of the spine is taking place, the individual may have little obvious deformity and only moderate disability when the fusion is complete. If the postural aspect is disregarded, however, the trunk is usually in marked flexion when fusion of the spine is complete. This is a position of severe deformity and associated severe disability.

The third group contains conditions in which a degree of permanent disability exists as a result of injury or disease but in which added postural strain can greatly increase the disability. The amputation of a lower extremity, for example, throws an unavoidable extra burden on the remaining weight-bearing structures. A postural alignment that minimizes (as much as possible) the mechanical strains of position and motion does much to keep these structures from breaking down.

ENVIRONMENTAL FACTORS

A number of environmental factors influence the development and maintenance of good posture. These environmental influences should be made as favorable to good posture as is practical. When no major adjustment is possible, small adjustments will often contribute considerably. The following discussion takes into account factors such as chairs, desks and beds, because they illustrate environmental influences on posture in the sitting and lying positions. After children start school, the amount of time they spend in the sitting position increases considerably. The school seat is an important factor affecting posture.

Both the chair and desk should be adjusted to fit the child. The child should be able to sit with both feet flat on the floor and with knees bent to about a right angle. If the chair is too high, there will be a lack of support for the feet. If the chair is too low, the hips and knees will bend in too much flexion. The seat of the chair should be deep enough from front to back to support the thighs adequately, but the depth should not interfere with bending of the knees. The back of the chair should support the child's back. It should also incline backward a few degrees so that the child can relax against it. (See the illustration of sitting postures on p. 85.)

The top of the desk should be at about elbow level when the child is sitting in a good position, and it may be slightly inclined. The desk should be close enough that the arms can rest on it without the need to lean too far forward or to sit forward on the seat of the chair.

DEVELOPMENTAL FACTORS

It is important to recognize marked or persistent postural deviations in the growing individual, but it is equally important to recognize that children are not expected to conform to an adult standard of alignment. This is true for a variety of reasons, but primarily because the developing individual exhibits much greater mobility and flexibility than the adult.

Most postural deviations in the growing child fall into the category of developmental deviations; when patterns become habitual, they may result in postural faults. Developmental deviations are those that appear in many children at approximately the same age and that improve or disappear without any corrective treatment, sometimes even despite unfavorable environmental influences (19). Whether a deviation in a child is becoming a postural fault should be determined by repeated or continued observation, not by a single examination. If the condition remains static or the deviation increases, corrective measures are indicated. Severe faults need treatment as soon as they are observed, regardless of the age of the individual.

A young child is not likely to have habitual faults and can actually be harmed by unneeded corrective measures. Overcorrection may lead to atypical faults that are more harmful and difficult to deal with than the ones that caused the original concerns.

Some of the differences between children and adults result because in the years between birth and maturity, the structures of the body grow at varying rates. In general, body structures grow rapidly at first, then at a gradually reduced rate. An example of this is the increase in size of the bones. Associated with increased overall length of the skeleton is a change in the proportionate lengths of its various segments. This change in proportions occurs as first one part of the skeleton and then another has the most rapid rate of growth (20,21). The gradual tightening of ligaments and fascia as well as the strengthening of muscles are significant developmental factors. Their effect is to gradually limit the range of joint motion toward the range that is typical of maturity. The increase in stability that results is advantageous because it decreases the danger of strain from handling heavy objects or from other strenuous activities. Normal joint range for adults should provide an effective balance between motion and stability. A joint that is either too limited in range or not sufficiently limited is vulnerable to strain.

The child's greater range of joint motion makes possible momentary and habitual deviations in alignment that would be considered distortions in the adult. At the same time, the flexibility serves as a protection against developing fixed postural faults.

As early as 8 or 10 years of age, handedness patterns related to posture may appear. The slight deviation of the spine to the side opposite the higher hip makes an early appearance. There also tends to be a compensatory low shoulder on the side of the higher hip. In most cases, the low shoulder is a less significant factor. Usually, shoulder correction tends to follow correction of lateral pelvic tilt, but the reverse does not occur. No attempts should be made to raise the shoulder into position by constant muscular effort.

Activities that are rather neutral in their effect on posture are games or sports in which walking or running predominates. Sports that exert an influence toward muscle imbalance are predominantly one-sided, such as those involving use of a racket or a bat.

The play activities of young children usually are varied enough that no problem of muscle imbalance or habitual alignment fault is present. However, when a child becomes old enough to engage in competitive athletics, a point may be reached at which further development of skill through intensive practice requires a sacrifice of some degree of good muscle balance and skeletal alignment. Although seemingly unimportant at the time, the faults acquired may progress until a painful condition results.

Specific exercises may be needed to maintain range of joint motion and to strengthen certain muscles if opposing muscles are being overdeveloped by the activity. These exercises must be specific for the part in question and therapeutic for the body as a whole.

Year Old Child Standing

Figure A shows a 10-year-old child who has very good posture for this age. The posture resembles the normal adult posture more than that of a younger child. The curves of the spine are nearly normal, and the scapulae are less prominent. It is characteristic of small children to have a protruding abdomen, but there is a noticeable change at approximately 10 to 12 years of age, when the waistline becomes relatively smaller and the abdomen no longer protrudes.

Figure B shows a 9-year-old child whose posture is about average for this age.

Figure C shows an 11 -year-old child whose posture is very faulty, with forward head, kyphosis, lordosis, anterior pelvic tilt and hyperextended knees.

A consideration of both normal and abnormal variations in the posture of children can be discussed from the standpoints of the overall posture and the deviations of the various segments. Variations in overall posture of children at approximately the same age are illustrated on pages 98 and 100.

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