P A R T

Posture and Gait

Gluteus
maximus

Soleus

Chapter 47: Characteristics of Normal Posture and Common Postural

Abnormalities
Chapter 48: Characteristics of Normal Gait and Factors Influencing It

835
 P A R T

V
The first part of this textbook presents the basic principles needed to understand the
mechanics and pathomechanics of the musculoskeletal system and presents the me-
chanical properties of the individual components of the musculoskeletal system. Most
of the text then examines the structural and functional properties of the individual
joint complexes in the body. This final portion of the textbook applies this knowl-
edge to the analysis of two intrinsically human functions, erect standing and bipedal
locomotion. The goals of this final segment are to:

■ discuss the biomechanical demands of these two functions

■ demonstrate how a basic understanding of the structure and function of the
components of the musculoskeletal system leads to the ability to analyze
functions that involve many different joint complexes

Patients seek help from rehabilitation experts typically for complaints of pain or dif-
ficulty in performing a task rather than with complaints of impairments in specific
anatomical structures. Clinicians must be able to observe the activity in question, an-
alyze the biomechanical demands of the activity, and determine what, if any, impair-
ments contribute to the pathomechanics producing the complaints. Examination and
evaluation of posture and gait require an understanding of the basic biomechanical
principles introduced in the first two chapters of this book and use knowledge of
muscle and joint function to explain how an individual produces these characteristic
human behaviors. Clinicians who can evaluate posture and gait and can identify im-
pairments that contribute to an abnormal movement pattern will be able to apply
these same skills to evaluate and treat any abnormal movement, including activities
as diverse as lifting boxcar hitches, performing a grand plié, typing at a computer,
or operating a cash register at the local supermarket.

Chapter 47 describes the current understanding of “correct” posture and discusses

the mechanisms to control the posture. Chapter 48 presents the characteristics of nor-
mal locomotion and discusses the factors that influence it.

836
 CHAPTER

47
Characteristics of Normal
Posture and Common
Postural Abnormalities

NORMAL POSTURE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .838

Postural Sway . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .838
Segmental Alignment in Normal Posture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .838
Muscular Control of Normal Posture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .846
POSTURAL MALALIGNMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .849
Muscle Imbalances Reported in Postural Malalignments . . . . . . . . . . . . . . . . . . . . .849
SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .850

Posture is the relative position of the parts of the body, usually associated with a static
position. Clinicians evaluate posture with the underlying assumptions that abnormal pos-
ture contributes to patients’ complaints and that many impairments within the neuro-
musculoskeletal system are reflected in an individual’s posture. Thus clinical interpretation
of an individual’s posture requires blending a description of an individual’s posture with
an understanding of the person’s physical condition and complaints.

Posture in erect standing is the focus of much clinical attention, but postures in sitting and
during activities, such as lifting or assembly line work, also may contribute to muscu-
loskeletal complaints. This chapter focuses on standing posture, but the issues considered
to understand erect standing posture are applicable to any other posture as well. It is im-
portant to recognize that even seemingly static postures such as erect standing exhibit
small, random movements, and typically, humans move in and out of several postures. As
a result, assessment of a single posture may be insufficient to understand the link between
posture and a patient’s complaints.

Analysis of posture is a well-established clinical tradition and forms a basic part of the
physical examination for many different health disciplines. Despite the frequency with
which such evaluations are carried out, there remains a surprising lack of unanimity in the
description of “normal” posture. Although faulty posture has been associated with such
diverse complaints as headaches, respiratory and digestive problems, and back pain
throughout the centuries, the direct consequences of faulty posture are not well docu-
mented. The purposes of this chapter are to describe the current understanding of normal

837
838 Part V | POSTURE AND GAIT

posture and to describe some common postural faults. Specifically, the objectives of this
chapter are to

■ Describe the alignment of the body in erect standing posture and its variability
■ Discuss the current understanding of the muscles needed to control erect standing
posture
■ Describe common postural faults
■ Briefly discuss the purported consequences of postural faults

NORMAL POSTURE Segmental Alignment in

Normal Posture
Posture is evaluated by examining its stability and also by de-
scribing the relative alignment of adjacent limb segments. SAGITTAL PLANE ALIGNMENT OF THE
BODY IN NORMAL POSTURE
Postural Sway Although both ideal posture and normal posture have
been described in the clinical literature, the criteria for the
Normal erect standing posture is often compared to the
movement of an inverted pendulum in which the base is fixed
and the pendulum is free to oscillate over the fixed base
(Fig. 47.1). Although erect standing appears static to the ca-
sual observer, it is characterized by small oscillations in which
the body sways anteriorly, posteriorly, and side to side; and
the body’s center of mass, approximately located just ante-
rior to the body of the first sacral vertebra, inscribes a small
circle within the base of support [6,36]. This normal pos-
tural sway in erect standing also is described by the move-
ment of the center of pressure, which is related to, but
distinct from, the location of the body’s center of mass
[25,42]. The center of pressure locates the center of the dis-
tributed pressures under both feet. In contrast, a vertical line
through the center of mass locates the center of mass within
the entire base of support. The normal sway of the body
during quiet standing moves the center of mass and the cen-
ter of pressure of the body anteriorly and posteriorly up to
7 mm [6,36,42]. Side-to-side excursions of the centers of
mass and pressure are only slightly less than those in the
anterior–posterior direction [6].

CLINICAL RELEVANCE: ASSESSING STABILITY IN

QUIET STANDING
Stability in quiet standing is assessed in different popula-
tions to better understand why some individuals are at
increased risk for falling. Changes in the magnitude or fre-
quency of postural sway determined by the oscillations of
either center of pressure or center of mass are reported in
healthy elders and in individuals with impairments such
as hemiparesis, sensory deficits, and vestibular dysfunc- Figure 47.1: Standing posture often is modeled as an inverted
tions [6,36,42]. pendulum in which the body sways over the fixed feet.
Chapter 47 | CHARACTERISTICS OF NORMAL POSTURE AND COMMON POSTURAL ABNORMALITIES 839

TABLE 47.1 Alignment in the Sagittal Plane of Body Landmarks with Respect to the Ankle
during Erect Standing
Opila et al. [40]a Danis [6]b
Description of Landmark Locationc (cm) Description of Landmark Locationc (cm)
Ankle Lateral malleolus Calculated joint center
Knee Lateral epicondyle of femur 5.1 Calculated joint center 4.24
2.14
Hip Greater trochanter 5.4 Calculated joint center 5.42
2.86
Shoulder Acromioclavicular joint 3.0 Acromion process 1.89
3.01
Head/neck Just inferior to the external auditory meatus 5.4 Approximately the atlanto-occipital joint 4.84
4.03
a
Based on 19 unimpaired males and females aged 21 to 43 years. Originally reported with respect to the body’s center of gravity.
b
Based on 26 unimpaired males and females aged 22 to 88 years. Originally referenced to the ankle joint.
c
Positive numbers indicate that the landmark is anterior to the ankle joint.

ideal posture remain hypothetical [27,48]. Ideal posture is var-

iously described as the posture that requires the least amount
of muscular support, the posture that minimizes the stresses
on the joints, or the posture that minimizes the loads in the
supporting ligaments and muscles [1,27]. In the absence of a
clear understanding of the meaning of the “ideal” posture,
careful measurements of the positions assumed by individuals
without known musculoskeletal impairments or complaints Acromion
provide a perspective on the typical, if not ideal, alignment
of limb segments.
Table 47.1 presents the relative orientation of landmarks
in the sagittal plane with respect to the ankle joint from two
studies examining the posture of individuals without any
known musculoskeletal impairment or complaint [6,40]. Fig.
47.2 presents the relative location of the landmarks with re-
spect to a line through the center of mass, which lies ap-
proximately 4 to 6 cm anterior to the ankle joint [6,40]. The
two studies report similar relative alignments, and both also Greater
agree somewhat with the “ideal posture” described by Kendall trochanter
et al. [27]. The relatively large standard deviations at the su-
perior landmarks reported by Danis et al. are consistent with
the normal postural sway that occurs in quiet standing.

Trunk and Pelvic Alignment

The data presented in Table 47.1 describe the sagittal plane Axis of
orientation of many body parts in erect standing but provide knee
little information regarding the normal alignment of the spine
and pelvis. The adult spine is characterized by a kyphosis in
the thoracic and sacral regions in which the curves are con-
vex posteriorly and a lordosis in the cervical and lumbar re-
gions in which the curves are concave posteriorly. At birth,
the spine is entirely kyphotic, and consequently, the thoracic
and sacral curves are primary curves. Development of head
Ankle
control by approximately 4 months of age induces the devel- joint
opment of a cervical lordosis, and a child’s progression to up-
right standing and bipedal ambulation lead to the formation
of the lumbar lordosis. Hence these curves are known as sec- Figure 47.2: In erect standing, the body is aligned approximately
ondary curves and do not develop in the absence of acqui- so that a line through the body’s center of mass passes very
sition of the respective skill. close to the ear, slightly anterior to the acromion process of the
scapula, close to the greater trochanter, slightly anterior to the
The most common means of characterizing the curvatures
knee joint, and anterior to the ankle joint.
of the spine use a radiographic method to assess the total
840 Part V | POSTURE AND GAIT

T1

Thoracic
Cobb angle

T12

L1
Lumbar
Cobb angle

L5

Figure 47.3: Cobb angles in the thoracic and lumbar spines are
determined radiographically by determining the angles formed
between the superior surface of the most superior vertebra of
the region and the inferior surface of the most inferior vertebra
of the region.

curve of a region. The Cobb angle describes the angle formed

by the surfaces of the superior and inferior vertebrae of
a spinal region (Fig. 47.3). Mean Cobb angles of 20 to 70 are
reported for the lumbar region and 20 to 50 for the thoracic
region [16,24,54,57]. These data demonstrate wide dispari- Figure 47.4: Surface methods to assess spinal curves. A. Clinicians
ties and are influenced by the measurement procedures used use inclinometers to measure the curvature of spinal regions
in each investigation, but also reflect the wide spectrum of from surface palpations. B. Flexible rulers are used to trace the
curvature in a spinal region, and the tracing can be quantified
spinal curvatures found in a population with no known pathol-
mathematically.
ogy. Despite the differences reported in the literature, some
Chapter 47 | CHARACTERISTICS OF NORMAL POSTURE AND COMMON POSTURAL ABNORMALITIES 841

observation of head posture, assessing head alignment as

normal or noting a “mild,” “moderate,” or “severe” forward
head. In the presence of an abnormal forward-head pos-
ture, the clinician typically initiates an intervention to
improve or normalize the posture. However, without oper-
ational definitions of the postural deviations, it is difficult
to identify changes in posture objectively and to associate
any changes in the patient’s complaints with changes in
posture. Third-party payers are challenging the value of in-
terventions to alter posture. Well-controlled outcome stud-
ies to measure the effectiveness of postural interventions
are needed, and these studies demand more precise and
more objective measures of postural alignment.

Orientation of the pelvis is a common postural evaluation

performed in conjunction with the assessment of spinal
curves. Pelvic alignment is determined from the orientation
of the sacrum or by the orientation of pelvic landmarks. Most
measurements based on sacral alignment derive from radi-
ographic assessment and report the angle made between
a vertical or horizontal reference line and either the supe-
rior or posterior surface of the sacrum [24,54] (Fig. 47.6).
Figure 47.5: Forward-head alignment observed in the clinic is
often assessed qualitatively as mild, moderate, or severe.

consistent findings are found. The studies that examine both

the thoracic and lumbar curves consistently report a larger
lumbar lordosis than thoracic kyphosis [2,16,53]. Also there
is general agreement that the peak or apex of the thoracic
curve occurs at approximately the midthoracic region, most
often at T7, and the apex of the lumbar curve typically is
located at either L3 or L4 [2,16,53].
α
Although the Cobb method is the most frequently used
method of quantifying spinal curves, it requires radiographic
assessment and is not part of a routine physical examination.
θ
Methods to evaluate the spinal curves from surface assessment
include the use of inclinometers to define the angulation and
flexible rulers to trace the shape of the spinal curvature
[15,52,64] (Fig. 47.4). The surface curvature methods yield
different measures from radiographic methods and lack nor-
mative data defining the range of curvature values found in a
healthy population [49]. Based on current knowledge, clini-
cians lack well-accepted criteria for normal curvatures of the
spine in the sagittal plane using surface methods and continue
to rely on qualitative assessments of the spinal curves [34].

CLINICAL RELEVANCE: MONITORING CHANGES IN

FORWARD-HEAD POSTURE
Forward-head posture is associated with a wide range of
patient complaints including headaches, vertigo, temporo-
mandibular joint pain, and neck and shoulder pain. A typ-
ical physical examination of a patient with any of these Figure 47.6: Sacral alignments determined from radiographs
complaints includes assessment of postural alignment typically measure the angle between the superior surface of the
sacrum and the horizontal () or an angle between the posterior
(Fig. 47.5). Although objective procedures to quantify head
surface of the sacrum and the vertical ().
position exist [15,21], the clinician often resorts to visual
842 Part V | POSTURE AND GAIT

purportedly accompanies an increased thoracic kyphosis.

PSIS
θ lumbar lordosis but finds no association between the kypho-
ASIS
Figure 47.7: Pelvic alignment from surface landmarks is defined
by the angle between a line drawn through the anterior
superior iliac spine (ASIS) and the posterior superior iliac spine
(PSIS) and the horizontal ().
Orientation of the pelvis from surface landmarks is reported
as the angle formed between the horizontal and a line con-
necting the posterior superior iliac spine with the anterior
superior iliac spine [3,14,64] (Fig. 47.7). Typical measure-
ments of sacral and pelvic orientation are reported in Table
47.2. Measurements based on the orientation of the sacrum
are larger than those based on the pelvis, and the two meas-
urement procedures show only slight-to-moderate correla-
tions with each other [17].
Clinical literature suggests interdependence among the
spinal curves and pelvic alignment [27]. An increased lordosis
Similarly, an anterior pelvic tilt reportedly accompanies an in-
creased lumbar lordosis, while a decreased lumbar lordosis
is reportedly associated with a posterior pelvic tilt. There
is limited evidence to support these purported relationships,
and the existing relationships may be more complex than
those reflected by the popular beliefs. The assessment pro-
cedures as well as the populations studied appear to affect
the strength of the associations reported. A study of 100 adults
over the age of 40 years reports a correlation between the
thoracic kyphosis measured between T5 and T12 and the total
sis in the upper thorax and the lumbar lordosis [16]. A study
of 88 adolescents reports no relationship between the tho-
racic kyphosis from T3 to T12 and the total lumbar lordosis
[53]. However, the same study does find correlations between
the thoracic kyphosis and the lordosis between L5 and S1.
Although additional research is required, these data suggest
some association between the thoracic and lumbar curves, but
their interdependence may be a function of age and the spe-
cific morphology of an individual’s spine.
Studies investigating the relationship of pelvic alignment
and lumbar lordosis also yield conflicting results. Studies that
use radiographic measures consistently demonstrate an asso-
ciation between pelvic tilt as measured by sacral alignment
and lumbar lordosis measured by the Cobb method
[11,16,53]. These studies demonstrate the expected positive
associations between an anterior tilt of the sacrum and an in-
creased lordosis and between posterior tilting and a flattening
of the lordosis (Fig. 47.8). Yet studies using surface methods
to assess pelvic and spinal alignment in static posture fail to
demonstrate any significant correlation between pelvic align-
ment using pelvic landmarks and the amount of lumbar
lordosis using inclinometers or flexible rulers [55,62,63]. In
contrast, studies using surface methods to assess the associa-
tion between pelvic tilt and lumbar position during active
movement demonstrate that posterior pelvic rotations do
appear to decrease the lumbar lordosis [8,30]. Controversy
continues regarding the effect of an active anterior pelvic tilt
and the lordosis, with studies showing an increased lordosis
with an anterior tilt [7,30] and others showing no change [8].

TABLE 47.2 Measurements of Pelvic Orientation Reported in the Literature

Sacral Orientation ASIS–PSIS Angle
Voutsinas and MacEwen [54] 56.5
9.3a
During et al. [11] 40.4
8.8b
Jackson and McManus [24] 50.4
7.7c
Levine and Whittle [30] 11.3
4.3
Crowell et al. [3] 12.4
4.5
a
Based on the angle made by the superior surface of the sacrum and the horizontal.
b
Based on the angle made by the posterior surface of the sacrum and the vertical.
c
Based on the angle made by the superior surface of the sacrum and the horizontal.
Chapter 47 | CHARACTERISTICS OF NORMAL POSTURE AND COMMON POSTURAL ABNORMALITIES
φ tient reports pain relief.
φ This case provides an example of the commonly re-
A B
Figure 47.8: An anterior pelvic tilt, which enlarges the angle ()
formed by the horizontal and a line through the anterior
superior iliac spine, is believed to lead to an increased lumbar
lordosis (A) and a posterior pelvic tilt in which the angle ()
decreases and produces a decreased lumbar lordosis (B). Data
supporting these beliefs conflict.
The studies reported here present confusing results for
clinicians. On the one hand, radiographic data support the
generally accepted clinical impression that pelvic alignment
and spinal curves are related, but assessments of those rela-
tionships using the evaluation procedures typically applied in
the clinic reveal weak or absent relationships. What do these
conflicts mean to the clinician? Existing evidence appears suf-
ficient to justify the continued belief that pelvic and spinal
alignments are interdependent. However, current clinical
assessment tools may be influenced enough by soft tissue
overlying the skeleton that they do not reflect true bony
alignment. The larger question that clinicians and researchers
must answer is whether knowing the alignment of the pelvis
and the spine, regardless of measurement technique, affects
treatment outcomes.
843
CLINICAL RELEVANCE: IS POSTURE REEDUCATION A
USEFUL INTERVENTION STRATEGY FOR A PATIENT
WITH LOW BACK PAIN?
A patient with low back pain provides a good model to
examine the role posture plays in some treatment strate-
gies. The patient reports pain with lumbar extension
and in quiet standing and decreased pain with forward
bending and sitting. Radiographs demonstrate a spondy-
lolisthesis at L4–L5. Spondylolisthesis is an anterior dis-
placement of one vertebra on the vertebra below, and
decreasing the lumbar curve would decrease the forces
that tend to increase the displacement. Although the ev-
idence regarding the effect of pelvic alignment on lumbar
curvature is conflicting, the clinician chooses to proceed
with a program to teach the patient to stand maintaining
a posterior pelvic tilt to flatten the lumbar curve. The
clinician teaches the patient abdominal strengthening
exercises and posterior pelvic tilts. The patient learns to
stand while contracting the abdominal muscles and the
gluteus maximus, rotating the pelvis posteriorly. The pa-
ported anecdotal evidence supporting the use of postural
education to treat patients’ complaints. Anecdotal evi-
dence by itself, however, is insufficient to determine the
effectiveness of the intervention, since many factors be-
sides pelvic alignment may contribute to the reduction
in symptoms, including the placebo effect. Without well-
controlled biomechanical studies to determine the me-
chanical effects of pelvic alignment on low back posture
and without similarly well-controlled effectiveness stud-
ies, the role of postural interventions in rehabilitation
remains a firmly held belief.
FRONTAL AND TRANSVERSE PLANE ALIGNMENT IN
NORMAL ERECT POSTURE
In the frontal and transverse planes, normal posture suggests
a right–left symmetry, with the head and vertebral column
aligned vertically, hips and shoulders at an even height, the
knees exhibiting symmetrical genu valgum within normal
limits, and symmetrical placement of the upper and lower ex-
tremities in the transverse plane (Fig. 47.9). Scoliosis de-
scribes a postural deformity of the vertebral column that is
most apparent in the frontal plane but includes both frontal
and transverse plane deviations. The curve is named accord-
ing to its location in the spine and the side of its frontal plane
convexity. For example, a right thoracic curve indicates that
the curve is located in the thoracic region of the spine and its
convexity is on the right side.
Scolioses can be either structural or functional. A func-
tional scoliosis results from soft tissue imbalances, but a
structural scoliosis includes bony changes as well as soft
844
Figure 47.9: Normal alignment of the head and trunk in the
frontal plane is characterized by a vertically aligned head and
vertebral column, with shoulder, pelvis, hips, and knees at the
same height, and the knees and feet exhibiting valgus and
subtalar neutral positions within normal limits.
tissue asymmetries. As noted in Chapter 29, idiopathic
scoliosis is the most common form of scoliosis. It is a struc-
tural scoliosis that is found most frequently in adolescent girls.
The curve usually involves at least two spinal regions, and the
curves typically are compensated, so that adjacent regions
have opposite convexities (Fig. 47.10). A structural scoliosis
in the thoracic region is accompanied by a rib hump on the
same side as the convexity as a result of the coupled move-
ments of the thoracic spine and their effects on the joints of
the ribs. (Chapter 29 reviews the mechanics producing a rib
hump.)
Part V | POSTURE AND GAIT
Figure 47.10: A. An individual exhibits a right thoracic left
lumbar idiopathic scoliosis. B. When flexed forward, the
individual exhibits a rib hump on the right, the side of the
thoracic convexity.
A popular theory in rehabilitation suggests that hand dom-
inance induces muscle imbalances that lead to functional
scolioses and asymmetry in shoulder and hip alignment [27].
Few objective studies exist that test this hypothesis, but a study
of 15 females aged 19 to 21 years reports no statistically sig-
nificant differences in frontal plane alignment of the scapula
between the dominant and nondominant sides, although 11 of
15 subjects demonstrated a lower right shoulder [47]. Hori-
zontal distances between the medial border of the scapula and
the vertebral column range from 5 to 9 cm [5,44,47]. Although
asymmetry in hip height, or pelvic obliquity, also is allegedly
Chapter 47 | CHARACTERISTICS OF NORMAL POSTURE AND COMMON POSTURAL ABNORMALITIES 845

associated with hand dominance, there is no known direct

CLINICAL RELEVANCE: RELATING POSTURAL FINDINGS TO
evidence to support or refute the contention [27].
IMPAIRMENTS OF THE NEUROMUSCULOSKELETAL
The relative alignment of the hip, knee, and foot in the
SYSTEM: A CASE REPORT
frontal and transverse planes during erect standing is dis-
A 45-year-old male with rheumatoid arthritis was evaluated
cussed in some detail in the respective chapters dealing with
in the clinic with hip, knee, and foot pain bilaterally. An
each joint (Chapters 38, 41, and 44, respectively). Figure
evaluation of his standing posture revealed a pelvic obliq-
47.11 provides a brief review of the characteristic alignments.
uity, right side higher than left, a slightly plantarflexed right
Because the lower extremities participate in a closed chain
ankle, and increased out-toeing on the left (Fig. 47.13).
during erect standing, lower extremity malalignments may
Many possible impairments could explain these findings,
indicate local deformities but also may reflect compensa-
and the clinician’s initial hypotheses included a structural
tions for more remote malalignments. Findings from a pos-
leg length discrepancy and a plantarflexion contracture. A
tural assessment lead a clinician to hypothesize underlying
thorough examination of all of the joints of the lower
impairments. Direct assessment of joints can identify the
extremities was required before an explanation for the
impairments that contribute to or explain the postural
posture emerged. The patient demonstrated bilateral hip
malalignments. A single contracture at either the hip, knee,
or ankle may produce the same posture as the individual com-
pensates for the functional limb length discrepancy produced
by the contracture (Fig. 47.12). An understanding of the
mechanisms contributing to faulty posture requires careful
assessment of each joint.

Lateral Medial

Figure 47.12: Flexion contractures of the hip or knee

A B
Figure 47.11: In normal alignment, the femoral condyles are
aligned in the frontal plane so that the hip is in neutral rotation
and the feet exhibit out-toeing of approximately 15–25ⴗ.
A. Frontal view. B. Superior view.
functionally shorten the lower extremity, and a common
compensation is plantarflexion to lengthen the limb so that
the individual can stand with the pelvis level. A plantarflexion
contracture produces a functionally lengthened lower extremity
so that an individual with a plantarflexion contracture may
stand with a flexed hip and/or knee to restore symmetry and
stand with a level pelvis. The resulting postures look
approximately the same although the precipitating factors
differ.
846
flexion contractures. In addition, range of motion assess-
ments revealed that the patient had a complex contracture
of the left hip, holding it flexed, laterally rotated, and ab-
ducted. The patient stood with an anterior pelvic tilt and
increased lordosis, consistent with the hip flexion contrac-
tures, but the lateral rotation and abduction contractures
on the left effectively shortened the left lower extremity
while turning the toes outward. The patient stood with the
left hip in obligatory abduction secondary to the abduction
contracture, while the right hip was adducted, and conse-
quently, the pelvis was higher on the right. Correction of
standing posture required reduction of the contractures of
both the left and right hip. Although conservative treat-
ment failed to reduce the contractures on the left, a total
hip replacement on the left restored normal joint alignment,
and standing posture was immediately improved.
Muscular Control of Normal Posture
Examples throughout this textbook demonstrate that ground
reaction forces and body segment weights apply external
Add
Abd
Figure 47.13: A patient with an abduction contracture of the
left hip stands with the left hip abducted. To maintain an
upright posture with the feet close together, the individual
adducts the right hip, producing a pelvic obliquity in the frontal
plane. The left hip is abducted and the right hip is adducted.
The right ankle plantarflexes to equalize limb length.
Part V | POSTURE AND GAIT
moments to the joints, which are balanced by internal mo-
ments supplied by the surrounding muscles and noncontrac-
tile connective tissue. The alignment of the body’s center of
mass relative to joint axes in quiet standing defines the exter-
nal moments applied to the joints during erect standing. These
external moments then are balanced by either active or pas-
sive support to maintain the upright posture against the ever-
present gravitational forces tending to press the body into the
ground. Examination of the external moments applied to the
joints of the lower extremities, trunk, and head by the ground
reaction forces helps explain the forces needed to support
these joints (Fig. 47.14). Using the data from the studies pre-
sented in Table 47.1, the sagittal plane external moments on
Hip joint
axis
Knee axis
Ankle
joint axis
Figure 47.14: In quiet standing, the ground reaction force
applies a dorsiflexion moment at the ankle, extension moments
at the knee and hip, and flexion moments on the spine.
Chapter 47 | CHARACTERISTICS OF NORMAL POSTURE AND COMMON POSTURAL ABNORMALITIES
TABLE 47.3 External Moments Applied to the Joints Based on the Center of Mass Line
Opila et al. [40]a External Moment
Ankle Dorsiflexion
Knee Extension
Hip Extension
Back Flexion
Head/neck Flexion
a
Based on 19 unimpaired males and females aged 21 to 43 years. Originally reported with respect to the body’s center of gravity.
b
Based on 26 unimpaired males and females aged 22 to 88 years. Referenced to the ankle joint.
c
Moment is reported directly in the study but is derived from the available data.
d
Although the moment arm is 0.03 cm, the standard deviation is almost 4 cm, suggesting that some individuals sustain a flexion moment, and others sustain an
extension moment.
many joints of the body are presented in Table 47.3. Biome-
chanical analysis of these moments and electromyographic
(EMG) studies combine to help explain the mechanisms used
to maintain upright posture.
Although the external moments described in Table 47.3
are the predominant moments applied during quiet standing,
it is important to recall that standing posture is dynamic and
that even so-called quiet standing is characterized by oscilla-
tions of the body over the fixed feet. Panzer et al. report that
during quiet standing, the EMG activity of muscle groups is
less than 10% of each group’s activity during a maximum vol-
untary contraction (MVC) [42]. These investigators also note
that many of these muscle groups exhibit sudden, brief ac-
tivity levels of 30–45% of their MVC and suggest that these
sudden bursts may reflect a muscle group’s response to the
sway of the body’s center of mass.
Because the body’s center of mass generates a dorsiflexion
moment on the ankle during quiet standing, the plantar flexor
muscles generate a plantarflexion moment to maintain static
equilibrium. EMG data demonstrate activity of both the
soleus and the gastrocnemius during quiet standing [1,42].
Brief, intermittent, and slight EMG activity is also found in
the dorsiflexor muscles, apparently in response to postural
sway [1,42].
In contrast to the ankle, the knee exhibits minimal mus-
cle activity during quiet standing [1,42]. In erect posture, the
ground reaction force applies an extension moment to the
knee allowing it to maintain extension using its passive con-
straints, including the collateral and anterior cruciate liga-
ments. Reports of slight electrical activity in the quadriceps
muscles (4–7% of MVC) and hamstrings (1% of MVC) are
consistent with the use of passive supports to sustain the ex-
tended knee during quiet standing [42]. However, like the
muscle activity at the ankle, larger brief bursts of activity in
the quadriceps and hamstrings muscles may reflect the mus-
cles’ response to sway.
Few studies examine activity of the hip musculature dur-
ing erect posture. The ground reaction force produces an
extension moment at the hip, and EMG data reveal activity
of the iliacus in quiet standing, exerting a stabilizing flexion
847
Danis [6]b External Moment
Dorsiflexionc
Extension
Extension
Flexion
Approximately zerod
moment [1]. Understanding the role of muscles and ligaments
in generating the internal moments needed to balance the ex-
ternal moments exerted by body weight and ground reaction
forces allows the clinician to intervene to provide postural sta-
bility in the absence of muscular support.
CLINICAL RELEVANCE: MAINTAINING ERECT POSTURE IN
THE PRESENCE OF MUSCLE WEAKNESS: A PATIENT WITH
PARAPLEGIA
A patient with a spinal cord injury resulting in loss of mus-
cle function from the level of L2 is beginning rehabilita-
tion. Functional goals include standing for stimulation of
bone growth and limited ambulation. Weakness second-
ary to the spinal cord injury begins at the hip flexors and
extends throughout the rest of the lower extremities. To
teach the individual safe and efficient standing, the clini-
cian uses an understanding of the effects of external
moments on the joints of the lower extremities and a
recognition of the passive structures that are available to
support the joints.
The individual lacks muscular support at the hip, knee,
and ankle, but the astute clinician knows that the hip
possesses strong anterior ligaments, the iliofemoral,
pubofemoral, and ischiofemoral ligaments. By maintain-
ing the hip in hyperextension, the individual can “hang
on” these anterior ligaments, even in the absence of the
hip flexors. Similarly, the knee normally maintains ex-
tension in erect standing without muscular support,
since the body’s center of mass falls anterior to the knee
joint and exerts an extension moment on the knee. As
long as the knee remains extended, no additional mus-
cular support is needed. Thus the individual can stand in
hip and knee hyperextension using passive supports at
these joints.
Stable erect posture requires that the body’s center of
mass remain over the base of support. To maintain hip and
knee hyperextension while keeping the body’s center of
mass over the base of support, the individual’s ankles as-
sume a dorsiflexed position, and the ground reaction force
848 Part V | POSTURE AND GAIT

applies an external dorsiflexion moment (Fig. 47.15). With

no muscle support at the ankle, the individual with weak-
ness from the hips distally requires external support from
an orthosis to exert a plantarflexion moment at the an-
kle, balancing the external dorsiflexion moment. Thus the
individual can stand with minimal external support to sta-
bilize the lower extremity by using the external moments
generated by the ground reaction force to apply external
moments at the knee and hip that can be balanced by pas-
sive joint structures.
For the individual described in this case to stand with
minimal external support, he or she must be able to as-
sume a position of hip and knee hyperextension. Flexion
contractures at the hips or knees or plantarflexion con-
tractures at the ankle produce disastrous results, prevent-
ing the individual from positioning the joints to use
passive supports (Fig. 47.16).

A B

Figure 47.16: Effect of sagittal plane contractures on standing

posture and the external moments applied to the hip, knees,
and ankles. A. Flexion contractures at either the hip or knee
cause an individual to stand in a flexed position at both the
hips and knees, generating external flexion moments at both
joints. Consequently, the individual is unable to use the passive
supports at the hip and knee joints. B. Plantarflexion
contractures at the ankles prevent an individual from moving
the center of mass over the base of support while still
maintaining hip and knee hyperextension. To relocate the
center of mass over the base of support, the patient flexes
the hip joints, thus requiring muscular support to support
the hip joints.

The weight of the trunk exerts an external flexion moment

Figure 47.15: Standing posture of an individual with weakness at
the hip, knees, and ankles. By hyperextending the hip joints, the
individual uses the passive restraint of the anterior ligaments of
the hip joint to support the hip. Hyperextension of the knee
increases the extension moment at the knee that is supported by
passive structures of the knee. To maintain hyperextension of the
hip and knees while keeping the center of mass over the base of
support, the ankles dorsiflex, producing a dorsiflexion moment
that is withstood by an externally applied plantarflexion moment
using an orthotic device.
on the back, requiring an extension moment to maintain erect
posture. EMG data show low-level activity of the erector
spinae and multifidus with intermittent bursts of increased
activity [1,42,56]. The cervical region also sustains an exter-
nal flexion moment because the head’s center of mass is an-
terior to the joints of the cervical spine. Active contraction of
cervical extensors maintains upright posture of the head and
neck, but as in the trunk, EMG data reveal that only slight
activity is required to hold the head erect. Although few stud-
ies examine activity in the cervical muscles during quiet stand-
ing, data show activity in the semispinalis muscles with no
activity in the splenius muscles [51].
Chapter 47 | CHARACTERISTICS OF NORMAL POSTURE AND COMMON POSTURAL ABNORMALITIES 849

The role of the abdominal muscles during quiet standing
continues to be debated. EMG studies of the abdominal mus-
cles identify activity, particularly in the internal oblique mus-
cle, with some activity in the external oblique muscle during
quiet standing [1,12,43,46]. Yet studies that investigate the as-
sociation between abdominal muscle strength as measured by
leg-lowering maneuvers and postural alignment of the pelvis
report either no association [55] or weak associations in fe-
males and no association in males [63]. The leg-lowering ex-
ercise recruits the rectus abdominis more than the oblique
abdominal muscles in most individuals and, consequently,
may not reflect the ability of the oblique abdominal muscles
to participate in postural support [43]. Chapter 34 discusses
the role of the abdominal muscles in stabilizing the spine. The
data presented here suggest that the oblique abdominal mus-
cles are important in erect posture, although their role may
be to function with the transversus abdominis muscle to sta-
bilize the spine rather than to position the pelvis.
The role played by muscles to maintain shoulder position
during quiet standing also lacks definitive conclusions. Inman
et al. demonstrate active contraction of the levator scapulae
along with the upper trapezius and upper portion of the ser-
ratus anterior muscles in quiet standing, suggesting that these
muscles are providing upward support for the shoulder gir-
dle and upper extremity [23]. However, Johnson et al. note
that only the levator scapulae and the rhomboid major and
minor muscles can directly suspend the scapula [26]. EMG
studies show that in the presence of voluntary relaxation of
the upper trapezius in quiet standing, there is an increase in
EMG activity of the two rhomboid muscles but a decrease in
activity in the levator scapulae [41]. These data support the
notion that the rhomboid muscles can and do support the up-
right position of the shoulder girdle, at least under certain
circumstances. Whether the levator scapulae contributes ad-
ditional support remains debatable.
[21,27]. Complaints attributed to postural deviations of the
head and spine include circulatory, respiratory, digestive, and
excretory dysfunctions; headaches; backaches; depression;
and a generalized increased susceptibility to disease
[4,21,38,39]. Pain in the back and lower extremities also is at-
tributed to abnormal alignment in the hips, knees, and feet
[10,28,29,32,59].
Despite the presumption of associations between postural
abnormalities and patients’ complaints, studies examining
these associations vary in their findings. Correlations between
the incidence of reported head, neck, and shoulder pain are
reported in people with forward head, rounded shoulders, and
increased thoracic kyphoses [21]. Studies investigating the as-
sociation between low back postural deviations and low back
pain draw variable conclusions, with some reporting little or
no difference in posture between those with and without low
back pain [7,11,62], and others finding differences between
the two groups [24]. Malalignments of the patellofemoral joint
are associated with a variety of pain syndromes at the knee
[22,35,45]. Considerably more research is required to deter-
mine the role that postural abnormalities play in muscu-
loskeletal complaints and to determine the effectiveness of
treatments directed toward improving posture to reduce pain.
Typical postural deviations are listed and defined in Tables
47.4 and 47.5. These postural abnormalities are presumed to
produce excessive or abnormally located stresses (force/area)
on joint surfaces or to contribute to altered muscle mechan-
ics by putting some muscles on slack while stretching others
[27]. Although evidence supports these effects in some cases,
evidence is lacking for others [9,29,32]. Determining the role
posture plays in the pathomechanics of musculoskeletal dis-
orders requires continued research in basic anatomy and
biomechanics, as well as well-controlled outcome studies
examining the effectiveness of treatments directed toward
posture reeducation.

POSTURAL MALALIGNMENTS Muscle Imbalances Reported in

Health care providers evaluate posture on the premise that
Postural Malalignments
postural malalignments contribute to altered joint and mus- A commonly held clinical perception is that postural malalign-
cle mechanics, producing impairments that lead to pain ments produce adaptive changes in the muscles surrounding

TABLE 47.4 Common Postural Abnormalities in the Sagittal Plane

Postural Deviation
Forward head
Forward shoulders
Excessive/flattened thoracic kyphosis
Excessive/flattened lumbar lordosis
Anterior/posterior pelvic tilt
Forward/backward translation of the pelvis
Genu recurvatum
Description
The mastoid process lies anterior to the body of C7
The acromion process lies anterior to the body of C7, or the scapula tilts anteriorly
The sagittal plane curve of the thorax is excessive or inadequate
The sagittal plane curve of the lumbar spine is excessive or inadequate
The angle made by a line through the ASIS and PSIS and the horizontal increases/decreases from
an angle of approximately 10–15
Determined by the location of the greater trochanter with respect to the vertical line through the
center of mass, which in normal alignment passes approximately through the trochanter
Angle between the mechanical axes of the leg and thigh in the sagittal plane is greater than 0
850 Part V | POSTURE AND GAIT

TABLE 47.5 Common Postural Abnormalities in the Frontal and Transverse Planes
Postural Deviation
Head tilt
Asymmetrical shoulder height
Scoliosis
Pelvic obliquity
Asymmetrical hip height
Genu varum/valgus
Foot pronation/supination
In-toeing/out-toeing
Description
The line through the center of the head deviates from the midsagittal plane
Measured by the height of the acromions or the inferior angles of the scapulae
Frontal plane deviation of the vertebral column as assessed by the spinous processes
Asymmetrical height of the pelvis as measured by the iliac crests
Measured by the height of the greater trochanters or gluteal folds
Angle between the mechanical axes of the leg and thigh in the frontal plane
Indicated by several different measures including (1) the frontal plane alignment of the heel and leg, (2) the
height of the navicular relative to the medial malleolus and the head of the first metatarsal, and (3) the
subtalar neutral position
The angle between the long axis of the foot and the malleoli is less than/greater than approximately 20

the malaligned joints. Specifically, it is believed that muscles
on one side of the joint are held in a lengthened position and
the antagonistic muscles are maintained in a shortened posi-
tion. Clinicians also suggest that these length changes pro-
duce joint impairments including weakness and limited range
of motion that contribute to a patient’s complaints. Although
these hypotheses are logical and may still prove true, studies
to date have failed to identify clear associations between
malalignments and joint impairments [9,37].
As noted in Chapter 4, studies in animals demonstrate that
prolonged length changes in muscles produce structural
changes in muscle, although those changes depend upon
many factors besides length. These additional mitigating fac-
tors include age, fiber arrangement within the muscles, and
fiber type within the muscle [31,33]. In general, prolonged
stretch of a muscle induces protein synthesis and the pro-
duction of additional sarcomeres [18,19,50,58,60]. The
lengthened muscle hypertrophies, and as a result, peak con-
tractile force increases with prolonged stretch [31,33]. The
structural remodeling that accompanies prolonged lengthen-
ing appears to maintain the muscle’s original length–tension
relationship so that, although the muscle has a larger peak
torque, it generates the peak torque at a different joint posi-
tion. The clinical literature describes stretch weakness in
which a muscle that has been held in a stretched position long
enough to remodel appears weak when tested in the tradi-
tional test position [20,27]. For example, at the shoulder,
stretch weakness suggests that a posture characterized by
rounded shoulders applies a prolonged stretch to the middle
trapezius, which undergoes the structural adaptations that
lead to weakness when assessed in the traditional manual mus-
cle test position. Although the changes described here are
logical and plausible, they remain unproved.
Animal studies examining prolonged shortening reveal that
shortening produced by immobilization appears to accelerate
atrophy, and muscles demonstrate a loss of sarcomeres
[18,50,60]. Studies examining the effect of prolonged length
changes in muscle reveal that the relationship between mus-
cle length and muscle performance is complex, requiring
independent investigation of the relationship with each mus-
cle. The complexity of the association helps explain the ab-
sence of clearly defined associations.
Attempts to confirm the expected muscle impairments with
postural abnormalities have failed to yield clear relationships.
Individuals with idiopathic scoliosis exhibit atrophy of the mus-
cles of the posterior thorax, particularly on the concave side,
and a higher percentage of type I muscle fibers than normal
on the convex side of the deformity [13,61,65]. The muscles
of the thorax on the concave side of the curve are likely short-
ened, while those on the convex side are lengthened; yet both
muscle groups exhibit atrophy. Although this atrophy may pre-
cede the development of the scoliosis, the expected adaptive
changes with prolonged lengthening apparently are lacking.
Similarly, attempts to relate scapular alignment and muscle
performance fail to reveal associations [9]. However, the
scapula moves in a complex, three-dimensional way, and stud-
ies so far may not accurately reflect the effects of scapular
malalignment on muscle length. These data demonstrate the
need for careful anatomical, biomechanical, and clinical stud-
ies to identify and explain any detrimental effects of postural
malalignment.
SUMMARY
This chapter describes the relative alignment of body seg-
ments identified in healthy adults during quiet standing. In
the absence of a validated description of “ideal posture,” the
documented alignments provide clinicians with a view of the
variability of alignments found in individuals without muscu-
loskeletal complaints. Although individuals demonstrate a
wide spectrum of alignments, the overall image of upright pos-
ture shows a head well balanced over the pelvis, which in turn
is well balanced over the feet. Using these alignments, the
chapter also demonstrates the external moments applied to
the joints of the lower extremities and trunk during upright
standing. The external moments are balanced by internal mo-
ments generated by muscle contractions and noncontractile
Chapter 47 | CHARACTERISTICS OF NORMAL POSTURE AND COMMON POSTURAL ABNORMALITIES
connective tissue support. EMG data are consistent with
the mechanical data, demonstrating low levels of activity in the
plantar flexors, hip flexors, and erector spinae muscles of
the lumbar and cervical regions. Additional activity in the
oblique abdominal muscles is consistent with their role as sta-
bilizers of the spine. In addition, other muscle groups such as
the dorsiflexor muscles, the quadriceps, and the hamstrings
demonstrate very brief bursts of activity that may be required
to control the small, but persistent sway of the body that occurs
throughout quiet stance.
Postural alignment is commonly assessed clinically, and
some abnormal postures are associated with musculoskeletal
abnormalities and clinical complaints. However, many of the
commonly held beliefs regarding the associations between
postural abnormalities and musculoskeletal impairments lack
objective evidence. Although these associations may well exist,
additional research is required to identify such relationships
and to demonstrate the effectiveness of treating postural
deviations to reduce pain or other impairments.
References
1. Basmajian JV, DeLuca CJ: Muscles Alive. Their Function Re-
vealed by Electromyography. Baltimore: Williams & Wilkins,
1985.
2. Bernhardt M, Bridwell KH: Segmental analysis of the sagittal
plane alignment of the normal thoracic and lumbar spines and
thoracolumbar junction. Spine 1989; 14: 717–721.
3. Crowell RD, Cummings GS, Walker JR: Intratester and in-
tertester reliability and validity of measures of innominate bone
inclination. J Orthop Sports Phys Ther 1994; 20: 88–97.
4. Culham E, Jimenez HA, King CE: Thoracic kyphosis, rib mo-
bility, and lung volumes in normal women and women with os-
teoporosis. Spine 1994; 19: 1250–1255.
5. Culham E, Peat M: Functional Anatomy of the Shoulder Com-
plex. J Orthop Sports Phys Ther 1993; 18: 342–350.
6. Danis CG, Krebs DE, Gill-Body KM, Sahrmann SA: Relation-
ship between standing posture and stability. Phys Ther 1998; 78:
502–517.
7. Day JW, Smidt GL, Lehmann T: Effect of pelvic tilt on stand-
ing posture. Phys Ther 1984; 64: 510–516.
8. Delisle A, Gagnon M, Sicard C: Effect of pelvic tilt on lumbar
spine geometry. IEEE Trans Rehabil Eng 1997; 5: 360–366.
9. DiVeta J, Walker M, Skibinski B: Relationship between per-
formance of selected scapular muscles and scapular abduction
in standing subjects. Phys Ther 1990; 70: 470–476.
10. Donatelli R, Hurlbert C, Conaway D, St. Pierre R: Biome-
chanical foot orthotics: a retrospective study. J Orthop Sports
Phys Ther 1988; 10: 205–212.
11. During J, Goudfrooij H, Keesen W, et al.: Toward standards for
posture—postural characteristics of the lower back system in
normal and pathologic conditions. Spine 1985; 10: 83–87.
12. Floyd WF, Silver PHS: Electromyographic study of patterns of
activity of the anterior abdominal wall muscles in man. J Anat
1950; 84: 132–145.
13. Ford DM, Bagnall KM, McFadden KD, et al.: Paraspinal mus-
cle imbalance in adolescent idiopathic scoliosis. Spine 1984; 9:
373–376.
851
14. Gajdosik RL, Simpson R, Smith R, Dontigny RL: Intratester re-
liability of measuring the standing position and range of motion.
Phys Ther 1985; 65: 169–174.
15. Garrett TR, Youdas JW, Madson TJ: Reliability of measuring for-
ward head posture in a clinical setting. J Orthop Sports Phys
Ther 1993; 17: 155–160.
16. Gelb DE, Lenke LG, Bridwell KH, et al.: An analysis of sagit-
tal spinal alignment in 100 asymptomatic middle and older aged
volunteers. Spine 1995; 2: 1351–1358.
17. Gilliam J, Brunt D, MacMillan M, et al.: Relationship of the
pelvic angle to the sacral angle: measurement of clinical relia-
bility and validity. J Orthop Sports Phys Ther 1994; 20: 193–199.
18. Goldspink G: The influence of immobilization and stretch in
protein turnover of rat skeletal muscle. J Physiol 1977; 264:
267–282.
19. Goldspink G: Changes in muscle mass and phenotype and the
expression of autocrine and systemic growth factors by muscle
in response to stretch and overload. J Anat 1999; 194: 323–334.
20. Gossman MR, Sahrmann SA, Rose SJ: Review of length-
associated changes in muscle. Phys Ther 1982; 62: 1799–1807.
21. Griegel-Morris P, Larson K, Mueller-Klaus K, Oatis CA: Inci-
dence of common postural problems in the cervical, shoulder
and thoracic regions and their association with muscle imbal-
ance and pain. Phys Ther 1992; 72: 425–431.
22. Holmes SW Jr, Clancy WG Jr: Clinical classification of
patellofemoral pain and dysfunction. J Orthop Sports Phys Ther
1998; 28: 299–306.
23. Inman VT, Saunders M, Abbott LC: Observations on the func-
tion of the shoulder joint. J Bone Joint Surg 1944; 26: 1–30.
24. Jackson RP, Mcmanus AC: Radiographic analysis of sagittal
plane alignment and balance in standing volunteers and patients
with low back pain matched for age, sex and size. Spine 1994;
19: 1611–1618.
25. Jian Y, Winter DA, Ishac MG, Gilchrist L: Trajectory of the body
COG and COP during initiation and termination of gait. Gait
Posture 1993; 1: 9–22.
26. Johnson GR, Spalding D, Nowitzke A, Bogduk N: Modelling
the muscles of the scapula morphometric and coordinate data
and functional implications. J Biomech 1996; 29: 1039–1051.
27. Kendall FP, McCreary EK, Provance PG: Muscle Testing and
Function. Baltimore: Williams & Wilkins, 1993.
28. Klingman RE, Liaos SM, Hardin KM: The effect of subtalar
joint posting on patellar glide position in subjects with excessive
rearfoot pronation. JOSPT 1997; 25: 185–191.
29. Laforgia R, Specchiulli F, Solarino G, Nitti L: Radiographic vari-
ables in normal and osteoarthritic hips. Bull Hosp Joint Dis 1996;
54: 215–221.
30. Levine D, Whittle MW: The effects of pelvic movement on lum-
bar lordosis in the standing position. J Orthop Sports Phys Ther
1996; 24: 130–135.
31. Lieber RL: Skeletal Muscle Structure and Function: Implica-
tions for Rehabilitation and Sports Medicine. Baltimore:
Williams & Wilkins, 1992.
32. Loudon JK, Goitz HT, Loudon KL: Genu recurvatum syndrome.
J Orthop Sports Phys Ther 1998; 27: 361–367.
33. Loughna PT: Disuse and passive stretch cause rapid alterations
in expression of developmental and adult contractile protein
genes in skeletal muscle. Development 1990; 109: 217–223.
34. Magee DA: Orthopedic Physical Assessment. Philadelphia: WB
Saunders, 1998.
852
35. Meyer SA, Brown TD, Pedersen DR, Albright JP: Retropatel-
lar contact stress in simulated patella infera. Am J Knee Surg
1997; 10: 129–138.
36. Murray MP, Seireg A, Sepic SB: Normal postural stability and
steadiness: quantitative assessment. J Bone Joint Surg 1975; 57A:
510–516.
37. Neumann DA, Soderberg GL, Cook TM: Comparison of max-
imal isometric hip abductor muscle torques between hip sides.
Phys Ther 1988; 68: 496–502.
38. Nicholson GG, Gaston J: Cervical headache. J Orthop Sports
Phys Ther 2001; 31: 184–193.
39. Nicolakis P, Nicolakis M, Piehslinger E, et al.: Relationship be-
tween craniomandibular disorders and poor posture. Cranio
2000; 18: 106–112.
40. Opila KA, Wagner SS, Schiowitz S, Chen J: Postural alignment
in barefoot and high-heeled stance. Spine 1988; 13: 542–547.
41. Palmerud G, Sporrong H, Herberts P, Kadefors R: Conse-
quences of trapezius relaxation on the distribution of shoulder
muscle forces: an electromyographic study. J Electromyogr
Kinesiol 1998; 8: 185–193.
42. Panzer VP, Bandinelli S, Hallett M: Biomechanical assessment
of quiet standing and changes associated with aging. Arch Phys
Med Rehabil 1995; 76: 151–157.
43. Partridge MJBS, Walters CE: Participation of the abdominal
muscles in various movements of the trunk in man: an elec-
tromyographic study. Phys Ther Rev 1959; 39: 791–800.
44. Peterson DE, Blankenship KR, Robb JB, et al.: Investigation of
the validity and reliability of four objective techniques for meas-
uring forward shoulder posture. J Orthop Sports Phys Ther 1997;
25: 34–42.
45. Singerman R, Davy D, Goldberg V: Effects of patella alta and
patella infera on patellofemoral contact forces. J Biomech 1994;
27: 1059–1065.
46. Snijders CJ, Slagter AHE, van Strik R, et al.: Why leg crossing?
The influence of common postures on abdominal muscle activ-
ity. Spine 1995; 18: 1989–1993.
47. Sobush DC, Simoneau GG, Dietz KE, et al.: The Lennie test
for measuring scapular position in healthy young adult females:
a reliability and validity study. J Orthop Sports Phys Ther 1996;
23: 39–50.
48. Steindler A: Kinesiology of the human body under normal and
pathological conditions. Springfield, IL: Charles C Thomas,
1955.
49. Stokes IA, Bevin TM, Lunn RA: Back surface curvature
and measurement of lumbar spinal motion. Spine 1987; 12:
355–361.
Part V | POSTURE AND GAIT
50. Tabary JC, Tabary C, Tardieu C, et al.: Physiological and struc-
tural changes in the cat’s soleus muscle due to immobilization
at different lengths by plaster casts. J Physiol 1972; 224: 231–244.
51. Takebe K, Vitti M, Basmajian JV: The function of the semispinalis
capitis and splenius capitis. Anat Rec 1974; 179: 477–480.
52. Tillotson KM, Burton AK: Noninvasive measurement of lumbar
sagittal mobility. Spine 1991; 16: 29–33.
53. Vedantam R, Lenke LG, Keeney JA, Bridwell KH: Comparison
of standing sagittal spinal alignment in asymptomatic adolescents
and adults. Spine 1998; 23: 211–215.
54. Voutsinas SA, MacEwen GD: Sagittal profiles of the spine. Clin
Orthop 1986; 210: 235–242.
55. Walker ML, Rothstein JM, Finucane SD, Lamb RL: Relation-
ships between lumbar lordosis, pelvic tilt, and abdominal mus-
cle performance. Phys Ther 1987; 67: 512–521.
56. Waters RL, Morris JM: Effect of spinal supports on the electri-
cal activity of muscles of the trunk. J Bone Joint Surg 1970; 52A:
51–60.
57. White AA III, Panjabi MM: Practical biomechanics of scoliosis
and kyphosis. In: Cooke DB, ed. Clinical Biomechanics of the
Spine. Philadelphia: JB Lippincott, 1990; 127–163.
58. Williams P, Kyberd P, Simpson H, et al.: The morphological ba-
sis of increased stiffness of rabbit tibialis anterior muscles dur-
ing surgical limb-lengthening. J Anat 1998; 193: 131–138.
59. Witonski D, Goraj B: Patellar motion analyzed by kinematic and
dynamic axial magnetic resonance imaging in patients with an-
terior knee pain syndrome. Arch Orthop Trauma Surg 1999; 119:
46–49.
60. Yang H, Alnaqeeb M, Simpson H, Goldspink G: Changes in
muscle fibre type, muscle mass and IGF-I gene expression in
rabbit skeletal muscle subjected to stretch. J Anat 1997; 190:
613–622.
61. Yarom R, Robin GC: Studies on spinal and peripheral muscles
from patients with scoliosis. Spine 1979; 4: 12–21.
62. Youdas JW, Garrett TR, Egan KS, Therneau TM: Lumbar lor-
dosis and pelvic inclination in adults with chronic low back pain.
Phys Ther 2000; 80: 261–275.
63. Youdas JW, Garrett TR, Harmsen S, et al.: Lumbar lordosis and
pelvic inclination of asymptomatic adults. Phys Ther 1996; 76:
1066–1081.
64. Youdas JW, Suman VJ, Garrett TR: Reliability of measurements
of lumbar spine sagittal mobility obtained with the flexible curve.
J Orthop Sports Phys Ther 1995; 21: 13–27.
65. Zetterberg C, Aniansson A, Grimby G: Morphology of the par-
avertebral muscles in adolescent idiopathic scoliosis. Spine 1983;
8: 457–462.