POSTURAL ASSESSMENT A formal postural assessment is done with a plumb line. The client is positioned side on with a plumb line passing just in front of the lat- eral malleolus (coronal plane). In an ideal posture, this line should pass just anterior to the mid-line of the knee and then through the greater trochanter, bodies of the lumbar vertebrae, shoulder joint, bodies of the cervical vertebrae and the lobe of the ear (3).

Next the subject is then viewed from the front (sagittal plane), with the feet about seven centimeters apart (three inches), the line should bisect the body into two equal halves. The anterior superior iliac spines (ASIS) should be approximately in the same horizontal plane, and the pubis and ASIS should be in the same vertical plane (3).

In conjunction with the sagittal and coronal plane assessments, it also follows to observe anatomical landmarks, such as the lat- eral malleolus, patella and acromion processes, as well as look- ing at the muscular and structural differences. Compare the right and left sides of the body on a horizontal level and observe any differences to the norm.

QUESTIONS AND OBSERVATIONS TO MAKE Feet and ankles Look for inversion, eversion, toeing out, low or high arches. The feet are often associated with knee, hip and back problems. Look for callouses on the feet, this is a good indicator that there could be a biomechanical failure. Knees Creases behind the knees - are they equal in height? Are the patel- lae at the same height and central or pushed to one side? Observe the height of creases - are they equal?

TABLE ONE: POSTURAL AND PHASIC MUSCLES Postural muscles Upper trapezius Levator scapulae

Pectoralis major (upper part) Rhomboids Pectoralis minor Scalenes

Flexors of the upper limb Erector spinae (especially

cervical. lumbar and thoracolumbar)

Quadratus lumborum

Tensor fascia latae Gluteus maximus,

medius and minimus Peroneals

Tibialis anterior Short hip adductors Gastrocnemius/soleus Piriformis Ilio-psoas Tibialis posterior

Pelvic rim Is the height equal or rotated? Back Are there an equal number of skinfolds? Look for differences in muscle size and shadows/contours of the skin.

Medication: She is taking non steroidal anti-inflammatory drugs (NSAIDs) four times a day which helps a little.

History: No evidence of a specific incidence that points to the current situation. She does not carry any heavy bags or crunch her phone. Her job is stressful and she spends her day at a computer. She is a single mother with an eight year old daughter and she does not have a good support system. She attends swimming training three times per week for one hour per session. attends yoga sporadically.

She

Treatment: The ergonomics of her workstation were assessed and altered. She increased her attendance to yoga and included Pilates. Her swimming technique and training regime were assessed and altered appropriately. Her situation as a single par- ent was also considered and the extra stress it was placing on her. As a result, she developed a better support system. Treatment consisted of deep tissue work to the areas of tension and a com- bination of remedial techniques that included soft tissue release, muscle energy technique and neuromuscular technique. Workstation stretches and mobility exercises were included. A vast improvement was noted.

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Despite the changes and improvement, a mild form of the condi- tion continued to return in the shoulders, conversely the hip area started to be more of a focal point of pain and discomfort. She was having regular massages, every two weeks, but could not go past this time period without her symptoms returning.

So it was time to rethink the situation. A couple of indicators that came up during the postural assessment were still not right, ie. the dropped shoulder and the extra skinfolds on her right side. Focusing on the right using superficial and deep tissue palpation skills, it was noted in the area of T11 - T12 anteriorly, there was evidence of a raised area of hard tissue and decreased space between the ribs. On further questioning the subject reflected that while going through childbirth with her daughter, eight years ago, she fractured a rib but did not pursue any treatment. This precipitated muscle misuse. A client will naturally protect an area of pain by limiting the normal range of motion to an area and transferring the demand to other muscles. This sets up a pattern of misuse that is not easily forgotten unless addressed and cor- rected. With the use of soft tissue release, myofascial and friction techniques, the muscles balance and functional aspects of the area started to return. Following this, she returned to have mas- sage as an MOT rather than a treatment.

Vastus medialis and lateralis Hamstrings Rectus femoris

Phasic muscles

Mid/lower trapezius Latissimus dorsi

Anterior cervical muscles Serratus anterior

Upper limb extensors Rectus abdominus

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