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Postural Assessment Skills

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An Essential Tool for Sports Massage Practitioners

As sport massage practitioners sometimes the solutions to our clients’ problems are simple, we do our magic, and the file is closed.  However, often the key to long-term success is the ability to follow the chain of muscular imbalances and dysfunction to a source. In cases of trauma the reasons for pain and dysfunction are normally fairly obvious but for clients with more long-term problems the symptoms can be camouflaged behind the presenting condition and the reasons for it are not so forthcoming.

There are many ways in which we can test and assess our clients but out of these postural assessment is easy to incorporate into the treatment session. It does not have to be a detailed and precise assessment with a plumb line, protractors and/or boards but a more general approach that can be invaluable in giving up vital clues.

A good posture will maximise the function of muscles and joints, aiding in the well-being and performance of an athlete. As sports massage practitioners, one of our goals is to develop and maintain the optimal balance between muscles and their relationship with the skeletal system.  

Postural dysfunction can be a result of faulty biomechanics, previous injury and psychosocial reasons. Whichever of these it might be, or a combination, it will play an important role in influencing a practitioner’s approach to treatment.

More often than not, the circumstances in which we first meet our clients will be related to an acute problem accompanied by pain, needing our immediate attention. The tendency is to focus on the area of pain so as to give some immediate symptomatic relief, which in itself is reasonable. However, in order to make an accurate assessment and correct the existing condition we need to understand the underlying influences that may have contributed to this problem.  
 
Posture and alignment
To appreciate posture and its relationship to alignment, it is necessary to comprehend a few basic principles about muscles and how they react to faulty loading. Postural muscles are classified as stablilisers, their job is to fix a joint and prevent movement while mobilisers, (phasic) create movement (1,2) (see table one).

Table one: Postural and phasic muscles
Postural Muscles    Phasic Muscles
Upper trapezius    Mid/lower trapezius
Levator Scapulae    Latissimus dorsi
Pectoralis major (upper part)    Rhomboids
Pectoralis  Minor    Anterior cervical muscles
Scalenes    Serratus Anterior
Flexors of the upper limb    Upper limb extensors
Erector spinae (especially cervical. lumbar & thoracolumbar)    Rectus Abdominus
Quadratus lumborum    Vastus medialis & lateralis
Tensor fascia latae    Gluteus maximus, medius & minimus
Hamstrings    Peroneals
Rectus femoris    Tibialis anterior
Short hip adductors    
Gastrocnemius/soleus    
Piriformis        
Ilio-psoas    
Tibialis posterior    
 
Postural muscles are stronger and deliver more work than phasic muscles. They are composed of more slow twitch muscle fibres which have a greater capacity for prolonged work. Because of this, postural muscles have a tendency to shorten and tighten to faulty loading, while phasic muscles tend to react by weakening & becoming inhibited. This leads to muscles suffering over and underuse symptoms, leading to a predisposition to poor joint alignment and function.

As a massage practitioner it is worth taking this into consideration when presented with this type of muscle condition, ask, “where is this coming from?” and try to follow the chain of events to its source. Simply treating the area of discomfort will limit the success of the sports massage.  

Postural assessments include: 
* Examination of the alignment when the subject is standing
* Tests for flexibility and muscles length 
* Tests for muscle strength as well as palpation techniques.  
But for our purposes we are only looking at the assessment procedure while standing and then expanding this to include sitting and lying down.  

Postural assessment
A formal postural assessment is done with a plumb line. Whereby, the client is positioned with a plumb line passing just in front of the lateral 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 cms 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 lateral malleolus, patella and  acromion processes, as well as looking 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? Is the patellae at the same height and central or pushed to one side?  

Buttock:
Observe the height of creases – are they equal?

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.  

Spine:
The spine has natural curvatures these can become exaggerated in one direction or another and the client can present with postural conditions such as flat back, sway back, lordotic-kyphotic and scoliosis.  

Scapulae:
Are there any height differences in the inferior angle? Do they rest flat against the upper back or is there “winging”?

Shoulders:
Are they level or is one higher? Is the distance from the acromion process to the cervical spine the same?

Arms:
How do they hang at the sides? Are they hanging close to the sides or sitting away from the body? Are the “windows” equal?

Head:
The head should not be tilted, retracted, rotated or forward. The eyes should stay on a level plane, vertically and horizontally, hence, a client can have an exacerbated spinal curvature but the head will adjust itself to compensate because of this tendency.   

It is not always ideal to use this procedure but after doing it a few times an imaginary plumb line starts to take its place. Once adept with this procedure, practitioners can obtain information from clients during the history-taking section of the interview. A practitioner can observe for any of the above when a client walks into the room, while they are sitting in the chair or lying on the plinth without the inconvenience of having someone stand baring all and feeling uneasy and conspicuous. This will give a good baseline of information followed up by palpation through the hands.

Case study
The following is a case study that proves the point that as sports massage practitioners we sometimes need to be persistent and work our way back to the original cause.  

The client is a single professional mother, 32 years of age and her sport is swimming.

Presenting complaint:
Right shoulder pain and tension that has developed gradually over a period of two years.

Symptoms: 
Progressed slowly over a couple of years, the pain comes and goes. Used to be able to resolve the symptoms with a bit of Iyengar Yoga and Alexander Technique.  Recently over the past few months there has been no relief from the discomfort and has started to keep her awake at night (Pain scale 6-7). No numbness or decreased sensation to her fingers. Range of motion in neck limited on both sides. Right hip also aches, the pain is more diffuse and is more or less in the background (Pain scale 4). The postural assessment showed right shoulder slightly dropped. Evidence of bilateral tension in upper trapezius. Pelvic rims even. Increased skinfolds on her right side between her T12 and the iliac crest. Alignment of feet and knees is normal.

Medication:
She is taking NSAID’s four times a day that 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. Swimming is her sport, she trains three times per week for one hour per session.  She attends yoga sporadically.  

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 parent 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 combination 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.

Despite the changes and improvement, a mild form of the condition 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 corrected. 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 massage as an MOT rather than a treatment.  

Use the evidence
By using their skills and experience, a practitioner can work their way back and follow the evidence to the original source. Of course, it does not always follow the expected pathways. If it doesn’t resolve, keep asking questions, dig a bit deeper, refer and get advice as appropriate and mostly keep at it. There is nothing like the feeling of satisfaction when you are able to resolve something that has been persistently elusive.

Postural assessment, as a tool, is essential. You need to develop it, along with other palpation and assessment skills, as it can help lead you to answers and give you valuable skills to improve your success rate and skills as a sports massage practitioner.  

References
1. Kuchera M. (2003) Postural considerations in coronal, horizontal and sagital Planes Foundations for Osteopathic Medicine – 2nd edition Ed. Ward Lippincott, Williams & Wilkins 2003
2. Magee D. Orthopaedic Physical Assessment, fourth edition. Saunders 2002
3. Kendall, McCreary, Provance, Rodgers, Romani.  Muscles Testing & Function with Posture & Pain 2005(5): 60-63, 86-88


By Susan Findlay BSc RGN, Dip SMRT
All rights reserved. Any reproducing of this article must have the author name and all the links intact.

Author: BSc RGN, Dip SMRT

Biography: Susan comes from a background in dance and gymnastics in which she competed nationally in Canada. She originally trained as a Nurse in her home country and practiced for 7 years before coming over to England in 1993.

After a year in the NHS she retrained as a health and fitness instructor working with GPs and health centers. After years of teaching 20+ classes a week and running health programmes she wanted to integrate her medical, health and fitness background under one umbrella. Hence, she trained once more qualifiying in Sport & Remedial Massage. After many years in private practice, Susan started teaching in various colleges and private institutions, and lecturing nationally. As is expected in an evolutionary process, she opened her own school in 2005, and also became a co-director in the Institute of Sport & Remedial Massage (ISRM).

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