The previous post dissected the process of examining the upper extremity, particularly the relationship between the thoracic/cervical spine with the glenohumeral joint and scapula positioning. In today’s post, we will be continuing the discussion of static postural assessment with the lower extremity.
I believe that everything is connected to everything, and therefore neither of these examinations should be performed in isolation. It also means, that for me, everything comes back to the trunk, somehow. Just like how the shoulder was made to serve our hands and provide distal mobility, so were our hips made to serve our feet.
While I normally start with the spine and trunk when looking at the upper quarter, for the lower extremity, I tend to start with the feet, mostly out of habit. When I look at the athlete’s feet, I look to see what their resting position is – is it over pronated, is it over supinated (essentially what are their arches like in weight bearing). It’ll also help give me a sense of, are they weight bearing equally through both feet. With over pronation, it’ll be helpful to assess the peroneals for trigger points/myofascial restrictions or weakness of the posterior tibialis muscle – look for the opposite (posterior tibilais) in over supination. In either case, it’ll affect the subtalar joint and calcaneal mobility – so manual joint assessment of rear foot eversion/inversion will be on my list of items to check manually following a postural assessment. Over pronation and supination can affect the first metatarsal’s ability to participate in the windlass mechanism/push off phase of gait due to reduced ability to extend, therefore, first metatarsal extension mobilizations may need to be addressed. This last point will be important for any athlete due to the role of first ray extension in jumping and running – most sports have an element of at least one of the two. It can affect stability in single leg stance as well, further impacting hip activation.
Then I move up to the tibia to see where the tibial tuberosity – is it externally or internally rotated? At the knee, I also take a mental note of their Q ankle in weight bearing – this is the angle formed by the ASIS-mid patellar point-tibial tuberosity. Eighteen degrees is usually a cutoff for Q angle norms – that is anything higher than 18° can indicate poor patellar tracking and increased valgus at the tibiofemoral joint. Females, due to wider hips and increased laxity in their ligaments, will have a higher Q angle by about 4-5°. Increased Q angles (outside of the normative values) also increase an athlete’s risk in knee injuries including ACL tears due to knee injuries being caused in mostly the frontal and transverse planes. I will assess posture from all sides of the athlete – in the sagittal plane, it’ll be important to note if there is any hyperextension at the knees.
At the hips it’ll be important to note whether the femoral heads are in proper alignment inside the acetabulum or if they are retro/ante-verted. The femoral head normally sits in the acetabulum with about 12-15° from the frontal plane; and increase in this angle is termed anteversion and a decrease of this angle is termed retroversion. The positioning of the femur can influence positioning of the tibiofemoral joint at the knees, resulting in either genu valgum or varum (can also be influenced bottom up from the feet). Based on the information found at the tibia and foot/ankle complex, it’ll clue me in what I might find on a biomechanical assessment of the hip joint.
If an athlete does not weight bear equally through both lower extremities, I will note their hip positioning as well as lumbar spinal curvature. If there is an increase in lumbar lordosis, it can anteriorly tilt the pelvis, either unilaterally or bilaterally, affecting leg length in a resting weight bearing position. It can also indicate that the athlete’s core is under active (TrA and multifidi, though if these are under active, the rest of the core including pelvic floor and diaphragm will also be affected) and that the athlete is relying primarily on the erector spinae to support the spine.
While this is a truncated version of my postural assessment for athletes, by this point in the evaluation, I will have made a mental note of all of the items that require further dynamic movement and biomechanical testing to properly determine the source of the dysfunction. In some cases, the deficit identified could be anatomical and would require preservation of their current range/mobility and proper strengthening and neuromuscular control around the joint. In others, it may be hypomobility and poor motor control that is limiting them and causing a poor resting posture. In either case, I always want to see the athlete move, and I utilize the SFMA for that component. The above is only a mental check list that I use – I always verify with the SFMA because I want to see how the client moves within their own anatomical means. I am by no means diagnosing them based solely on static posture. Stay tuned for some highlights in Part 4: Movement Assessment, based on the SFMA.
Nguyen, A et al Relationship between lower extremity aligment and quadriceps angle. Clin J Sport Med. Author manuscript; available in PMC 2010 Jun 7.