BLUE SKY SCHOOL OF PROFESSIONAL MASSAGE AND THERAPEUTIC BODYWORK Musculoskeletal Anatomy & Kinesiology POSTURE & GAIT ASSESSMENT MSAK201-I Session 4 LEARNING OBJECTIVES: By the end of session 4, the student will be expected to: 1. Apply all review material. 2. Compare Structural and Functional Postural Distortions. 3. Describe the three types of Functional Distortions. 4. Describe and perform a basic postural analysis. 5. Chart postural findings using a Postural Analysis Worksheet. 6. Document assessment findings in appropriate SOAP format. 7. Describe and perform Actual and Apparent Leg Length tests. 8. Discuss the implications of a positive Apparent Leg Length test. 9. Recognize and describe four common postures. Palpation Quiz NEXT WEEK: In addition to a written quiz, the Instructor/TA will ask each student to palpate four muscles on a partner. Please see the grading sheet at the end of this session for details on how the student will be assessed. Please review all muscles covered in Semester 1 and through today s class. 1) CHARTING POSTURAL FINDINGS a) Postural worksheet b) Soap notation 2) LEG LENGTH TESTING a) METHOD i) Measurements of the client s leg length can be made while the client is standing. Therapist measures from the client s ASIS to the floor and from the PSIS to floor bilaterally. 08/12 Blue Sky School of Professional Massage and Therapeutic Bodywork 1
b) ACTUAL LEG LENGTH TEST Assessment for Anatomic Leg length Discrepancy i) If the ASIS and PSIS are lower on the same side, an anatomic leg length difference exists. Actual length shorting is caused by an abnormality above or below the trochanter level. ii) MASSAGE IMPLICATION: This type of client has a anatomic short tibia, femur or both. Continue with assessment, treat any other findings and consider referring to appropriate provider for heel lift to balance the pelvis. c) APPARENT LEG LENGTH TEST Assessment for Functional Leg length Discrepancy i) If the ASIS is lower and the PSIS is higher on the same side, a functional leg length discrepancy exists. The difference is the length of the legs is probably the result of pelvic obliquity (torque, tilt or twist of the pelvis). ii) MASSAGE IMPLICATION: This type of client may have a muscle imbalance issue. (1) POSITIVE FUNCTIONAL LEG TEST (a) Look for adduction contracture of shortened hip or an abduction contracture, which gives an appearance of lengthening on the opposite or lengthened side. 3) POSTURAL ASSESSMENT REVIEW a) Nearly every postural finding has a soft tissue correlation. This list is by no means comprehensive. Note that most hypertonic or shortened muscles are agonistic for that action and that the corresponding antagonist muscles tend to be weakened because of its lengthened state. * Contra = Contralateral * Ipsil = Ipsilateral 08/12 Blue Sky School of Professional Massage and Therapeutic Bodywork 2
POSTURAL FINDING HYPERTONIC MUSCLES WEAKENED MUSCLES Head rotation Contra Upper trapezius Paired muscles Ipsil Splenius group Ipsil Levator scapulae Ipsil Suboccipital group Contra SCM Contra Anterior scalene Contra Longus colli Contra Transversospinalis group Head tilt (Lateral flexion finding) Ipsil Upper trapezius Paired muscles Ipsil Splenius group Ipsil Levator scapulae Ipsil SCM Ipsil Scalene group Ipsil Longus colli Ipsil Erector spinae Ipsil Transversospinalis group Shoulder elevated Upper trapezius Levator scapulae Rhomboids Lower trapezius Pec Minor Scapular winging Abdomen protrudes Anteriorly rotated pelvis The term Anterior Rotation is often used by practitioners but in a vague context. Anterior tilt is when the entire pelvis inclines anteriorly as in the case of lumbar hyperlordosis. An Extended ilium is when the one ASIS moves inferiorly and anteriorly compared to the contralateral side. Either Postural Distortion is considered a Rotated pelvis. The difference lies in whether the musculature is affected BILATERALLY (An Anterior Tilt) or UNILATERALLY (An Extended Ilium) Pectoralis minor Levator scapula Upper trapezius Iliopsoas Lumbar extensors (due to hyperlordosis) QL Lumbar erector spinae (Iliocostalis and Longissimus) Multifidus Latissimus dorsi Iliopsoas Gluteus medius (anterior fibers) Gluteus minimus (anterior fibers) TFL Sartorius Rectus femoris Pectineus Adductor brevis and longus Gracilis Serratus anterior Rhomboids Middle and lower trapezius Teres minor Infraspinatus Rectus abdominus Obliques Transverse abdominus Rectus abdominus External obliques Internal obliques Gluteus maximus Gluteus medius (posterior fibers) Gluteus minimus (post. fibers) Adductor magnus Biceps femoris Semitendinosus Semimembranosus 08/12 Blue Sky School of Professional Massage and Therapeutic Bodywork 3
Posteriorly rotated pelvis High ilium Low ilium Knees abduct (Genu Valgum) Rectus abdominus External obliques Internal obliques Gluteus maximus Gluteus medius (posterior fibers) Gluteus minimus (post. fibers) Adductor magnus Biceps femoris Semitendinosus Semimembranosus Quadratus lumborum Lumbar Erector Spinae Multifidus Latissimus dorsi Obliques Gluteal group Hamstring Group Rectus Femoris TFL Sartorius Gluteus maximus TFL Biceps femoris Vastus lateralis QL Lumbar erector spinae Multifidus Latissimus dorsi Iliopsoas Gluteus medius (anterior fibers) Gluteus minimus TFL Sartorius Rectus femoris Pectineus Adductor L and B Gracilis Gluteal group Hamstring Group Rectus Femoris TFL Sartorius Quadratus lumborum Lumbar Erector Spinae Multifidus Latissimus dorsi Obliques Sartorius Gracilis Vastus medialis Semitendinosus Semimembranosus (Knock knee appearance) Knees adduct (Genu Varus) Sartorius Gracilis Vastus medialis Semitendinosus Semimembranosus Gluteus maximus TFL Biceps femoris Vastus lateralis (Bowlegged appearance) Foot pronates (everts) Foot external rotates (can be due to hip rotation) Gastrocnemius and Soleus Plantaris Peroneus group Peroneus group Biceps femoris Deep six including piriformis Gluteus maximus Gluteus medius Gluteus minimus Posterior tibialis Gluteus medius Gluteus minimus 08/12 Blue Sky School of Professional Massage and Therapeutic Bodywork 4
4) TYPES OF POSTURE a) Ideal alignment Body Area Postural Finding Muscle Imbalance Head Neutral Balance muscle tone Cervical Spine Normal curve between the Scapula Flat against back abdominal and hip Thoracic Spine Normal curve extensor muscles Lumbar Spine Normal curve and low back and Pelvis Neutral hip flexor muscles. Hip joints Neutral Knee joints Neutral Ankle joints Neutral b) Kyphosis-lordosis Posture Body Area Postural Finding Muscle Imbalance Head Anterior Weakness often exists Cervical Spine Hyperextended in anterior neck and Scapula Abducted upper back muscles Thoracic Spine Kyphotic and muscles of lower Lumbar Spine Lordotic abdomen. Muscle Pelvis Anterior Tilt shortness frequently Hip joints Flexed present in hip flexors Knee joints Slightly hyperextended and, to a lesser extent, Ankle joints Slight plantar flexion the low back extensors. 08/12 Blue Sky School of Professional Massage and Therapeutic Bodywork 5
c) Flat Back Posture Body Area Postural Finding Muscle Imbalance Head Anterior Shortened hamstrings Cervical Spine Slightly extended pull the pelvis into Thoracic Spine Upper Kyphotic Lower Straight posterior tilt with associated weakness Lumbar Spine Flat or straight in the hip flexors. Pelvis Posterior Tilt Slight knee flexion Hip joints Extended may be noted due to Knee joints Extended tightness in Ankle joints Slight plantar flexion hamstrings. d) Military-Type Posture Body Area Postural Finding Muscle Imbalance Head Slight posterior tilt Chest is elevated and Cervical Spine Normal or slightly anterior pelvis is tilted Thoracic Spine Normal or slightly posterior anteriorly putting Lumbar Spine Lordotic Rectus abdominis in Pelvis Anterior Tilt an elongated Knee joints Slightly hyperextended position. Low back Ankle joints Slightly plantarflexed and hip flexors are shortened. 08/12 Blue Sky School of Professional Massage and Therapeutic Bodywork 6
e) Sway-back Posture Body Area Postural Finding Muscle Imbalance Head Anterior This position places Cervical Spine Slightly extended stretch on the hip Thoracic Spine Kyphotic with posterior displacement of trunk flexors and obliques. The lower back and Lumbar Spine Flat or straight hamstrings are likely to Pelvis Posterior Tilt be strong and somewhat Hip joints Hyperextended short. Upper back Knee joints Hyperextended muscles show stretch Ankle joints Neutral weakness. It is important to note that postural assessment is not preformed in a vacuum. Postural analysis is only the first step in the assessment process. Findings are utilized to direct further assessment in specific body regions. Other assessment tools will be discussed later in this Semester. 08/12 Blue Sky School of Professional Massage and Therapeutic Bodywork 7
BLUE SKY SCHOOL OF PROFESSIONAL MASSAGE AND THERAPEUTIC BODYWORK Musculoskeletal Anatomy & Kinesiology POSTURE & GAIT ASSESSMENT continued MSAK201-I Session 4b LEARNING OBJECTIVES: By the end of this session, the student will be expected to: 10. Apply all review material. 11. Define Gait Cycle. 12. Describe the 5 sub-phases of the stance phase and the 3 sub-phases of the swing phase. 13. Define the normal parameters of gait. 14. Critically assess the gait of a client in preparation for soft tissue treatment. 15. Document assessment findings in appropriate SOAP format. 5) GAIT CYCLE a) Normal gait cycle occurs during walking. It is the sequence of motions occurring between two consecutive initial contacts for the same foot. b) During walking, one foot is always touching the ground. While running, both feet are off the ground at some point during the stride or running activity. c) Two phases of gait cycle: i) Stance phase occurs when one foot (for our purposes, we ll start with the right foot) is on the ground and bearing weight. It comprises 60% of the full cycle. ii) Swing phase occurs when the right foot, which was the stance leg, is now the non-weight bearing leg and moving forward. It comprises 40% of the gait cycle. 6) STANCE PHASE a) Stance phase has 5 sub-phases: i) Heel strike: The right heel touches the floor. This is the beginning of the weight-loading period of the stance leg. Here, the left foot is coming off the floor while the right is accepting the body weight and absorbing shock of initial contact. Since both feet are on the floor, this period is called double support. 08/12 Blue Sky School of Professional Massage and Therapeutic Bodywork 8
ii) Flat foot: The whole right foot is flat on the floor. Both feet are still on the floor, so this continues to be a period of double support. iii) Mid-stance: The next two sub-phases make up the single leg stance or single support period. The right leg alone carries the body weight while the left leg goes through its swing phase and becomes the leading leg. iv) Heel off: The heel of the right foot rises off the floor. v) Toe off: The final two sub-phases make up the weight unloading period. During this period the stance leg unloads body weight to the opposite leg. The toe of the right foot rises off the floor. This returns the body to a period of double support. 7) SWING PHASE a) This phase consists of 3 sub-phases: i) Acceleration: Occurs when the right foot is lifted off the floor; rapid knee flexion and ankle dorsiflexion are observed. ii) Mid-swing: occurs when the swing leg is adjacent to the weight bearing left leg. iii) Deceleration: The swing right leg slows down to make contact with the floor; active quadriceps and hamstring movements are required. 8) DOUBLE STANCE a) This is the phase of gait in which both feet are on the ground. It occurs twice in the gait cycle. Once at the beginning of stance phase and once at the end of stance phase. b) Single leg stance occurs when only one leg is on the ground. It takes place twice in the cycle. Once for right leg and once for the left leg during the stance phases. 9) NORMAL PARAMETERS OF GAIT (KNOW DEFINITION; NOT VALUES) a) Base width The distance between the two feet when viewed anteriorly or posteriorly i) Normal base width = 5-10 b) Gait or step length The distance between successive contact points on opposite feet. (Heel of right foot and heel of left) i) Normal step length = 70-82 cm (should be equal for both legs) c) Stride length The linear distance between successive points of contact of the same foot (heel of left foot to the heel of left foot when it touches floor again.) i) Normal stride length = 140-164 cm (EQUAL TO ONE GAIT CYCLE!) 08/12 Blue Sky School of Professional Massage and Therapeutic Bodywork 9
d) Lateral pelvic shift: Side to side movement of pelvis during walking necessary to center the weight over the stance leg for balance. i) Normal pelvic shift = 2.5-5 cm e) Vertical pelvic shift i) Highest point is at mid-stance. ii) Lowest point is at initial contact (heel strike). f) Pelvic and Thoracic rotation Necessary to lessen the angle of the femur with the floor. The thorax rotates in opposite direction to pelvis to maintain balance. g) Normal cadence (Speed of walking) i) 90-120 steps per minute. 10) GAIT ANALYSIS (Begins week 7 in CST) a) Initial analysis i) Ask clients to walk in their usual manner using any aids that they require (canes, walkers etc). Observe any obvious limp or deformity. ii) Perform general overview of client s gait. Look at: (1) Stride length (2) Step frequency (3) Time of swing (4) Speed of walking (5) Duration of complete walking cycle iii) Examine slow and fast gait speeds to see if changes affect gait. iv) Observe lumbar spine, pelvis, hips, knees, feet and ankles. 08/12 Blue Sky School of Professional Massage and Therapeutic Bodywork 10
b) Detailed analysis i) Anterior view checking for any of the flowing findings: lateral tilt to the pelvis sideways swing of trunk pelvic rotation on the horizontal plane trunk and upper extremity rotation in the same direction bowing of femur or tibia medial rotation of the hips position of feet as client goes through gait cycle abduction or circumduction of swing leg atrophy of musculature of anterior leg and thigh a normal base width ii) Lateral view checking for any of the following findings: lumbar hyper or hypolordosis, hip movement limitation of hip flexion and extension lack of coordination or movement between jip, knee, and ankle. uneven gait length uneven duration of steps iii) Posterior view checking for any of the following findings: observe same structures as anterior view this view is best to examine weight-unloading period of gait cycle note whether heels rise is equally in both feet note whether heels turn in or out observe lateral movement of spine and the musculature of back, buttock, posterior thigh, and calf iv) Feet and footwear checking for any of the flowing findings: observe client walking in normal footwear and barefoot observe wear on the shoes examine feet for callus formation, blisters, corns and bunions 08/12 Blue Sky School of Professional Massage and Therapeutic Bodywork 11
BLUE SKY SCHOOL OF PROFESSIONAL MASSAGE AND THERAPEUTIC BODYWORK Palpation Practical Quiz /20 pts Muscle Assessed Excellent = 5 Good = 4 Average = 3 Poor = 2 Unacceptable = 1 Score TA/Instructor verified that Student can palpate Student cannot palpate can verbalize or palpate bone(s) but cannot identify specific attachment landmarks. Student correctly identified basic location of muscle on partner. (i.e. anterior forearm) Student cannot add any additional information as to O and I or landmarks. Student cannot locate muscle on partner. TA/Instructor verified that Student can palpate TA/Instructor verified that Student can palpate TA/Instructor verified that Student can palpate Student cannot palpate Student cannot palpate Student cannot palpate can verbalize or palpate bone(s) but cannot identify specific attachment landmarks. can verbalize or palpate bone(s) but cannot identify specific attachment landmarks. can verbalize or palpate bone(s) but cannot identify specific attachment landmarks. Student correctly identified basic location of muscle on partner. (i.e. anterior forearm) Student cannot add any additional information as to O and I or landmarks. Student correctly identified basic location of muscle on partner. (i.e. anterior forearm) Student cannot add any additional information as to O and I or landmarks. Student correctly identified basic location of muscle on partner. (i.e. anterior forearm) Student cannot add any additional information as to O and I or landmarks. Student cannot locate muscle on partner. Student cannot locate muscle on partner. Student cannot locate muscle on partner. 08/12 Blue Sky School of Professional Massage and Therapeutic Bodywork 12