By Jon Trister MD and Diana Trister DO
Evaluation of the posture.
Observe symmetry. Look at the level of gluteal folds- asymmetry indicates inhibition or weakness of the ipsilateral side, which will be lower.
Slight asymmetry indicates inhibition or weakness-look at the upper external quadrant. In this case, it will be flat on palpation as the result of a decrease of muscle tone.
The asymmetry of the pelvis will cause changes to lower back extensors and hamstrings.
The weakness of the Gluteus Maximus will lead to a lowering of the gluteal fold on the same side.
Then look to the lumbar and thoracolumbar area. Look for scoliosis, rotation, or kyphosis which may influence the shape of the muscles.
Then compare muscles at the lower lumbar region to the muscles at the thoracolumbar junction. Atrophy at the lower segment of the lumbar muscles will require stabilization and lead to the hypertrophy of the muscles at the thoracolumbar segment.
Normally, the lumbar segment is symmetrical and flatter than the thoracolumbar segment which is slightly more prominent but still symmetrical.
Then proceed to the upper part of the body:
Shoulder blades can be protracted, retracted, shifted upward, or abducted.
Look at the stabilizers: lower stabilizer (lower trapezius) interplays with upper stabilizers (upper trapezius,m. levator scapulae)
This area will be flat in the case of muscular inhibition. Weakness or inhibition of the serratus anterior will lead to the winging of the scapulae.
If you see atrophy of the lower stabilizers (lower trapezius) than observe upper stabilizers (upper trapezius and m. levator scapulae) which will be compensatory hypertrophic, which will lead to abduction and weaning of the scapula.
To look closely to the quality of the upper trapezius and levator scapulae focus on the reference line from the occiput/lateral neck and the Acromion. This line normally should have an “S” shape. When levator scapulae and trapezius are overactive this line became straight. This called “Gothic shoulders”.
Another example of insufficient scapular stabilization will be protracted scapulae due to inhibition of the medium and lower trapezius, rhomboids, and overactive serratus anterior.
The upper trapezius in these cases usually overactive which leads to a superior shift of the scapulae.
Observation of the anterior shoulder provide information about humeral control:
flattening of the deltoid abductors indicates deltoid atrophy, altered pattern of the shoulder’s muscles and impaired proprioception from the shoulder joint.
In the assessment of the lower extremity first view the subject general posture.
E/Rotation of the feet exists may indicate a problem with the muscles or the joint of the hip.
Look at the knee joints: varus, valgus, or hyperextension
Correlate limb alignment with calcaneal bone and the position of the forefoot.
Varus leg deformity associated with pronation of the foot and flattening of the foot.
Then estimate the shape of each individual muscle group.
First, look at the Hamstrings: note if the size of the hamstrings is symmetrical
Usually, if the gluteal muscle is weaker ipsilateral hamstring compensatory stronger.
Hamstrings have best seen in the medium and upper thirds of the thigh.
The second important group of the thighs is ADDUCTORS
In general, there are two groups of adductors: Short (cover upper and middle thigh)and Long(cover entire thigh).
Normally, from the posterior view adductors create very shallow letter “S”
If upper adductors are in spasm then the upper portion of the “S” will be bulkier. As compensation of this process lower portion of the “S” will be flat -hypotrophy,-hollow just above the knee.
Then look at the lower leg: shape and symmetry. Estimate the tightness of hypotrophy of the m.soleus muscles in the relation to gastrocnemius muscles
If the solei are tight and short, the muscle belly is evident at the medial border just superior to the Achilles tendon. (The m.soleus is located just underneath the gastrocnemius, and together these two muscles form the Achilles tendon. Since these are the 2 biggest muscles in the calf, they provide the majority of the push-off when walking, running, and jumping)
If m.The soleus is tight than Achilles tendon becomes slightly thicker and shorter.
observation of the heel.
No symmetrical person.No specific norms.
Variation of the muscle
ASIS and umbilicus
Rectus abdominis : Upper quadrants more active than lower quadrants. But left and right are symmetrical.
Observe the groove on the lateral edge of the rectus abdominis: it reflects quality of interplay between m.rectus abdominis and m.obliqus abdominis externus. The more prominent this groove -the stronger m.obliqus abdominis externus and m.Rectus abdominis is inhibited.
Next, look at the lateral edge of the waist, which is normally concave. If it become flat or convex shape- sign of weakness of m.transversus abdominis which stabilize abdominal wall and spine properly.
In the upper trunk look at the symmetry of the muscles and respiratory movement of the chest wall. Focus mainly on the pectoralis major.
Compare muscular folds on both sides. The pectoralis muscle is more prominent on the dominant side. Positions of the nipples. If the pectoralis is tightened, the nipple will be displaced superiorly and laterally. In females, asymmetry of breasts may indicate m.pectoralis tightness.
Observe neck: SCM muscle, which under normal circumstances will be almost invisible.
Usually, we only see insertion in the sternoclavicular region. If the muscle belly is pronounced it indicates muscle hypertrophy.
The groove in the area medial to SCM (between SCM and Scalenus muscles )
The more prominent this groove the weaker (hypoactive)the Scalenus muscle
“Facial scoliosis”-asymmetry of the face
These points must be symmetrical. Also, observe lateral bending and rotation of the head.
Observe hip, knee, and feet position.
First look at the tensor fascia latae. normally this muscle is invisible. If the muscle is visible it indicates hypertonus of the MTFL.
Then look at the position of the patella: Symmetry, presence of the shift: if quadriceps is tight than patella shifted superiorly
if MTFL is tight patella will shift supero-lateraly and tilt
If vastus medialis is hypertrophied you will see muscle bulk medially to the patella
It is usually a sign of overstressed knee joint
When proprioception of the knee is altered patella will move in an irregular manner from the intermittent activity of the m.quadriceps to improve stability of the knee joint.
This vertical translation of the patella is an important sign of poor proprioception of the knee joint.
Look at the lower leg, primarily tibias anterior.
If M.tibialis anterior (an anterolateral aspect of the lower leg, just below the knee) is weak then it’s fibers become flat or even they develop the groove-early sign of L4-L5 irritation.
Look at the toes.
”Unquiet foot” irregular twitching movement of the tendons of the toes in the different directions-sign of impaired proprioception and the more demanding effort to maintain the balance.
Lateral view: Look at the presence of anterior or posterior tilts.
Look at the lumbar, thoracic and cervical curvatures:The interrelationships of which may depend on the balance between hips flexors and extensors or abdominal muscles and back extensors.
Look at the position of the head, particularly “push forward head position”
Observe line running from the jaw to the hyoid bone: if the supra-hyoid muscles is tight this line become more straight, indicating TMJ problems
Look at the position of the legs, particularly knees (genu recurvatum)
Look at the greater trochanter- MTFL: if the groove is present-MTFL is tight