Postural Deformities
What bony segment alignment changes are associated with Swayback?
- Long kyphosis with pelvis the most anterior body segment, hip joint moves forward of posture line (thoracic spine mobile to compensate) - Lower lumbar area flattens - Pelvis neutral or in posterior tilt - Hip and knee joints hyperextended - Where subject stands predominantly on one leg, pelvis is tilted down to non-favored side - Favored leg appears longer in standing only
What is lordosis?
- Lordosis is an anterior curvature of the spine. - Pathologically, it is an exaggeration of the normal curves found in the cervical and lumbar spines.
What are the body segment alignment changes associated with a flat back form of kyphosis?
- Loss of lordosis with pelvis in posterior tilt - Hip and knee joints hyperextended - Forward head posture with increased flexion to upper thoracic spine
Which muscles are commonly short and strong with pathological lordosis?
- Lumbar erector spinae - Hip flexors - Upper trapezius - Pectoralis major and minor - Levator scapulae - Sternocleidomastoid - Scalenes - Suboccipital muscles
Which joints are commonly affected by pathological lordosis?
- Lumbar spine - Hip joints - Thoracic spine - Scapulothoracic joints - Glenohumeral joints - Cervical spine - Atlanto-occipital joints - Temporomandibular joints
What are causes of increased lordosis?
1. Postural or functional deformity 2. Lax muscles, especially the abdominal muscles, in combination with tight muscles, especially hip flexors or lumbar extensors 3. A heavy abdomen, resulting from excess weight or pregnancy 4. Compensatory mechanisms that result from another deformity such as kyphosis 5. Tight and commonly strong muscles 6. Spondylolisthesis 7. Congenital problems, such as bilateral congenital dislocation of the hip 8. Failure of segmentation of the neural arch of a facet segment 9. Fashion (e.g., wearing high-heeled shoes) *Image: Faulty posture illustrating exaggerated lordosis and kyphosis*
What is Kypholordotic Posture?
Combination of a kyphosis and lordotic posturing. In some cases, both the thoracic and lumbar spine may be affected.
What is Humpback or Gibbus form of kyphosis?
With humpback, there is a localized, sharp posterior angulation in the thoracic spine. This is commonly a structural deformity as a result of a fracture or pathology
Which muscles are commonly elongated and weak with pathological lordosis?
- Anterior abdominals - Small muscles of lumbar spine (multifidus, rotators) - Lower and middle trapezius - Hamstrings may lengthen initially or shorten to compensate where posture has been present for some time - Rhomboids (may or may not be) - Upper (thoracic and cervical) erector spinae - Hyoid muscles
Which muscles are commonly short and strong with Swayback deformity?
- Hamstrings - Hip extensors - Upper fibers of internal obliques - Internal intercostal - Low back musculature short but not strong - Where one leg is favored, tensor fascia lata is strong and iliotibial band is tight on favored side
What body segment alignment changes are associated with kypholordotic posture?
- Head held forward with cervical spine hyperextended - Scapulae may be protracted - Increased lumbar lordosis, and increased thoracic kyphosis - Pelvis anteriorly tilted - Hip flexed, knee hyperextended - Head is usually most anteriorly placed body segment
What body segment alignment changes are associated with a round back form of kyphosis?
- Head held forward with cervical spine hyperextended - Scapulae may be protracted - Increased thoracic kyphosis - Hips flexed, knees hyperextended Head is usually most anteriorly placed body segment
What are some causes of structural scoliosis?
- Idiopathic (genetic) - Neuromuscular, resulting from an upper or lower motor neuron lesion - Myopathic, resulting from muscular disease - Arthrogryposis, resulting from persistent joint contracture - Conditions such as neurofibromatosis, mesenchymal disorders, or trauma - May accompany infection, tumors, and inflammatory conditions that result in bone destruction
Describe pathological lordosis.
- In the patient with pathological lordosis, one may often observe sagging shoulders (scapulae are protracted and arms are medially rotated), medial rotation of the legs, and poking forward of the head so that it is in front of the center of gravity. - This posture is adopted in an attempt to keep the center of gravity where it should be. - Deviation in one part of the body often leads to deviation in another part of the body in an attempt to maintain the correct center of gravity and the correct visual plane - This type of exaggerated lordosis is the most common postural deviation seen
What is kyphosis?
- Kyphosis is a posterior curvature of the spine - Pathologically, it is an exaggeration of the normal curve found in the thoracic spine.
Which joints are commonly affected by Swayback deformity?
- Lumbar spine - Pelvic joints - Hip joints - Thoracic spine - Scapulothoracic joint - Glenohumeral joints - Cervical spine - Atlanto-occipital joints - Temporomandibular joints
What joints are commonly affected with a flat back form of kyphosis?
- Lumbar spine - Pelvic joints - Scapulothoracic joints (may or may not be) - Thoracic spine (may or may not be) - Cervical spine (may or may not be)
Which joints are commonly affected with postural scoliosis?
- Lumbar spine - Thoracic spine - Pelvic joints - Hip joints - Foot joints - Scapulothoracic joints - Glenohumeral joints - Cervical spine (torticollis) - Atlanto-occipital joints - Temporomandibular joints
What muscles are commonly short and strong with postural scoliosis?
- Muscles on the concave side - Hip adductors on convex side - Foot supinators on short side
What muscles are commonly elongated and weak with postural scoliosis?
- Muscles on the convex side - Hip abductor muscles on concave side - Foot pronator muscles on the long side
What muscles are commonly short and strong with a round back form of kyphosis?
- Neck extensors - Hip flexors - If scapulae are protracted, serratus anterior, pectoralis major and/or minor, upper trapezius, levator scapulae - Upper abdominal muscles - Intercostals
What muscles are commonly short and strong with kypholordotic posture?
- Neck extensors - If scapulae are protracted, serratus anterior, pectoralis major and/or minor, upper trapezius - Intercostals
What muscles are commonly elongated and weak with a round back form of kyphosis?
- Neck flexors - Upper erector spinae - External obliques - If scapulae are protracted, middle and lower trapezius - Thoracic erector spinae - Rhomboids
What muscles are commonly elongated and weak with kypholordotic posture?
- Neck flexors - Upper thoracic spinae - External obliques - If scapulae are protracted, middle and lower trapezius - Thoracic erector spinae - Middle and lower trapezius - Rhomboids
What are reasons that torticollis may occur?
- Neuromuscular problems - Congenital problem (abnormal SCM muscle) - In conduction with malocclusion of the TMJ or with ear problems (referred to the cervical spine)
What structural scoliosis, what may the patient lack?
- Normal flexibility and side bending becomes asymmetrical
Which muscles are commonly elongated and weak with Swayback deformity?
- One joint hip flexors - External obliques - Lower thoracic extensors - Lower abdominals - Neck flexors - Where one leg is favored, gluteus medius (especially posterior fibers) on favored side
What muscles are commonly elongated and weak with a flat back form of kyphosis?
- One joint hip flexors - Lumbar extensors - Local stabilizers (multifidus, rotators) - Scapular protractors (may or may not be) - Thoracic erector spinae
What are the two types of exaggerated lordosis?
- Pathological lordosis - Swayback deformity
Describe the body segment alignment changes associated with pathological lordosis.
- Pelvis is anteriorly tilted with lordosis increased - Knees are hyperextended - Ankle joints slightly plantar flexed
What are causes of nonstructural or functional scoliosis?
- Postural problems - Hysteria - Nerve root irritation - Inflammation - Compensation caused by leg length discrepancy or contracture (in the lumbar spine)
What are the 4 types of kyphosis?
- Round back - Humpback - Flat back - Dowager's hump
What pathological conditions can lead to Kyphosis?
- Scheuermann's vertebral osteochondritis (may lead to structural kyphosis). In this condition, inflammation of the bone and cartilage occurs around the ring epiphysis of the vertebral body. The condition often leads to an anterior wedging of the vertebra. The most common area for the disease to occur is between T10 and L2
What is Scoliosis?
- Scoliosis is a lateral curvature of the spine (e.g., "hunchback of Notre Dame") - In the cervical spine, a scoliosis is called a torticollis - There are several types of scoliosis, some of which are nonstructural and some of which are structural
What body segment alignment changes are associated with postural scoliosis?
- Spine curves to left or right - May not have single or double curve or one main curve and one or two compensatory curves - Ribs may protrude on one side and be depressed (paravertebral valley) on the other side ("hump and hollow" on forward flexion because of vertebral rotation) - May have short leg-pelvis tilted laterally- concave side high - Shoulder/scapula may drop on concavity side of curve
Describe structural scoliosis.
- Structural scoliosis primarily involves bony deformity, which may be congenital or acquired, or excessive muscle weakness, as seen in a person with long term quadriplegia - This type of scoliosis may be caused by wedge vertebra, hemivertebra, or failure of segmentation
Describe Round back.
- The patient with a round back has a long, rounded curve with decreased pelvic inclination (<30°) and thoracolumbar kyphosis. - The patient often presents with the trunk flexed forward and a decreased lumbar curve - On examination, there are tight hip extensors and trunk flexors with weak hip flexors and lumbar extensors
What is the pelvic angle increased to with pathological lordosis?
- The pelvic angle, normally approximately 30°, is increased with lordosis. With excessive or pathological lordosis, there is an increase in the pelvic angle to approximately 40°, accompanied by a mobile spine and an anterior pelvic tilt. - Exaggerated lumbar lordosis is usually accompanied by weakness of the deep lumbar extensors and tightness of the hip flexors and tensor fasciae latae combined with weak abdominals
Which joints are commonly affected with kypholordotic posture?
- Thoracic spine - Lumbar spine - Scapulothoracic joints - Glenohumeral joints
What joints are commonly affected with a round back form of kyphosis?
- Thoracic spine - Scapulothoracic joints - Glenohumeral joints
What are causes of kyphosis?
- Tuberculosis - Vertebral compression fractures - Scheuermann's disease - Ankylosing spondylitis - Senile osteoporosis - Tumors - Compensation in conjunction with lordosis - Congenital anomalies (include a partial segmental defect, as seen in osseous metaplasia, or centrum hypoplasia and aplasia) - Paralysis may lead to a kyphosis because of loss of muscle action needed to maintain the correct posture combined with the forces of gravity
What is Swayback deformity?
- With swayback deformity, there is increased pelvic inclination to approximately 40°, and the thoracolumbar spine exhibits a kyphosis - A swayback deformity results in the spine's bending back rather sharply at the lumbosacral angle. - With this postural deformity, the entire pelvis shifts anteriorly, causing the hips to move into extension - To maintain the center of gravity in its normal position, the thoracic spine flexes on the lumbar spine. The result is an increase in the lumbar and thoracic curves - Such a deformity may be associated with tightness of the hip extensors, lower lumbar extensors, and upper abdominals, along with weakness of the hip flexors, lower abdominals, and lower thoracic extensors
What is Flat Back form of kyphosis?
A patient with flat back has decreased pelvic inclination to 20° and a mobile lumbar spine.
What is Dowager's Hump?
Dowager's hump is often seen in older patients, especially women. This deformity commonly is caused by osteoporosis, in which the thoracic vertebral bodies begin to degenerate and wedge in an anterior direction, resulting in a kyphosis
What are some differences between structural and non structural scoliosis?
Structural scoliosis: - Side bending becomes asymmetrical - May be progressive - Curve does not disappear on forward flexion - Most commonly seen in the thoracic or thoracolumbar spine Nonstructural scoliosis: - No bony deformity - Not progressive - Spine shoes segmental limitation, and side bending is usually symmetrical - Scoliotic curve disappears on forward flexion - Usually found in the cervical, lumbar, or thoracolumbar area