After covering all the “what’s” and “how’s” of the most common postural problems in Part 1, we focused on some self-assessment tools in Part 2. Those self-assessments are certainly valuable tools, but they can sometimes be too subjective if you aren’t accustomed to assessing these problems. With that in mind, use the results of those tests in conjunction with the cases studies featured in this article to really get an idea of how significant your problems are and how to correct them.
Before we get into the case studies, a brief discussion of the planes of movement is in order. Up until now, we’ve dealt almost exclusively with sagittal plane postural problems; this plane divides the body into right and left sides. Flexion and extension occur in this plane. Since kyphosis and lordosis occur in a “front to back” scheme, they’re termed sagittal plane problems.
Postural abnormalities may also occur in the frontal plane, which divides the body into anterior and posterior halves. Abduction and adduction occur in this plane. The most notable frontal plane postural affliction is scoliosis, which may be functional (a structurally normal spine that seems to be curved due to another factor, such as muscular tightness) or structural (a fixed curve resulting from a congenital birth defect, disease, infection, or tumor).
We’ll use the term pseudo-scoliosis instead of functional scoliosis during this article simply because most gym-goers with some degree of lateral spinal curvature have slight problems at best.
Lastly, we can experience postural problems in the transverse plane. This plane, in which internal and external rotation occur, divides the body into top and bottom sections. Many people have difficulty visualizing transverse plane movements; your best bet is to think about the way the humerus and femur “swivel” at the shoulder and hip. Pronation and supination of the forearms are good examples, too.
Frontal plane problems implicated in the typical Neanderthal posture include accentuated internal rotation of the femurs and tibiae, over-pronation at the subtalar joint, and excessive internal rotation of the humeri.
With all that out of the way, let’s get to the real world case studies!
Case Study #1
Nineteen year-old male with a training age of four years. During this four-year period, the primary focus has been training for aesthetics with a secondary emphasis on strength (but, unfortunately, none on structural balance!) The client has experimented with a variety of traditional bodybuilding training methods along with the occasional powerlifting and Olympic lifting programs, all of which were geared inevitably toward looking better.
- Chronic on-and-off diffuse shoulder pain and joint soreness during and after all chest exercises.
- Acute “elbow tendonitis” (only once; no diagnosis was made).
- Chronic headaches (frequency has diminished greatly since initiation of an upper trap/levator scapulae stretching program).
- Most recently, bilateral pain in hip flexor/groin regions during quad dominant movements. Pain is worse on the right, but present on the left as well. Pain has been severe enough to cut three consecutive squatting sessions short.
The client has had difficulty making progress on the following lifts (client comments follow):
- Squat: “I can make a lot of progress for a couple weeks, but it always seems too slow and even drops off soon after. I’m really slow on this lift, which I always assumed was wrong.”
- Bench Press: “I’ve struggled with the bench until recently. With all the extra work I’ve been doing for the scapula retractors, my bench is finally moving up.”
- Bent-over row: “Well, it’s most kinds of rows, but bent-over rows especially. I don’t ever seem to be able to progress and gain any measurable strength in them. On most other types of rows I can slowly gain strength, but the bent-over just seems to stay. And it tends to be a really low weight, which sucks, and can’t be helping me in my goal of fixing all my problems.”
- Military Press: “The lift I’ve had the most problems with is the military press. No matter what I try, it never seems to improve. It’s like that with a lot of my shoulder lifts. The only other thing I thought I should mention was that I’ve been doing my best to stretch my pecs and lats, and I’ve been using a roller a bit for self myofascial release, but it seems like no matter how much I stretch them, they go right back to being tight. So, I think I have some serious tightness or weaknesses in other places like the serratus anterior.”
Front View: Client exhibits slight internal rotation of the humeri.
A “kneecaps out” appearance (to compensate for internally rotated femurs) is also apparent, and laterally rotated feet are noticed with apparent pronation.
Side Views: Client exhibits prominent anterior pelvic tilt, anterior weight bearing, moderate kyphosis, rounded shoulders, and internally rotated humeri.
Back View: Client exhibits anteriorly tilted scapulae, but no scapular winging. Internal rotation of the humeri and lateral rotation and pronation of the feet are confirmed.
No unilateral deficits (asymmetries) are apparent.
The history of shoulder pain is consistent with anteriorly tilted scapulae, moderate kyphosis, and internally rotated humeri, each of which can contribute to decreased space between the acromion process and humeral head (primary subacromial impingement of the supraspinatus, and possibly the infraspinatus tendons). In other words, he’s dealt with rotator cuff tendonitis.
The acute “elbow tendonitis” may or may not be related to postural abnormalities, as the client related that it occurred during rugby season when lifting volume wasn’t scaled down as it should’ve been. Conversely, this overuse could also have resulted from imposed overload on the musculature of the arms to compensate for weakness of the muscles acting at the injured shoulder.
As an example, consider the pitching motion. The wrist extensors; biceps; infraspinatus, teres minor, and posterior deltoid; rhomboids and middle and lower trapezius; ipsilateral and contralateral core musculature; and contralateral glutes, hamstrings, and quadriceps are just a few of the numerous important decelerators of the throwing arm. If one link in this kinetic chain isn’t doing its job, the others must pick up the slack.
The chronic headaches were definitely related to the forward head posture (compensation for the kyphosis). The forward head position and, in turn, headache frequency, have diminished since the introduction of stretching for the levator scapulae and upper trapezius.
The pain in the hip flexor and groin can be attributed to tight hip flexors and adductors, both of which contribute to the anterior weight bearing and anterior pelvic tilt. Unless he does something about this tightness, he’s on the fast track to a strain, or lower back or knee injury.
The client is definitely in need of a complete kinetic chain overhaul! In other words, the corrections must address the core, lower body, and upper body. He’s a prime candidate for doing the programs that’ll be outlined in Parts 4 and 5.
Case Study #2
Twenty year-old male with a training age of 2.5 years, most of which was spent bodybuilding with programs that only trained what could be seen in the mirror. Long-term goal is to get involved in powerlifting.
- Constant popping and cracking of the shoulders, but no pain.
- Chronic knee pain (since childhood), but never any diagnosed condition.
- More recently, sore ankles and lateral lower legs following “ass-to-grass” squats.
Front View: Client exhibits slight internal rotation of the humeri. Moreover, the right iliac crest is raised when compared with the left. A knock-knee appearance is noted, and a “kneecaps out” appearance (indicative of tightness laterally and compensation for internally rotated femurs) is also apparent. Bilateral tibial internal rotation is also present.
Side View: Client exhibits classic exaggeration of the double S-curve posture. Forward head posture and chin protraction are evident. Rounded shoulders combined with an exaggerated kyphosis are apparent in the upper thoracic region. Significant anterior pelvic tilt with a concomitant increase in lumbar lordosis is also evident in the lumbo-pelvic region. Anterior weight bearing is difficult to determine due to the cropping of the photo, but still seems to be an issue of concern.
Back View: The client’s left shoulder girdle appears raised when compared to the right. The elevated right iliac crest noted in the front view is confirmed in the back view. A right lateral listing of the thoracic region is also noted, and is evidenced by the elevation of the right iliac crest and depression of the right shoulder girdle.
The client’s chronic knee pain may or may not be related to the excessive anterior weight-bearing that’s readily apparent. His anterior pelvic tilt and excessive lordosis shift the center of gravity forward and put a lot of pressure on the quadriceps and patellar tendon during weight-bearing activities, as the glutes are inhibited.
If the knee pain occurs laterally, there are also implications for the vastus medialis. Given his internally rotated femurs, it certainly isn’t functioning optimally as a knee stabilizer. Tightness of the ITB/TFL is highly likely if this is the case, too.
The pain in the ankles and lateral shins can most likely be attributed to tightness in the peroneals, which serve to evert the feet (a component of pronation) as compensation for internal rotation of the tibias.
Some of the problems may also result from the pseudo-scoliosis condition, although it’s impossible to make such an inference from one photo alone. Nonetheless, it’s a valuable point to make: an overactive quadratus lumborum (QL) is the primary cause of a functional scoliosis that originates with lateral flexion of the lumbar spine.
- The QL has points of attachment on the last rib, pelvis, and L1-L4 vertebrae. If it’s tight, the rib cage is pulled down, the pelvis is pulled up, and the lumbar spine is pulled laterally, creating a curve that initiates a chain reaction in two directions.
- Usually, this tightness of the QL is seen along with over-activity of the tensor fascia latae (TFL). The TFL, QL, and gluteus medius and minimus are functionally associated through hip abduction and lateral flexion (depending on whether the trunk is moving and the leg is fixed, or vice versa) and stabilization of the pelvis and femur in the frontal plane. Often, these problems occur because the glutes are weak (also related to reciprocal inhibition from tight adductors, their true antagonist), so the TFL and QL become overactive through a process known as synergistic dominance.
- In order to counteract this lateral “lean” further up the spine, the contralateral erector spinae are constantly in action to realign the torso. As a result, a lateral curve of the thoracic spine emerges in the opposite direction of the lumbar flexion.
- The scapula on the side opposite the overactive QL also appears elevated and anteriorly tilted (recall that the rib cage is still depressed on the opposite side, too).
- The cervical erector spinae on the same side as the tight QL then compensate for this thoracic curve, in turn, by contracting to keep the head upright.
The end result? A double S-curve in the frontal planes to match the Neanderthal look that occurs in the sagittal plane! Furthermore, just as one can experience problems in the upper body from the unilateral pelvic elevation occurring with a tight QL, problems can occur in the lower body as well.
If the pelvis is elevated on the side of the overactive QL, the leg on the same side as the irksome QL is functionally shorter, as the pelvis sits further up from the ground. The shorter leg always takes on the greater burden from both the force and speed of loading standpoints; the end result is over-pronation on this side.
Suffice it to say, excessive pronation isn’t something with which you want to deal. As we mentioned in Part I, it’s a potential cause of chronic knee pain, not to mention problems at the hips, lower back, ankles, and feet.
By strengthening the gluteus medius, minimus, and maximus, he could likely shift some of the burden off of his quadriceps and patellar tendon, alleviating some – if not all – of his pain. Some extra work for the vastus medialis and dorsiflexors, coupled with stretching and myofascial release of the ITB/TFL, calves, and peroneals are highly recommended as well. Obviously, given his excessive anterior pelvic tilt, a lot of work needs to be done on strengthening the core and loosening up the hip flexors, hamstrings, and erector spinae as well.
Even though there’s currently no pain in the shoulders, this may not be the case down the road. Specific strengthening of the scapular retractors and depressors is needed, coupled with concomitant lengthening of the internal rotators (pectoralis major, latissimus dorsi, teres major, anterior deltoid and subscapularis) and scapular elevators (upper trapezius and levator scapulae).
Even though the left clavicle and scapula are elevated, they appear otherwise symmetrical in shape/tonus to the right side. This indicates the problem is farther down in the kinetic chain. The forward head posture should be addressed using activation work for the deep neck flexors, coupled with stretching of the suboccipitals and sternocleidomastoid (SCM) (and the levator scapulae, as noted earlier).
Like our first client, he needs the whole package, as it’s impossible to isolate within a kinetic chain with so many glaring dysfunctions. That said, the client’s pseudo-scoliosis-like unilateral deficits merit special considerations that focus on unilateral training.
In addition to the aforementioned focus on glute-strengthening/activation, these modifications should include right QL stretching (e.g. standing or seated side bend stretches), with QL activation work on the left hip side (e.g. side bridges and side hip thrusts). Specific focus in stretching should also be emphasized with respect to the left thoracic and right cervical erector spinae.
Numerous other compensations occur, resulting in tightness and weakness through the kinetic chain from head-to-toe. As such, it’s best to assess these functional decrements individually with tests of range of motion and strength. If conservative measures fail (and there is in fact a pseudo-scoliosis), the client would be wise to visit a qualified orthopedist to determine if:
- An overactive QL is indeed the cause of the problems.
- An actual structural leg-length discrepancy (possibly requiring an orthotic) is present (they’re not as common as people think).
- The curvature is structurally-based at the spinal level (i.e. vertebral shape or positioning).
Case Study #3
Thirty-five year old male with a training age of 21 years. The first 17 years were geared toward athletic performance in a variety of sports and the Marines, and the last four have been exclusively devoted to bodybuilding for vanity. The client has experimented with everything from Heavy Duty to high volume to Olympic lifting. Prior to devoting himself completely to weight training, the client was involved in teaching aerobics and competing as a triathlete and distance runner for fifteen years.
- Primary subacromial impingement in left shoulder.
- Left biceps tendonitis (elbow, not shoulder).
- Arthritic left knee (chronic), especially painful with impact.
- Chronically tight hamstrings and calves.
- Torn left vastus lateralis.
- “My main concern is my weight shift onto the left leg when squatting; my right knee falls inward at the same time. In fact, the right knee does that all the time, regardless of whether or not I’m squatting!”
- “I also feel my pelvis rotate laterally when I deadlift.”
- “My shoulder turns to junk almost every time my bench weight gets close to 250 pounds!”
- “I’ve noticed I have tightness more on one side than the other, but in different places. For instance, my left pec and left upper trap are really tight, yet my right lat is, too.”
- “Personally, I attribute the knee to having been a long jumper in my youth and having had to run miles and miles carrying heavy loads when I was in the Marines.”
- “The biceps tendonitis is generally brought on by anything heavy with a pronated grip (e.g. weighted chins). It first came on when I was big into rock climbing and has come and gone over the last five years.”
- “I initially hurt the shoulder arm-wrestling a few years ago, and it’s been on-and-off pain ever since. I think it has altered my benching technique.”
Front View: The left shoulder girdle is clearly elevated in comparison to the right, and, as evidenced by the hands pointing backward with resting posture, both humeri are internally rotated. The feet are slightly externally rotated, and are likely pronated, although it’s tough to clearly determine degree of pronation from this distance.
Side Views: Kyphosis, lordosis, and forward head posture are slightly accentuated, but not overly significant. The left humerus is held further in front of the body than that right, indicating that it’s more internally rotated.
Back View: The left hip is slightly elevated, and the elevated left shoulder girdle is confirmed, especially in light of the fact that the right hand is closer to the ground. Lateral rotation of the feet is also confirmed.
As with Cases #2 and #3, there appear to be both sagittal, frontal, and transverse plane components to this client’s problems. The impingement problems will likely resolve with the implementation of a program to lengthen the internal rotators and scapular elevators while strengthening the external rotators and scapular retractors and depressors. Obviously, reduction of inflammation through therapeutic modalities and avoidance of overhead activities is the first step.
The elbow is likely a compensation for the shoulder injury, as weakness in one area will usually lead to overuse at another joint. Obviously, biceps tendonitis is a function of overuse of the biceps; one role of the biceps is to decelerate elbow extension (as occurs with a bench press). Likewise, at the glenohumeral joint, the external rotators serve to decelerate the internal rotation of the humerus during movements such as overhand throwing and – you guessed it – bench pressing!
So, if our external rotators are weak, and we still need to decelerate the same load, the biceps (along with a few other muscles) are going to be working overtime. The end result is two half-ass sets of decelerators; one is weak because it never received any attention in the first place, and the other is weak because it received too much attention and is just beaten up! We’re going to go out on a limb here and assume that this might alter one’s benching mechanics to some extent!
The client is also likely dealing with a pseudo-scoliosis. Based on the photographs provided, a tight left QL is the culprit, and leads to the following compensations and problems:
- Tight right thoracic erector spinae.
- Tight left cervical erector spinae, upper trapezius, and pectoralis major.
- Tight right lats, relating to the depression of the right shoulder girdle.
- Possibly a functional leg length discrepancy (left is shorter).
The client would be wise to approach these problems from both a sagittal and frontal double-S posture perspective. Important measures to undertake include:
- Stretching the levator scapulae, upper traps, and cervical erector spinae with particular emphasis on the left side.
- Stretching the internal rotators of the humerus, with a particular emphasis on the left side pectoralis major and right side latissimus dorsi.
- Stretching the left QL and right thoracic erector spinae.
- In the case of muscles that are unilaterally tight, in strength training, the same muscles – only on the contralateral side – should be given slightly more volume to take care of the imbalance.
- Stretching the hip flexors, adductors, IT band, calves, and peroneals.
- Strength training should focus on the neck flexors, scapular depressors and retractors, humeral external rotators, glutes, core (comprehensively), and dorsiflexors.
We’ve outlined the corrective modalities that directly apply to our disciplines and educational backgrounds. That’s not to say, however, that other disciplines wouldn’t be excellent complements to our recommended initiatives. Most notably, Active Release Techniques (ART) are incredibly effective in breaking down soft tissue adhesions, reducing pain, promoting healing, and getting you back on the road to proper movement patterns. In many cases, a single session can make a world of difference.
Likewise, myofascial release and massage may be suitable implements in the correction of your problems. Remember, it’s necessary to address not only the length of the muscle through flexibility training, but also to address and adjust the tonus of the muscle through modalities such as ART, massage, and myofascial release. All of these modalities should be used in addition to intelligent training protocols designed to correct existing imbalances. Plus, it’s important you learn how to effectively balance a wide variety of movement patterns in future programs.
Lastly, you might spend three to ten hours per week training; that’s a miniscule amount of time in comparison to the time you spend sitting at your desk and car, or just walking around in your daily life. Very simply, the training recommendations we’ve made in this article must be accompanied by a constant focus on proper postural habits all the time, so sit up straight!
Hopefully, taking a look at these folks gave you a great appreciation for how you stack up. Don’t think we’re going to leave you hanging, though; if you’re one of those people whose posture closely resembles that of a knuckle-dragger, our next two parts will give you specific training programs that’ll help you kick your postural afflictions and return to the world of the upright!
We’d like to extend a special thanks to those T-forum [link] members who were gracious enough to pose for the photos in this article; we really appreciate your help!
- O’Toole GC, Makwana NK, Lunn J, Harty J, Stephens MM. The effect of leg length discrepancy on foot loading patterns and contact times. Foot Ankle Int 2003 Mar ; 24(3): 256-9
- Smith, L.K., Weiss, E.L., & Lehmkuhl, L.D. Brunnstrom’s Clinical Kinesiology: 5th Edition. F.A. Davis Company, 1996.
- Tiberio, D. Pathomechanics of structural foot deformities. J Am Phys Ther Assoc. 1988 Dec;68:1840-49.
- White SC, Gilchrist LA, Wilk BE. Asymmetric Limb Loading with True or Simulated Leg-Length Differences. Clin Orthop. 2004 Apr;1(421):287-292