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Posture

 

Postural Muscle Pain


 

Poor posture is related to musculoskeletal pain complaints with findings of muscle imbalance and weakness.


 

Balanced posture observed from the side, finds the center of gravity passing through the ear of the auditory canal, in the shoulder through the acromion following the mid axillary line through the midpoint of the iliac crest of the pelvis. This line continues distantly in the lateral epicondyle of the femur to a point approximately 2 cm posterior to the lateral condyle. This proper alignment of posture places minimal strain on the muscles and ligaments of the musculoskeletal structure.


 

A poor posture or slouch posture usually results in excessive lumbar lordosis and excessive thoracic kyphosis and forward head positioning. This slumped posture mandates that the posterior cervical musculature must increase its activity to maintain support for the head otherwise the head would fall forward. The thoracolumbar “S” curve depends on ligamentous tension to maintain its alignment.


 

In the seating position, a slumped posture required sustained activity of the posterior cervical muscles to keep the head from falling forward and places a strain on the spinal ligaments supporting the curve of the spine.


 

One study evaluating poor sitting posture found that by placing forward pressure in the fifth thoracic vertebrae in the sitting position prevented spinal flexor muscle shortening.


 

One source of muscular strain to do is the result of skeletal asymmetry from a lower leg length discrepancy. A lower leg length discrepancy creates for a tilted pelvis requiring increased contraction of the quadratus lumborum muscle to align the lumbar spine over the pelvis. As the spine is tilted to one side, this tilt requires further compensation in addition to the quadratus lumborum muscle, which may recruit the neck muscles and upper shoulder muscles such as the sternocleidomastoid and upper trapezial muscles.


 

There are few studies that looked at the origin of postural pain. Summaries seem to indicate that it is not so much that the pain was caused by muscle spasm as the primary source of pain was caused by sustained tension on the joint capsules and ligaments.


 

Two studies exhibited the evidence of non-muscular spasm pain. One study evaluated healthy female subjects, who were asked to sit in a prolonged forward neck hanging down position until they could not tolerate the pain. The subjects tolerances varied from 18 to 62 minutes utilizing a visual analog scale with pain levels have ranging from 57 to 100. Surface EMG did showed some increase during the first 3 minutes of this posture. The subjects reported the most pain during the test found to have at least increase in muscle contractile activity. Evidence of voluntary effort to reduce discomfort by decreasing flexion was not associated with any identifiable reduction.

Another study assessed carrying a heavy load such as a suitcase in one hand and supporting it with the arm hanging down the side for several minutes. EMG activity was recorded in the deltoid and supraspinatus muscle, but again eliminated the muscles as the source of the pain and identified that the ligaments rather than the muscles created the discomfort. Postural changes frequently occur when there is a relationship between weakened and tight muscles.


 

Low back pain studies showed that these patients also had weak gluteal muscles. Testing of multiple muscles from the low back through the hamstrings identified a common set of imbalance patterns. The imbalance patterns identified that at the pelvic level there were tight or shortened hip flexors notably the iliopsoas and tensor fascia lata muscles. Additionally, there were weak hip extensors in the gluteal muscles. At the lumbar level, the trunk flexors, which were the abdominal wall muscles were weak and the trunk extensors, which were the erector spinae were tight. The quadratus lumborum and hamstrings also tended to be tight. This combination of weakness and tightness cause a muscular imbalance, which resulted in a forward tilt of the pelvis creating increasing lumbar lordosis and slightly increased hip flexion. This increased in lumbar lordosis initiated a chain reaction that also produced thoracic kyphosis and more superiorly cervical lordosis with the head forward position.


 

In one study, it was found that patients with low back pain with weak gluteal muscles, the contraction of the gluteus maximus was delayed.


 

In a comparable study of the cervical spine pain, it was found that tight upper trapezial, sternocleidomastoid, levator scapulae, and pectoralis muscles are the most common to be tight. Whereas these are tight, the muscles that are weak and inhibited are the lower stabilizers of the scapula being the serratus anterior, rhomboids, middle and lower trapezial muscles, and the primary neck flexors of the suprahyoid, mylohyoid, longus colli, and longus capitis muscles. As a result, these patients when standing exhibited elevation and protraction of the shoulder along with rotation and elevation of the scapula resulting in variable winging of the scapula. This abnormal scapular posture reduces the stability of the glenohumeral joint, which required compensatory recruitment of the levator scapula and upper trapezial muscles.


 

Other studies observed that in the head forward posture, findings of tightened muscles of both pectoralis muscles, but specifically the pectoralis major and then frequently the subscapularis muscle.


 

Multiple studies have shown that there are functionally related muscles where one muscle may reflexively inhibit the activity of a functionally related muscles in the same region. This has been shown where the quadratus lumborum and gluteal muscles are functionally related. When the gluteal muscles have weak recruitment, they were improved by decreasing the trigger points of its functionally related quadratus lumborum muscle. Therefore, if the quadratus lumborum muscle is in spasm it therefore reduces firing of the gluteus muscle.


 

There is also relationship of the soleus muscle and the lumbar paraspinal muscles on the ipsilateral side. Therefore, inactivation of the right soleus trigger points relieved the spasm of the right lumbar paraspinal muscles.


 

Another muscle group functionally related was the sternocleidomastoid muscle having a relationship of the upper trapezial and supraspinatus muscles.

In terms of relationship, the following were noted: Inactivation of the sternocleidomastoid created an inactivated gastrocnemius muscle.


 

Inactivation of the upper trapezial, inactivated the rhomboid minor. Inactivation of the lumbar paraspinals, inactivated the gluteus maximus gastrocnemius and soleus. Inactivation of the quadratus lumborum, inactivated the gluteus maximus.


 

Therefore, research confirms a direct relationship to functional muscle groups and their effect on spinal elements which determines spinal posture.


 

 


 

Taras V. Kochno, M.D.

Board Certified in Physical Medicine & Rehabilitation

Copyright July 2, 2012




 

 

 

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