As you know, posture reveals a great deal about the body. Posture is a unique mental and physical landscape revealing compensations and adaptations to life. It's a classic mind-and-body story. As clinicians, we must be open and attune to hearing and seeing the story. Observing, listening, touching and moving are fundamental steps of discovering the underlying truth. The clinical audit process guides us in the journey.
Compensation, dysfunction and pain are requests for change. The brain and body are communicating their need for something different. We simply need to listen.
A common posture story is an elevated shoulder/scapula. Let's take a look at one culprit in detail, including how to identify the problem and then address it.
Quadratus Lumborum Inhibition
The quadratus lumborum (QL) originates on the posterior iliac crest and inserts on the last rib and transverse processes of the first through the fourth lumbar vertebrae. It's action is to unilaterally tilt (elevate) the pelvis, laterally flex the vertebral column to the same side and assist in extending the vertebral column.
If the quadratus lumborum becomes inhibited, the pelvis drops on the ipsilateral side and the lateral subsystem (LSS) of movement stabilization will become dysfunctional (quadratus lumborum, contralateral hip adductors and abductors). When this occurs, the opposite-side quadratus lumborum may become neurologically unregulated and facilitated, causing lateral flexion of the torso.
Lack of central zone stabilization of the LSS during bipedal locomotion causes a compensatory elevation of the shoulder on the side of the inhibited quadratus lumborum. What looks like an elevated shoulder is actually a dropped pelvis from an inhibited QL.
Assessment
Evaluate the quadratus lumborum for hyper/hypotonicity. Palpate and compare bilaterally. Suspect inhibition when you discover hypotonicity.
Now move the legs 6 inches to the right away from midline. Stand on the left side facing table. Place your right hand on the outside of the left hip and left forearm underneath the patient's ankles, with the left hand grabbing their right ankle. Pull legs back to the center and have them meet your pressure. This is assessing the right quadratus lumborum.
Inability to hold and resist the muscle test is a sign of inhibition. Now go back and retest the first QL side again (in this example, the left) to see if it changes. Why? You are checking a pattern. By going back, you are observing how muscles react to each in a pattern. Both sides should be strong. If either QL goes weak, it indicates dysfunction.
Interventions
The goal here is to establish a pattern of function in a stable environment. Soft-tissue therapy bilaterally to the QL muscles will help release tension and fascial restrictions. Also release the tissue surrounding the opposite-side anterior-superior iliac spine (ASIS). The contralateral anterior hip and thigh region become overworked when the quadratus lumborum is inhibited and the pelvis drops. Tenderness is most often felt on the medial border of the ASIS.
Have the patient perform an ipsilateral crawling pattern on the ground on the inhibited side. The ipsilateral crawl integrates full-body patterning with a low-load threshold stabilization strategy. Then progress them to a supine, single-leg-stance, isometric-hold movement.
Example with left QL inhibition: Instruct patient tolie on the ground in a prone position with their arms overhead and legs straight. Patient turns their head to the left and then brings the left knee and left elbow together in a crawling pattern, holds for 4 seconds and returns. Repeat four times.
Next, instruct patient to lie supine with arms overhead and legs straight. Patient brings right leg into hip-flexion, single-leg-stance position and holds for 4 seconds; then lowers back to the ground and repeats four times. Make sure knee passes the waist midline.
Ida Rolf once said, 'Where you think it is, it ain't.' That should be a mainstay of musculoskeletal pain assessment. Start where it hurts and then look elsewhere. Observe posture and movement, look for the pattern of dysfunction and you will find the answer.
Pain only tells you there is a problem, it does not tell you what it is. Full-body assessment is a linchpin to unlocking the posture and movement story.
Resources
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