Tip #4 Posture - Change the dialogue, don't dump key elements of a successful management approach
Posture has become a contentious topic over the last few years. I wrote a blog on this topic this time last year. You might like to read this here. Some would have us throw out any assessment of posture and avoid drawing attention to posture for fear of encouraging hypervigilance or inappropriately attributing blame to subtle variations in alignment.
While there is still much work to be done on establishing a clear evidence base for what and when posture is important, it cannot be denied that we are all slaves to gravity, and how we position our body segments under gravitational load will impact on musculoskeletal loads and muscle behaviour.
Let’s change the dialogue with our patients and with our colleagues, to find a way forward that does not deny the importance of controlling sustained loads in musculoskeletal conditions but also does not sentence our patients to a lifetime of chasing the enigma of ‘good posture’. From my own clinical experience with managing hip conditions, I have found that training patients to take control of their sustained joint and tendon loads by making some alterations to habitual positioning can have a powerful and often rapid effect. Even an optimal exercise program with high compliance will struggle to impart a long-term change when the mechanobiological processes are driven by repetitive overload related to sustained or repetitive everyday tasks. Delivered appropriately, this information is empowering, not fear inducing. Below are some of my favourite cues.
Don’t be afraid to empower your patients.
Useful cues to reduce hip loads in standing:
Grow gently tall through the crown of your head
This simple cue will assist in reducing excessive hip extension or sagging into hip adduction when standing, thereby reducing excessive anterior and lateral hip loads respectively. The word 'gently' is important, as we are trying to achieve the most efficient position, ie a position where bones align fairly vertically with load dispersed over the main weightbearing aspects of our joints, thus avoiding sustained edge loading (which is where we most commonly see early chondrolabral pathology at the hip). This optimisation of weightbearing capacity of our passive structures, allows us to reduce the requirement of tonic activation of our active, muscular system, like the efficient beings into which we have evolved. Watch for those who respond to this cue by elevating their shoulder girdle, sticking out their chest (military style) or sucking in their belly. This is not the intention! There is of course no 'one perfect posture', and we should encourage regular shifts in positioning for optimal load sharing, but let's aim to reduce time spent hanging at the end of range.
Position your weight a little more on your heels than the balls of your feet
This can be another useful cue that works on a focus at the other end - where the weight is distributed at the feet. We see many people with hip pain that habitually stand with their pelvis translated well forward of their ankles. This tends to push the centre of mass forward towards the balls of the feet. Apart from potentially contributing to forefoot pain and that feeling of persistent calf tightness, this position tends to increase the loads at the anterior hip and low lumbar region. Simply asking people to feel where their weight is distributed under their feet and then shifting the weight more towards the heels can immediately bring the pelvis back towards the ankles. Watch that they don't just move their trunk backwards and if so you may need to cue the shift from their pelvis. And, if their tibialis anterior tendons are jumping out of the front of their ankles, they haven't quite reached a balanced, 'quiet' position. Let's keep it efficient, simple and subtle.
Asking patients to hold muscles on
Not efficient! And at worst, this may contribute to ongoing pain states. The number of times I have treated a patient with upper buttock or lower back pain who stands with their glute max at full attention is worthy of note. Perhaps more concerningly is the fact that a considerable number of these patients have been coached to use such strategies by well-meaning health or exercise professionals. Unless you're leaning forward and the hip extensors need to control the centre of mass around the hip, glute max should be having a pretty cruisy time in upright standing. Gluteus maximus is a large muscle with the ability to transfer large loads. Holding this muscle tonically contracted unnecessarily for sustained periods may have implications not only for the hip but the whole lumbosacral region due to its extensive fascial connections. Let's encourage patients to let this powerhouse have a rest when not required.
Asking patients to 'unlock' their knees
While you might want to reduce time spent in extreme hyperextended knee positions, standing with straight knees is important for energy conservation. Bending the knees unlocks the screw-home mechanism and requires inefficient tonic activation of the quadriceps, with implications for joint and tendon loading, and of course energy consumption!
Our LEAP randomised clinical trial for management of gluteal tendinopathy returned an almost 80% success rate through a targeted education and exercise program1. The load management education had a strong focus on reducing cumulative aggravation in sustained positions – standing, sitting and lying.
Click on the box above to read Day 3 miniblog
Click on the box above to read Day 5 miniblog
- Mellor, R., Bennell, K., Grimaldi, A., Nicolson, P., Kasza, J., Hodges, P., Wajswelner, H. and Vicenzino, B., 2018. Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: prospective, single blinded, randomised clinical trial. British Medical Journal, 52(22), pp.1464-1472.