Does Posture Affect Neck Pain and Headaches? Maybe or Maybe Not…

When helping people with neck pain, we tend to always tell them to sit up straight and have good posture.  Posture, Posture, Posture!!!  But what does it mean to sit up straight and does it really help?  Maybe…

A cross-sectional study out of Australia assessed 1,108 seventeen-year-old individuals between 2006 and 2009.  They used photographic posture analysis with the hips and knees standardized.

They measured thoracic flexion, neck flexion, cervicothoracic angle, craniocervical angle (upward tilt), and head displacement (forward head).

Neck ranges

They analyzed the data and created 4 clusters of postures.  These clusters are:

Neck postures

  1. Upright/Normal Posture (28% of subjects) – individuals with slightly limited thoracic and cervical flexion, limited craniocervical upward tilt
  2. Intermediate Posture (24% of subjects) – limited cervical flexion, increased cervicothoracic angle, less neck flexion, forward head, and less craniocervical upward tilt
  3. Slumped Thoracic and Forward Head Posture (16% of subjects) – excessive thoracic and cervical flexion and craniocervical upward tilt
  4. Erect/Flat Thoracic and Forward Head Posture (32% of subjects) – least cervicothoracic angle, forward head, and slight craniocervical upward tilt

They measured the subjects’ Body Mass Index (BMI), frequency of exercise, computer use, sitting time, depression, neck pain and headaches.  Their goal was to see the correlation between these variables and sitting posture.

They did not find a correlation to neck pain and headaches between the postures.  They did find correlations to exercise, depression, sex, and BMI.

  • Category 1 (Upright Posture) was found to exercise significantly more than the other groups
  • Category 3 (Slumped Thoracic and Forward Head Posture) was found to be more significantly correlated to depression than the other groups
  • Categories 1 and 4 (Upright Posture and Erect Thoracic and Forward Head Posture) were found to be more correlated to females than males
  • Categories 3 and 4 (Slumped Thoracic and Forward Head Posture and Erect Thoracic and Forward Head Posture) were more correlated to a high BMI
  • Females tend to have a greater prevalence of neck pain than males with a prevalence of 64%

What does this mean for helping people with neck pain and headaches?

Posture can place abnormal stress on muscles, ligaments, and joints but may be a small factor in neck pain and headaches.  These symptoms may be more correlated to other factors such as mechanism of injury, repetitive use/how the neck moves, stress, psychosocial factors, etc.

What we can take away is that if someone has a Slumped Thoracic and Forward Head Posture they tend to be overweight and suffer from depression.  If we want to improve their sitting posture it can be as easy as having them complete generalized exercise more often throughout the week without having to give specific exercises for posture. (Individuals tend to respond better with less cues.)  It is still important to work on posture but more focus can be placed on movement and functional during evaluations and treatments.

So instead of Posture, Posture, Posture! maybe the saying should be Posture! Exercise! Function!




Richards KV, Beales DJ, Smith AJ, O’Sullivan PB, Straker LM. Neck posture clusters and their association with biopsychosocial factors and neck pain in Australian adolescents. Phys Ther. October 2016; 96(10): 1576-1587.

The Effect of Stretching Alone

Stretching is a common principle used to improve resistance during activity, when feeling a sensation of tightness, or to lengthen a short muscle.  But how much is enough?  We as practitioners prescribe 30 second holds, repeat 30 second holds, or to hold for up to 2 minutes.  Some studies show a benefit from holding for those lengths of time.  But that is in the short-term.

What is the effect in the long term?

A randomized controlled study by Youdas et al. assessed the effects of a closed-kinetic chain stretch of the ankle dorsiflexors over a 6 week period.  They compared a control group versus 3 experimental groups (30 second hold, 1 minute hold, and 2 minute holds).  This was conducted 1 time a day.  Sixty to seventy-two hours later after the final day of the 6 week period the ankle range of motion was taken again.  They found no significant change in the range of motion between the experimental and the control groups.


So what does that mean?

As practitioners, we know that stretching will help with lengthening a muscle.  We prescribe the stretch for multiple times a day and hope that is followed.  But in reality, how many people are able to set time aside (three, four, or five times a day) to complete the prescribed home exercise program as well as remember to complete in their busy schedules.

Should we be prescribing stretching multiple times a day or should we prescribe the stretch 1 time a day but combine it with functional activities that make use of that range gained from the stretching?  Example, complete a calf stretch for 60 seconds and then teach them to walk with a longer step length and trying to keep the heel down a little longer during terminal stance to use that increased motion.

We can know and educate individuals the right thing to do for themselves with stretching or exercise but the carryover comes from incorporating it into everyday life.



Youdas JW, Krause DA, Egan KS, Therneau TM, Laskowski ER. The effect of static stretching of the calf muscle-tendon unit on active ankle dorsiflexion range of motion. J Orthop Sports Phys Ther. 2003; 33(7):408-417.

Modality’s Place in PT


Talking Passive Treatments and Adjuncts with Jack and Rob

I came across this podcast that discussed the physical therapist’s role in healthcare, what our “Core” treatments consist of, and what are/should we use supplementary (i.e. manual therapy, acupuncture, etc.) techniques in our profession?

I think the three physical therapists bring up strong points that show how physical therapy has changed and invites physical therapists (veterans and novices) to challenge the status quo.

Sorry, the podcast may have 2-3 uses of strong language as you listen to the speakers passionately explain their points of view.  I hope you all enjoy the podcast.

Talking Passive Treatments and Adjuncts with Jack and Rob



Types of Muscle Tightness

Rectus femoris length

When assessing the flexibility of a muscle, it is easy to just look at the muscle itself.  But it is important to look at the response of joint(s) that the muscle acts on.

First we must understand that there are different types of tightness.  There is a short muscle and there is a stiff muscle.

  • Short muscle – a muscle that has a reduction of sarcomeres limiting its length
  • Stiff muscle – a muscle that has appropriate length but maintains increased tension through that range

Now that this is addressed we can look further at assessing muscle flexibility.  There can be different presentations of a short/stiff muscle.  The 6 categories will be presented with assessment of the rectus femoris (RF) muscle.  This muscle is most easily assessed in the prone position and by flexing the knee; normal motion will be between 115-125 degrees knee flexion.

  • Normal – the knee is able to be flexed >115 degrees without compensatory pelvic motion
  • Short RF- knee flexion is <115 degrees without compensatory pelvic motion.  The anterior abdominal muscles have normal tension.
  • Stiff RF – the knee is flexed >115 degrees with sensation of tension in the muscle and compensatory anterior pelvic tilt and when the pelvis is stabilized to prevent tilting the knee continues to its initial range.
  • Stiff + Short RF – the knee is flexed >115 degrees with anterior pelvic tilt and when the pelvis is stabilized knee flexion <115 degrees.  This shows that the abdominal muscles have less stiffness than RF but there is also a component of shortening of the RF.
  • Stiff RF with automatic stabilization – passive knee flexion will cause compensatory anterior pelvic tilt.  Active knee flexion does not have an associated anterior pelvic tilt.  This is a sign that the body will maintain stability due to the stiffness of the RF.
  • Deficient counter stabilization – the initial motion of knee flexion will cause a posterior pelvic tilt (the opposite anticipated reaction).  Motor control issue.

Being able to differentiate between these 6 categories when assessing flexibility of a muscle will help appropriately guide treatment.  I encourage you to use this when assess muscle flexibility for other areas of the body; such as the latissimus dorsi, hamstrings, pecs, gastrocs, etc.


Resisted Upright Side Stepping or Resisted Squat Side Stepping. That is the Question.

The Journal of Orthopedic and Sports Physical Therapy published an article in the September 2015 issue about the differences between completed a resisted upright side step verses a resisted squat side step.  I found this article to be very interesting because I use these two exercises in my practice when trying to help patients who have hip abduction weakness and present with a hip drop or a trunk lean while walking.  Here is the synopsis of the article and hopefully it helps you achieve your goals.

The researchers studied the muscle activation of the gluteus maximus, gluteus medius, and tensor fascia lata (TFL).  The subjects were given a theraband and wrapped it around their ankles with about 110% tension in the band.  Pt participant was then instructed to start with their feet 12 inches apart and side step to about 24 inches apart  and back to 12 inches apart for 8 steps in each direction.  The two posture used were upright standing without flexion in the hips and knees and the subject’s preferred squatting position.

The researchers found that the greatest muscle activations of the gluteus maximus, gluteus medius, and TFL were found in the stance limb compared to the moving limb, the muscle activation of the TFL was less and the gluteus muslces was greater in the squatting position compared to the upright position, and their was more hip abduction excursion in the stance limb compared to the moving limb.

So when completing these exercise, it is important to consider which muscles you want to focus on and the functional goal that you would like to improve upon.

Berry JW, Lee TS, Foley HD, Lewis CL. Resisted side stepping: the effect of posture on hip abductor muscle activation. Phys Ther. September 2015; 45(9):675-682.

Nerve Mobilizations to Treat Anterior Knee Pain?


People suffering from anterior knee pain/patellofemoral pain usually will benefit from proper strengthening, stretching, and alignment during functional activities.  But some people tend to continue to have discomfort at their knee even when those deficits are corrected.  There has been recent research showing that people suffering from anterior knee pain can also be from mechanosensitivity/hypersensitivity.

Continued irritation and swelling tends to promote blood vessel and nerve proliferation.  Also, nerves can eventually adhere to structures at the knee such as the bone, ligament, fascia, etc. from injury.  Treatment for improving neurodynamics at the femoral nerve, and associated medial and lateral patellar branches, around the knee can prove beneficial.

Two studies by Lin et al. and Huang et al. examined the use of the Femoral Slump Test to assess neurotension at the knee and other predictors that an individual might benefit from nerve tensioning/gliding.

Individuals that may benefit from this type of treatment are people with symptoms at the anterior knee at the knee cap during stair climbing, squatting, kneeling, or sitting for a long time.  They will also be positive for more than 2 of these clinical tests:

Clarke’s sign – The individual is supine with their knee extended and pressure is applied to the knee cap as they contract their quadriceps.  The test is positive if there is a reproduction of their symptoms.

Waldron Test – The individual is supine with their knee slightly flexed and pressure is applied to the knee cap the knee is progressively flexed more.  The test is positive if there is a reproduction of their pain or crepitus.

Active Patellar Grind Test – The individual sits with their knee at 90 degrees and the examiner palpates the knee cap as the individual straightens their knee.  The test is positive if crepitus is felt during the motion.

Patellar Compression Test – The individual is supine with their knee extended.  Their knee cap is compressed and shifted superiorly.  The test is positive is there is a reproduction of their symptoms.

Assessment and completion of nerve tensioning/gliding is not appropriate if the individual’s anterior knee pain is due to other pathologies such as meniscus, ligaments, etc.

The Femoral Slump Test should be completed with measurement of hip flexion bilaterally when symptoms come on.

The test is positive if the individual’s anterior knee pain is reproduced and then reduced or eliminated with extension of the head.  If the individual has a history of lower back pain and there is a difference of hip flexion during the slump (>3 degrees on the affected side) then the prediction that nerve tensioning/gliding is greatly improved.

The authors of the article completed tensioning of the nerve by taking the hip into extension in the Femoral Slump Test position until the individual’s anterior knee pain is  first felt  then held for 2 seconds.  This was completed 10 times for 3 sets.  Improvement of knee pain was seen on the first session in 50% of subjects and in all subjects by the sixth session.


  1. Lin PL, Shih YF, Chen WY, Ma HL. Neurodynamic response to the femoral slump test in patients with anterior knee pain syndrome. J Ortho Phys Ther. May 2014; 44(5):350-357.
  2. Huang BY, Shih YF, Chen WY, Ma HL. Predictors for identifying patients with patellofemoral pain syndrome responding to femoral nerve mobilization. Arch Phys Med Rehabil. 2015; 96:920-927.

Looking Beyond the Elbow for Lateral Epicondylalgia


Lateral epicondylalgia/epicondylitis is generally seen in individuals who live an athletic lifestyle such as tennis players or baseball players.  It is pain at the outside of the elbow and forearm.  It affects the extensor bundle of the elbow (predominantly the extensor carpi radialis brevis).  The primary reason that an individual may get pain in this area is from repetitive movements.  But what would cause this muscle to be over worked?


A study by Lucado et a. showed that reduced lower trapezius muscle strength and endurance will change the movements of the elbow of tennis players.  Another study showed that increased pain and activation of the upper trapezius caused an increase in the extensor bundle muscle activation at the elbow.

A study by Day et al. wanted to compare scapular muscular strength, endurance, and change in thickness of individuals with and without lateral epicondylalgia.  They assessed the middle trapezius, lower trapezius, and serratus anterior muscles.  They found there were significant differences for middle trapezius, serratus anterior, and lower trapezius muscle strength and endurance and a significant change in serratus anterior muscle thickness.

So the moral of the story is that if someone has lateral epicondylalgia then muscles of the shoulder should be checked out as well.  If those muscles cannot control and stabilize the shoulder blade then the muscles of the arm have to work just a little bit harder.


Day JM, Bush H, Nitz AJ, Uhl TL. Scapular muscle performance in individuals with lateral epicondylalgia. J Orthop Sports Phys Ther. May 2015; 45(5): 414-424.

Assessing and Rehabilitation for a Quadriceps Muscle Strain


The quadriceps muscle is generally strained during activities that require high demand such as soccer, rugby, and football.  The more commonly injured muscle out of the four muscles that make up the quad is the rectus femoris muscle.  The reason for this is that it is a muscle that spans two joints; the hip and the knee.  Usually muscles that have been exposed to a high eccentric load to the muscle or excessive load to an overly stretched muscle.

Strains can be characterized into 3 grades:

Grade 1 = minor tears with no to minimal loss of strength with minor to moderate pain and no palpable tissue damage

Grade 2 = tears that result in moderate pain and loss of strength and a defect in the tissue can possible be felt

Grade 3 = a complete tear with significant pain and complete loss of strength with an obvious palpable change in tissue

Treatment should be broken down into Acute and Post-acute.

  • Acute treatment (the first 24-72 hours) should involve RICE or rest, ice, compression and elevation.  For Grade 3 and possible Grade 2, crutches may be recommended to prevent further injury to the muscle.  The purpose of this phase of treatment is to let the muscle heal and recover.
  •  Post-acute treatment (about 3 to 5 days after the initial injury) should involve a more active approach such as stretching, strengthening, range of motion, aerobic activity, proprioceptive activities, and functional activities.
    • Strengthening should follow a specific progression: isometric, isotonic, isokinetic, finally followed by functional activities.  Before progressing to the next type of strengthening, an individual should be able to fully complete normal strength levels or be comparable to the other leg.

If an individual is not healing, symptoms are worsening, and there is a loss of knee flexion range of motion after 2-3 weeks one can start considering Myositis Ossificans as a potential diagnosis.


Kary JM. Diagnosis and management of quadriceps strains and contusions. Cur Rev Musculoskelet Med. 2010; 3: 26-31.

Joint Mobilizations to Improve Muscle Strength

mobsPeople with poor posture tend to have weakness of certain muscles.  Dr. Vladimir Janda described an Upper Cross Syndrome with lower trapezius weakness associated with a flattened cervical spine, forward head posture, protracted and elevated shoulders, and an increased thoracic kyphosis.

Muscles require normal unrestricted joint mobility to activate more efficiently.  People who present with this Upper Cross Syndrome posture do not have optimal activation of the lower trapezius muscles in order to stabilize the shoulder blades and draw them downward.  Also, individuals who have shoulder pain tend to have weakness of the lower trapezius muscles and limited thoracic extension.  The body gets the last 20 degrees of shoulder flexion range of motion from the thoracic spine.

I came across a study that compared the strength of the lower trapezius muscles in people who received Grade I joint mobilizations versus Grade IV joint mobilizations.

The origin of the lower trapezius is the spinous process of thoracic vertebrae 4/6 to 12.  The researchers focused on applying the mobilizations to those vertebrae for 30 seconds with a posterior to anterior force using the technique shown above at each spinous process.  They reported a significant increase in strength (6%) of the lower trapezius muscle for individuals who received Grade IV joint mobilizations to the thoracic spine.

It is important to incorporate joint mobility treatments to individuals who present with muscle weakness.


Liebler EJ, Tufano-Coors L, Douris P, et al. The effects of thoracic spine mobilization on lower trapezius strength testing. J Man Manip Ther. 2001; 9(4):207-2012.

An Ambiguous Dorsal-Lateral Foot Pain Case Study


I found this case study interesting and beneficial when considering treatment for painful ankles.  The article presents with very vague symptoms with limited objective measures eliciting abnormal findings.  I thought this article showed the importance of assessing joint end feels during standard range of motion assessments.

This article examined a 54 year old male software engineer with chief complaint of right dorsal lateral foot pain described as an ache at the dorsal joint line of the cuboid and fourth metatarsal.  Symptoms were of insidious onset about 3 years ago when hiking.  He noticed the symptoms about 1 hour into the hiking and quickly resolved when he stopped hiking.  The subject continued to hike about 1x/week.  He then noticed an increase in symptoms about 1 year ago due to unknown cause with the symptoms occurring about 10 minutes into walking and took about 30 minutes to resolve.  The subject presented with negative x-rays and MRI’s and did not respond to orthotics or electrical stimulation; all provided by a podiatrist.

Physical therapy examination revealed:

1. Tenderness to the dorsal base of the fourth metatarsal

2. Manual Muscle tests of foot, ankle, knee, and hip to be 5/5

3. Negative ligament stress tests for anterior and posterior talo-fibular ligaments, calcaneal-fibular ligament, deltoid ligaments, anterior interosseus, and medial and lateral subtalar ligaments

4. Gait assessment did not show any obvious deviations or pain

5. Posture did not present with any asymmetries or faults

6. All range of motions were normal at the hip, knee,, ankle, and midfoot but the subject had pain at the end range of nonweight bearing plantar flexion and mid-range weight bearing dorsiflexion.  He also presented with a more firm capsular end feel at end range of nonweight bearing dorsiflexion.

7. Joint mobility of talocrural, tarsal, and metatarsal articulations showed decreased posterior and lateral glides with restricted firm capsular end feel of the talus on the tibia.  All others were normal.

Treatment consisted of a high-velocity low amplitude traction joint mobilization of the talocrural joint causing an audible cavitation and a palpable distraction of the joint.  This improved accessory motion of the talocrural joint, the end feel of joint mobility, and the elimination of pain during range of motion assessment.

The subject was given a home exercise program that consisted of wearing shoes as much as possible during the first week to allow the fourth metatarsal to heal and two exercises: completing squats with proper alignment and then a lunge with the affected leg forward and slight internal rotation of the tibia to promote external rotation of the talus both for 10 repetitions 4-5 times a day.

The subject’s symptoms improved and he was able to return to his activities.

Callan B. Clinical reasoning and multi-modal treatment for dorsal-lateral foot pain: a case study. Ortho Pract. 2015; 27(1): 26-31.