Posture, etiology of a syndrome

Evidences

• Clinical evaluation findings: everything that may be assessed by external observers;
• Symptomatic and degenerative findings: resulting from pain sensation, uneasy sensation or completely asymptomatic but confirmed by lab exams;
• Self evaluation: motor disorders that may be fully assessed by internal observers (patient) and only partly evident to external observers;
• Regression events: precious finding, thoroughly described;
• Orthodontic treatment, outcome and followup: description of the treatment and relationship with the above evidences.

EVIDENCES: clinical evaluation findings
#	Finding	Images & details
Ecl01	Left ankle: slighty pronated	No image
Ecl02	Left soleus (S): contracted, hypertrophic	click to enlarge
Ecl03	Left hip adductor: contracted	No image
Ecl04	Left tensor fascia lata (TFL) and rectus femoris (RF) : contracted, hypertrophic	click to enlarge
Ecl05	Gluteus maximus (GM): inhibited	Inhibited with habitual pelvis pathologic tilt click to enlarge		Tonic with forced pelvis physiologic tilt click to enlarge
Ecl06	Hamstring: inhibited	No image, palpation evaluation
Ecl07	Left hip: medially rotated	Habitual unilateral left hip pathologic medial rotation, hands fall asymmetrically click to enlarge		Forced bilateral hip physiologic rotation, hands fall symmetrically click to enlarge
Ecl08	Pelvis: anterior tilted	click to enlarge		Courtesy of Carol Oatis "Kinesiology: the mechanics and pathomechanics of human movements": left physiologic pelvis tilt as opposed to right pathologic anterior tilt lamented by the patient, see also Ecl04, Ecl06.
Ecl09	Penis: right curved	No image
Ecl10	Left internal oblique (IO): contracted	click to enlarge
Ecl11	Right abdominal and chest hair: less thickness	click to enlarge		click to enlarge
Ecl12	Spine curves: increased lumbar lordosis, increased dorsal kyphosis	click to enlarge		Differential evaluation: red ordinary pathologic curves, blue more physiologic curves due to induced mandible slight protrusion by bite cotton thickness appliance
Ecl100	Left erector spinae (ES): inhibited	No image, self evaluation
Ecl13	Left pectoralis major (PM) (clavicular portion): hypertonic	Courtesy of Henry Grey "Anatomy of the human body" click to enlarge	reduced scapular abducted lateral rotation ROM due to hypertonic PM click to enlarge		normal scapular abducted lateral rotation ROM click to enlarge
Ecl14	Shoulder girdle: forwarded	click to enlarge	click to enlarge		Differential evaluation: left pre orthodontic humeral convergence, right post orthodontic humeral divergence
Ecl15	Left shoulder: scapulohumeral joint (SHJ) further forwarded	forwarded SHJ increased adducted medial rotation range of movement (ROM) click to enlarge		less forwarded SHJ normal adducted medial rotation ROM click to enlarge
Ecl16	Left scalenes: contracted			Courtesy of Carol Oatis "Kinesiology: the mechanics and pathomechanics of human movements"
Ecl101	Left splenius capiti (SC) and trapezius (T): contracted	No image, palpation evaluation
Ecl17	Cervical spine: forwarded	Courtesy of Carol Oatis "Kinesiology: the mechanics and pathomechanics of human movements" click to enlarge		click to enlarge
Ecl18	Temporomandibular joint (TMJ): retruded	click to enlarge		click to enlarge
Ecl19	Bite occlusion: distocclusion II class II division, incisors crowding, deep bite, mandibular wisdom teeth extrusion over the bite plate, maxillary wisdom teeth extrusion under the bite plane, lack of canine and incisor guidance	click to enlarge	click to enlarge		click to enlarge
Ecl20	left emitongue: weak	click to enlarge		Protruded tongue deviation is a neurological indicator of unilateral weakness effecting the side the tongue deviates to
Ecl21	Palate: velopharynx asymmetry	click to enlarge
Ecl22	Left maxillary arch: insufficiently expanded	click to enlarge		After orthodontic therapy, the "before" situation doesn't allow reliable inter incisors line location to evaluate the arches asymmetry
Ecl23	Cheek and lips muscles: contracted	click to enlarge		Differential evaluation: red ordinary pathologic mimic expression, blue forced expressionless

EVIDENCES: self evaluation
Findings reported by the patient, assessed by means of self analysis and self designed test generic co-contraction test: the co-contraction disorder is easily assessed by an operator rapidly and randomly flexing and extending the involved joint having the patient resisting the action, he will not find any resistance in the first degree of each direction change (lack of underlying co-contraction) but only after a slight delay (eliciting antagonist voluntary contraction); ankle co-contraction test: the co-contraction disorder is easily assessed with the shoe wearing task where the patient attempts to wear a shoe without using hands, the foot has to sneak in the shoe using toe and ankle deformations by co-contraction of tibialis anterior (TA) / tibialis posterior (TP) as well as extensor hallucis longus (EHL) / flexor hallucis longus (FHL) and extensor digitorum longus (EDL) / flexor digitorum longus (FDL); difficulties in the task may underline co-contraction disorder; genioglossus (GG) contraction test (Ese08): put a stick in the mouth having one end deep (as deep as possible) in the mandibular sub-lingual cavity and the other free outside the mouth, pulling vertically using pre molar teeth as fulcrum and having the patient exert as much tongue depressing torque as possible it is possible to manually test the GG force. Maximal torque left-to-right-side unbalance supports unilateral tongue weakness.
#	Finding	Images & details
Ese01	Left hallux: motor disorder	Inhibited co-contraction of extrinsic foot muscles extensor EHL and FHL, resulting in impossibility to voluntarily flex the first phalangeal joint (PJ), furthermore, visibly low EHL basal contraction (EHL tendon not tight), slight improvement with specific exercises; the finding is further supported by generic co-contraction test applied to big toe first phalangeal joint. Solid blu line in the image represent tendon activated by concentric muscle contraction, dashed blu line represents passive tendon due to muscle inhibition. This condition is harmful because leads to ingrown big toe nail: inability to flex the big toe during swing phase of gait causes EHL to extend a straight big toe having its nail excessively pushing against the shoe.	click to enlarge
Ese02	Left intrinsic foot muscles: muscular spasm	Systematic intrinsic muscle spasm (cramp) during left foot unresisted toes flexing, supposed reason is the unresisted flexing torque (due to lack of extensors muscle basal tone) causing muscle to cotract close to minimum length excursion range, cramps subside with passive toes hyperextension.
Ese03	Left ankle: motor disorder	Inhibited co-contraction of tibialis anterior (TA) and tibialis posterior (TP) to control and stabilize the foot resulting low plantar arch (slight pronation), unsteady motion and pathologic motor compensations (alternative muscular firing pattern) and ankle joint degeneration, the finding is further supported by ankle co-contraction test.
Ese04	Left hip: motor disorder	Inhibited posterior thigh muscles semimembranosus (SM), semitendinosus (ST), biceps femoris (BF), GM due to overactive TFL and RF, resulting in poor coxofemoral joint stabilization, pathologic motor compensations (alternative firing muscular pattern) and joint degeneration; the finding is assessed by generic co-contraction test applied to left hip joint.
Ese05	Postural cycling analysis	The chart, resulting from instrumental cycling evaluation, perfectly assists in describing the self evaluated motor unbalance during cycling activity and its harmful features: at high power demand (high and mid lines) corresponds great left/right load unbalance causing ipsilateral joint overload, at high neuromuscular coordination demand (low lines) corresponds great motor disorder causing uncontrolled motion.
		Protocol: 6 pedalling modes with fixed power of 200 watt at changing frequencies and handlebar grip: 120 rpm high grip 120 rpm low grip 80 rpm high grip 80 rpm low grip 40 rpm high grip 40 rpm low grip Chart: X axis = pedal cycle (degrees), Y axis = power outlet (N); Chart lines and quadrants: lower lines couples display fast pedalling (high/low grip), mid lines display normal pedalling, high lines display slow pedalling, left quadrant for left lower limb, right quadrant display right lower limb.	click to enlarge
Ese06	Postural gait analysis	Inhibited posterior thigh muscles semimembranosus (SM), semitendinosus (ST), biceps Motor disorder in the left stride: Left Ground contact: in this context left PM and PMI should be inhibited to facilitate left shoulder backward motion, their pathologic contraction results in visibly disharmonious shoulder motion; Left Flat Foot: pathologically inhibited TP action resulting in unstable and pronated ankle; Left Mid Stance: pathologically contracted TFL inhibits hamstring keeping pelvis in pathologic anterior tilt, resulting in low propulsion and poor balance; Left Heel Off: pathologic hamstring elongation secondary to pelvis anterior tilt requires early knee flexion resulting in early heel off, in this phase GM that should be providing propulsion but pathologically contracted TFL inhibits it, supplementary motion is supplied by S; Left Late Stance: early heel off and poor knee flexion due to pathologically inhibited hamstring result in vertical push off causing left hip adduction and poor propulsion; Left swing: previous phase (late stance) fails in delivering limb inertial angular velocity to swing pahase, limb enhancement is then actively taken over by frontal muscles (TFL, RF) and clearance is optimised by quadratus lumborum (QL) providing hip adduction, it all results in poor foot clearance and easiness in stumbling. In this context EHL and FHL co-contraction (Ese01) should provide big toe clearance, but pathologically inhibited FHL is not able to flex phalangeal joint, as such, big toe is straight extended by EHL inducing harmful pressure of the nail against the shoe and threatening its ingrowing.
Ese07	Left thorax: motor disorder	Inverted rib expansion during inspiration: chest expansion for inspiration is compromised by anterior scalenus and intracostalis contraction (as well al PM and suspect pectoralis minor (PMI)) and is compensated by posterior expansion and augmented kyphosis resulting in dorsal expansion respiration.
Ese08	Tongue: motor disorder	Left unilateral tongue weakness (no apparent muscle loss): extraoral manifestation is a slight tongue deviation (Ecl20) assessable by GG contraction test as well, but the dramatic pharyngeal and intraoral consequences are upper airway patency loss (Ptd01), maxillary arch insufficiency (Ptd03) and swallowing disorder. Given the resulting functional limitation, tongue weakness is not confined to GG only but reasonably extend to hyoglossus (HG) and SG. Although GG contraction test may reliably assess genioglossus weakness, strength assessment on other extrinsic tongue muscles has to be otherwise performed.	click to enlarge click to enlarge
Ese09	Mandible: motor disorder	Mandibular left mastication pattern disorder (right is physiologic): lateral-retrusive jaw motion with maxillary canine distal guidance instead of the physiologic lateral-protrusive with maxillary canine mesial guidance; the evaluation is performed after orthodontic treatment because in the pre treatment teeth crowding kept from canine and incisors guidance employment, hence, from physiologic mastication.
Ese10	Facial expression: motor disorder	Due to permanent cheeks activity in smile wise expression (Ecl23) impacting on mood and, according to context, resulting in social uneasiness, moreover, permanent orbicularis activity encourages upper incisors internal inclination;

EVIDENCES: orthodontic treatment, outcome and follow up
Evidences emerging from the initial kinesiologic diagnostic evaluation demonstrated dental occlusion disorder involvement in part of the patient postural deviation, unfortunately no direct evidence of relationship with the unilateral lamented symptoms emerged, despite this lack of confirm the orthodontic treatment has been decided to be worth undertaking.
#	Phase	Images & details
Eot01	Therapy	Orthodontic treatment: 1 year appliance of maxillary planas removable plate with tracks, arch expansion of 5mm; 1 year appliance of mandibular planas removable plate with tracks, arch expansion of 1mm; 4 wisdom teeth extraction. click on each item to enlarge
Eot02	Outcome	Effects: Resolved: distocclusion, teeth crowding, maxillary arch insufficiency, wisdom teeth conflicts, incisor and canine guidance; Improved: deep byte; Unchanged: maxillary arch asymmetry; Worsen: palatal gums lesions. click on each item to enlarge
		Before/after:: click on each item to enlarge
Eot03	Subsided postural symptoms	Subsided symptoms per category: unilateral postural symptom improvement: none; symptoms wirth great improvement: Ecl03 (suddenly when wearing planas plate), Ecl05, Ecl06, Ecl08, Ecl12, Ecl14, Ecl19, Esy03, Esy04, Esy08; symptoms wirth small improvement: Ecl17, Ecl18 (persisted in phonation and respiration), Ecl22, Ecl23; other improvements: dorsal spine mobility, balance improvement in skiing, athletic tasks economy improvement (aerobic threshold power outlet).;
Eot04	Newly onset symptoms	Esy06, Esy07.
Eot05	Follow up	2 months after orthotic removal: Stable correction: right maxillary arch expansion, wisdom teeth conflicts; Regression to initial: teeth crowding, deep byte, distocclusion, incisor and canine guidance, left maxillary arch collapse; Regression to worse then initial: maxillary arch asymmetry; Regression cause: left maxillary arch collapse.
		Left maxillary arch collapse unilateral incisors crowding click to enlarge	Right maxillary arch stability canine diastema have been introduced by orthodontic treatment and witness right arch expansion stability click on each item to enlarge
Eot06	Restored symptoms	Ecl03, Ecl05, Ecl06, Ecl08, Ecl12, Ecl14, Ecl19, Esy03, Esy04, Esy08.
Eot07	Subsided symptoms	Esy07 (improved but not subsided).