Why observation matters (and what it can and cannot tell you)
Observation is your fastest, least provocative screening tool. It helps you identify (a) likely priority regions for movement testing, (b) protective behaviors that may bias your exam, and (c) visible signs that warrant caution before you ask the person to move. Observation does not diagnose a specific tissue injury by itself; instead, it provides a structured snapshot of alignment, symmetry, and behavior that guides your next steps.
Use a consistent routine so you do not “chase” whatever stands out first. The goal is to compare what you see to the person’s own baseline and to functional expectations, not to an ideal posture.
Set-up: how to observe without provoking symptoms
- Environment: adequate lighting; enough space to view front, side, and back.
- Exposure: as appropriate and consented; at minimum, you need to see head/neck, shoulders/scapulae, thorax, lumbar region, pelvis, and lower limb alignment cues.
- Instructions: “Stand/sit comfortably as you normally would. Don’t try to correct anything.”
- Views: anterior, lateral, posterior. If time is limited, prioritize lateral (curves) plus posterior (scapula/pelvis).
Step-by-step observation routine (standing)
1) Global alignment scan
Work top-to-bottom, then confirm from the side view. Use simple landmarks and relative comparisons rather than precise angles.
- Head position: note forward head, chin poke, head tilt/rotation. Why it matters: may indicate cervical loading strategy or protective positioning; can influence shoulder girdle mechanics and symptom provocation during neck/arm testing.
- Shoulder height and clavicular line: compare left vs right; note elevated or depressed shoulder, protraction/retraction bias. Why it matters: can reflect guarding, scapular dyskinesis, or compensations for thoracic stiffness.
- Thoracic kyphosis: observe excessive kyphosis, flattened thoracic curve, or focal “hinge” areas. Why it matters: thoracic shape affects rib mechanics, breathing strategy, and cervical/lumbar load distribution.
- Lumbar lordosis: observe increased lordosis, flattened lumbar curve, or a segmental hinge. Why it matters: may suggest extension- or flexion-biased resting strategy and helps you choose which movements to test first (and how gently).
- Pelvic tilt: anterior tilt (increased lordosis), posterior tilt (flattened lumbar), or neutral. Why it matters: pelvic position influences apparent lumbar posture and can be a clue to hip vs lumbar contribution to symptoms.
Quick lateral “plumb line” check (visual): ear over shoulder, shoulder over greater trochanter, trochanter over knee/ankle. You are not measuring; you are noticing large deviations and where the body “stacks” or avoids stacking.
2) Movement guarding and pain behaviors
Before you ask for any test movement, watch how the person transitions and stands.
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- Guarded transitions: slow sit-to-stand, using hands on thighs, bracing abdomen, holding breath, “log roll” style turning while standing. Why it matters: indicates symptom sensitivity and informs how gradually you should progress movement testing.
- Antalgic posture: trunk shift, leaning away from one side, flexed or side-bent resting posture, avoiding head rotation. Why it matters: suggests a high-irritability presentation; prioritize gentle, low-load screens and consider deferring end-range testing.
- Facial cues and self-touch: grimacing, rubbing a region, frequent repositioning. Why it matters: helps you identify the person’s perceived threat area and likely pain drivers during movement.
3) Asymmetry clues
Asymmetry is a clue, not automatically a problem. Look for patterns that are consistent across views and that match the person’s symptoms.
- Scapular positioning: winging, downward rotation, excessive protraction, one scapula more elevated or more medial border prominence. Why it matters: may signal altered scapulothoracic control, thoracic stiffness, or protective shoulder girdle bracing that can influence cervical and thoracic testing.
- Rib flare: lower ribs prominent anteriorly, asymmetrical flare, or wide subcostal angle with visible upper-chest dominance. Why it matters: can be associated with thoracic extension bias, reduced rib excursion, or breath-holding strategies that increase thoracolumbar tone.
- Pelvic obliquity: one iliac crest higher, apparent leg length difference, weight shift to one leg, asymmetric gluteal fold height. Why it matters: can bias lumbar side-bending/rotation and may indicate a compensation strategy that should be considered when interpreting movement tests.
4) Skin and soft tissue signs relevant to screening
These findings can change your risk assessment and how you proceed with movement testing.
- Bruising after trauma: especially extensive bruising, expanding ecchymosis, or bruising with swelling. Why it matters: suggests significant tissue injury; avoid aggressive movement testing and consider urgent medical evaluation depending on context and severity.
- Swelling: localized swelling over a spinous process, paraspinals, or around the neck/shoulder girdle. Why it matters: may indicate acute inflammation, hematoma, or other pathology; proceed gently and avoid compressive or end-range maneuvers.
- Surgical scars: location, adherence, redness, drainage, or signs of infection. Why it matters: informs tissue tolerance, potential movement restrictions, and whether the area is appropriate to test today.
- Skin changes: redness, rash, abnormal warmth, or visible deformity. Why it matters: may indicate inflammatory or infectious processes; treat as a caution sign and correlate with symptoms.
5) Breathing pattern observation (and relevance to thoracic stiffness)
Breathing is a continuous “movement test” of the thorax. You can observe it without provoking pain.
- Where does the breath go? upper chest lift vs lower rib expansion vs abdominal excursion. Why it matters: upper-chest dominant breathing can coincide with increased accessory muscle use (scalenes/upper traps) and may amplify cervical tension; limited lower rib expansion can suggest thoracic stiffness or bracing.
- Rib motion symmetry: compare left vs right lower rib excursion during quiet breathing. Why it matters: asymmetry may point to thoracic rotation bias, rib mobility restrictions, or protective guarding.
- Breath holding and sighing: frequent breath holds during transitions, shallow rapid breaths, or repeated sighs. Why it matters: may reflect pain-related bracing; it can increase trunk stiffness and alter movement quality during spinal testing.
Practical tip: observe 3–5 quiet breaths in standing, then again in sitting. A change between positions can hint at postural bracing strategies or thoracic mobility limitations.
Step-by-step observation routine (seated)
Seated observation reduces lower-limb and balance demands and can reveal different compensations.
1) Global alignment scan (seated)
- Head/neck: forward head, head tilt, resting rotation. Note whether the person “stacks” head over trunk or braces with chin jut.
- Shoulders/scapulae: shoulder height, protraction, scapular winging more visible from behind.
- Thoracic curve: slumped vs over-extended sitting; look for a single hinge point.
- Pelvic position: posterior pelvic tilt (slumped) vs anterior tilt (arched). Why it matters: pelvic position strongly drives lumbar posture in sitting and can explain why symptoms differ between sitting and standing.
2) Guarding and pain behaviors (seated)
- Frequent repositioning: shifting weight, leaning on armrest, sitting on one buttock.
- Hand support: supporting head with hand, bracing on chair to unload spine.
- Reluctance to rotate: turning whole trunk instead of head/neck, or moving eyes first then avoiding head movement.
3) Asymmetry clues (seated)
- Scapular asymmetry: one scapula more abducted/winged; note if it changes when the person relaxes arms by their sides.
- Rib flare and thoracic rotation bias: one side of rib cage more prominent; trunk rotated relative to pelvis.
- Pelvic obliquity in sitting: one ASIS higher, weight shift to one ischial tuberosity, knees not level (if feet are flat).
4) Skin/soft tissue (seated)
Seated can improve visibility of posterior scars, bruising, or swelling around the cervicothoracic junction and scapular region.
5) Breathing (seated)
Seated often increases slumping and can reduce rib excursion. If breathing becomes more apical in sitting, consider thoracic stiffness, postural bracing, or symptom-related guarding as factors that may influence thoracic rotation/extension testing.
Simple decision points: using observation to prioritize movement testing (and to choose caution)
Observation suggests priority areas for movement testing when you see:
- Forward head + elevated shoulders + apical breathing: prioritize cervical AROM quality, cervicothoracic junction mobility screens, and scapular control checks (low-load first).
- Excess thoracic kyphosis or a visible thoracic hinge: prioritize thoracic extension/rotation movement testing and rib excursion assessment; expect compensations in cervical and lumbar regions.
- Flattened lumbar posture in sitting with posterior pelvic tilt: prioritize lumbar flexion/extension tolerance and hip contribution screens; consider symptom behavior with sustained sitting.
- Pelvic obliquity or consistent weight shift: prioritize lumbar side-bending/rotation quality and observe whether hip strategy dominates during trunk movements.
- Scapular winging/asymmetry: prioritize scapulothoracic observation during arm elevation and thoracic rotation screens (gentle, symptom-guided).
Observation suggests caution (slow down, modify, or defer provocative testing) when you see:
- Significant deformity after trauma: visible step-off, marked postural collapse, or new severe curvature/shift. Treat as high concern; avoid end-range testing.
- Severe antalgic posture: rigid trunk shift, inability to find a comfortable position, or extreme guarding with minimal movement. Use minimal, low-load screens and consider medical referral pathways based on overall presentation.
- Extensive bruising/swelling: especially if worsening or associated with marked tenderness and functional loss.
- Concerning scar appearance: redness, warmth, drainage, or signs of infection around surgical sites.
Practical examples: turning observations into next-step choices
| What you observe | What it may mean for testing today | How to adjust |
|---|---|---|
| Head held slightly rotated and patient turns whole body to look | Neck rotation may be sensitive; guarding likely | Start with small-range cervical AROM, monitor pain response, avoid sustained end-range early |
| Marked thoracic kyphosis with rib flare and shallow upper-chest breathing | Thoracic stiffness/bracing may bias cervical/lumbar motion | Include thoracic rotation/extension screens early; cue relaxed breathing during movement |
| Pelvis shifted left in standing with right shoulder slightly elevated | Asymmetric loading; lumbar side-bending/rotation bias possible | Compare movement quality left vs right; interpret asymmetries in context of habitual stance |
| Slow sit-to-stand using hands, breath holding | High irritability or fear of movement | Use graded exposure: smaller ranges, more support, frequent check-ins on baseline pain |
| Fresh bruising over thoracolumbar area after fall | Potential significant injury | Defer provocative testing; prioritize safety and appropriate referral if indicated |
Documentation templates (copy/paste)
Use short, objective phrases. Document what you see, not what you assume.
Observed posture
Position observed: Standing / Seated (circle) Views: Anterior / Lateral / Posterior (circle) Footwear: On / Off (circle) Assistive device: None / ________ Time observed: ________ Pain at rest: ____/10 Location: ____________ Behavior: calm / guarded / distressed (circle) Head/neck: neutral / forward head / tilt L/R / rotation L/R Shoulders: level / R elevated / L elevated / protracted / retracted Thoracic curve: WNL / increased kyphosis / flattened / focal hinge at ________ Lumbar curve: WNL / increased lordosis / flattened / focal hinge at ________ Pelvis: neutral / anterior tilt / posterior tilt Weight bearing: even / shifted to L / shifted to RSymmetry
Scapulae: symmetric / winging L/R / protraction L/R / elevation L/R Rib cage: symmetric / rib flare L/R / trunk rotation bias L/R Pelvis: level / pelvic obliquity (L high / R high) Trunk shift: none / L / R Notes: ____________________________________________Guarding
Transitions: sit-to-stand WNL / slow / uses hands / avoids trunk flexion / avoids rotation Pain behaviors: grimace / breath holding / bracing / frequent repositioning / self-touching area Antalgic posture: none / flexed / side-bent L/R / shifted L/R Tolerance to observation position: standing ____ min, sitting ____ min Notes: ____________________________________________Baseline pain before testing
Baseline pain (0–10): ____/10 Primary location: ____________ Secondary location: ____________ Quality: ache / sharp / burning / tightness / other: ________ Irritability right now: low / moderate / high (circle) Aggravating posture observed: standing / sitting / both / neither Easing posture observed: standing / sitting / both / neither Patient-stated goal for today’s testing: __________________________
