Link to recording https://youtu.be/PA6TihXCaQU

Biomechanical Implications

• Leg Length Discrepancy (LLD):
  → Causes pelvic tilt and uneven weight distribution.
  → Increases stress on the lumbar spine, hip, and knee joints.
  
  

• Pelvic Tilt + Compensatory Trunk Lean:
  → Leads to asymmetric muscle activation (erector spinae, obliques).
  → Over time, it may cause back pain, hip joint degeneration, or scoliosis progression.
  
  

• Hallux Valgus (HAV) on Right Foot:
  → Alters weight transfer during gait.

Link to more via YouTube:

https://youtu.be/19ZVpyh5CyM

The posture shows a compensatory alignment strategy:

• • Forward trunk lean (from weak hip/knee extensors).

  • Head/neck extension (to maintain gaze).

  • Reliance on AFOs for lower-limb stability.

• This suggests challenges with antigravity extension control (hips/knees), requiring bracing and trunk compensations.

https://dzwick.substack.com/publish/post/170193936?r=56vjf&utm_campaign=post&utm_medium=web&showWelcomeOnShare=false

Poor posture can be described as a habit because it often develops over time through repeated behaviors and positions. Bodies naturally adapt to frequently adopted postures, whether consciously or unconsciously.

Wide stance in both front and rear views—conveying a stability‑seeking base often described in ASD.

Subtle pelvic asymmetry/weight shift suggests variable loading—common when balance confidence is low.

The hip hike on the right and torso turns to the left.

Contrapposto-like stance—but not intentional: it seems habitual or compensatory rather than posturally controlled.

Arms show tone imbalance—potentially linked to sensory seeking or avoidance behaviors seen in Autism.

Ankle/Foot - unstable bilaterally.  Subtalar Joint pronation on the left foot is more than on the right foot
https://substack.com/home/post/p-169070300

Clinical Considerations

• Pelvic obliquity may contribute to apparent or actual leg length discrepancy, affecting seated alignment.

• Lower extremity malalignment alters pressure distribution and compromises postural stability in the wheelchair.

• Foot and ankle stiffness, along with increased tone, necessitate the use of SAFOs and careful selection of supportive footwear.

• Postural asymmetry increases the risk of secondary complications, including scoliosis, skin breakdown, and hip subluxation.

• Externally rotated feet with foot and toe deformities require adjustments to footplate angle, depth, and width to optimize positioning.

• Prolonged sitting contributes to localized pressure (e.g., medial foot redness) and calls for pressure-relief strategies and frequent repositioning.

• https://substack.com/@dzwick/note/c-134429766

This sketch illustrates a young person with Autism standing in a casually asymmetrical pose. This highlights several important biomechanical and postural deviations through both contour and directional arrows. For more on this:

https://substack.com/@dzwick/note/c-132870528

Hips: Appears to be in external rotation and adduction.
Knees: Backward Bowing of the Knees:
The leg lines show a posterior curve at the knee joint, creating a slight “C” shape backward — a hallmark of genu recurvatum (knee hyperextension). This suggests that the tibia is displaced behind the vertical line of the femur, instead of aligning beneath it.
Locked Joint Appearance:
The knees are drawn as if snapped straight or beyond, lacking the soft flexion normally present in relaxed or balanced posture.
The overall form gives an impression of "locked knees" often seen in standing positions when muscular support is absent or when posture is compensatory.
Ankles/Feet: Feet are turned outward, pronated 

This drawing shows an individual sitting upright with a level pelvis, feet supported on a footrest, and a mid-thigh strap providing pelvic stability, promoting alignment, comfort, and safety. In contrast, the posture shown in the previous blog post depicts a slouched position with a forward-flexed trunk, unsupported feet, and knees splayed outward, highlighting the impact of inadequate support on sitting posture.

Many individuals with Down syndrome often do not reach the floor when seated on a conventional chair due to a combination of shorter leg length, lower muscle tone (hypotonia), and unique foot morphology, including shorter, wider feet with increased girth and higher fifth-toe height. These anatomical characteristics result in a mismatch between their body dimensions and standard chair design, which is typically based on average adult proportions. When feet dangle without support, it compromises pelvic stability and spinal alignment, leading to poor posture, increased fatigue, and potential discomfort or strain on the lower back and hips. Additionally, the lack of foot grounding reduces sensory input and proprioceptive feedback, which can affect balance and attentiveness, particularly in learning or therapeutic environments. Proper seating adaptations are essential to ensure comfort, support, and postural integrity.

Simple observation. Spinal and Trunk Alignment

1. Spine appears curved or laterally shifted, suggesting a collapsed trunk or mild scoliosis-like posture. The right shoulder is lower than the left, possibly indicating habitual leaning or weight shift.

2. Pelvis and Hips

The pelvis is elevated and posteriorly tilted (slouched back), with the sacrum bearing weight instead of the ischial tuberosities.

Asymmetrical leg positioning suggests that one hip (likely the right) is more abducted and externally rotated.

3. Legs and Feet

Legs are spread in an open, externally rotated position, sometimes known as a "lazy W" or windswept position.

Feet are not grounded symmetrically – left foot/ankle more pronated, right foot slightly pronated and plantar flexed

I was sitting in the waiting room of a medical office, trying to pass the time, when a woman—probably in her seventies—caught my attention. As she walked over to pour herself a cup of coffee, I noticed her from behind. She stood in a noticeably asymmetrical posture, her weight shifted predominantly onto her left leg. Her left shoulder drooped slightly lower than the right, and her left hip was distinctly elevated. The imbalance was hard to miss.

Even at a glance, it was clear she had developed an acquired leg length discrepancy—her left leg appeared shorter than the right. Without even thinking, I began to anticipate what she might do next. I predicted she would sit with her left leg crossed over the right, as compensation, and sure enough, she did. She remained in that position for the full 20 minutes I was there, seemingly unaware of how her body had adapted and settled into this pattern over time.

These sketches show an individual who is a wheelchair user with his trunk turning and flexing at the thoracolumbar region of the spine. Arrows highlight key issues in posture and alignment.

This sketch illustrates how rotation primarily occurs at the thoracic vertebrae and partly at the pelvis, as well as how body weight is distributed when a person sits on the floor and turns.

While waiting for a public bus in NYC, I observed a young individual moving back and forth near the bus stop. It made me reflect on the relationship between posture, habit, and possible neurodevelopmental patterns. Of course, no diagnosis can or should be made based on posture alone — but I find it interesting how certain postural habits may influence musculoskeletal alignment over time. I created a digital sketch to capture the moment.

This blog aims to highlight how any sketch tool used by a therapist can assist in identifying postural issues. The key is to observe the individual in both standing and sitting positions. While this image focuses on the side view in standing and includes the sitting position, the front view—though not shown here—is also important. These visual observations can offer valuable insights into a person’s posture and movement patterns, as the way someone stands and sits often reflects and influences how they walk.

Standing Posture of a young 17-year-old individual with Dx of ASD - This drawing helps me document some key issues during the evaluation.  The left leg bears most weight, and it has a bow shape of the tibia fib structure, plus Genu Varus, plus pronation at the ankle/foot complex, plus feet pointing out, which the individual innocently said: I have no idea how to turn them forward.

The consequence of staying in this posture is obvious.  What can we do?  Please don't hesitate to email me, and I'll try to post your answer anonymously. I will also write more about my approach...

More of the case for learning to draw as a PT and OT.

Drawing improves focus on observation.

A sketch of a young adult with a diagnosis of ASD who often stands with most weight bearing on his right leg.  Notice the left ASIS is turning clockwise, his left knee bends, left thigh is in internal rotation, and the left foot pronates severely.  The consequence of staying in this posture is obvious.  What can we do?  Please feel free to email me, and I will try to post your answer anonymously.

As physical and occupational therapists, we rely heavily on our powers of observation, communication, and clinical reasoning. But one often-overlooked skill that can elevate all of these areas is drawing. Whether you're working with individuals with Autism Spectrum Disorder, cerebral palsy, recovering stroke patients, or clients with orthopedic conditions, the ability to sketch what you see and imagine can become a powerful clinical tool.

https://lermagazine.com/article/clinical-perspective-posture-and-autism-sitting-standing-and-toe-walking-behavior Link below

https://youtu.be/QTc2zNo-CPY?si=UcIUs7geS9U5mvfq

Observing and drawing lines or box shape for the head, chest and pelvis, the three main body structures that form posture.  George Bridgman – an artist and an art teacher said: "In the drawing, one must look for or suspect that there is more than is casually seen." (Constructive Anatomy -George Bridgman)

By Dalia Zwick PT, PhD