… But, mostly irrelevant.

One quick Google search and you will learn that posture causes low back pain, neck pain, shoulder pain, headaches, and cardiovascular disease… Amongst many, many other pathologies.

Before we determine the impact of posture on painful conditions, we first need to define what “bad posture” is considered and that starts with the lower and upper crossed syndromes proposed by Dr. Vladimir Janda.

In these models, certain muscles are determined to be “over-active” and “tight”, whereas other muscles are found to be “over-lengthened” and “weak”. These muscular characteristics are then extrapolated to contribute to an individual’s posture, which is then extrapolated to their painful condition.

Seems like a bit of a leap, no? But, before we disregard a long-standing therapeutic approach, we should understand if there is support in the literature…

Based on a study conducted by Bae and colleagues the performance of middle and upper trapezius strengthening combined with stretching of the levator scapulae and upper trapezius was more beneficial than doing nothing at all when treating neck pain. However, this study evaluated improvements in neck pain by a measuring change in localized body temperature. So, doing something is better than doing nothing when trying to raise body temperature, and apparently changes in body temperature mean a change in pain. Interesting conclusions that the authors drew from this one.

Lets try again…

Unfortunately, I cannot find much in support of utilizing Janda’s Upper/Lower Crossed Syndromes in the treatment of painful conditions. But, lets see what happens when we break down the component parts…

Heino and colleague attempted to find a relationship between hip extension range of motion (hip flexor “tightness”) and standing pelvic tilt, standing lumbar lordosis, and abdominal muscle performance. This study of 25 healthy volunteers found no relationship between hip flexor “tightness” and factors related to the posture of the lumbopelvic complex (pelvic tilt).

To further question this approach, Walker et al. once again set out to determine the relationships between measurements of lumbar lordosis, pelvic tilt, and abdominal muscle performance during normal standing. Similar to the study performed by Heino and colleagues, the researchers found no correlation between these factors. Both of these studies were performed in the late 1980s and early 1990s, so surely we have found something to support this theory in the past 30 years, right?

Recently, in 2015, Mills and colleagues once again attempted to find a correlation between hip extension range of motion and measures supportive of the lower crossed syndrome. This study did find a statistically significant decrease in gluteus maximus activation with pelvic tilt. However, both groups achieved the same levels of torque during hip extension with no associated increase in the hamstring activation in the “tight hip flexor” group. This means that, potentially, the demands of the task were met prior to the need for significant activation of the gluteus maximus musculature in the “tight” group.

Sam’s note – Additionally, Van Gelder et al. demonstrated similar findings that challenge the notion of glute max inhibition. Check out this great write up from Greg Lehman on this topic. Similar to the above paper, it is likely that the glute max was not inhibited, just not required for those thresholds of demand and there are other muscles being utilized such as the adductor magnus (which isn’t measured in these papers as it doesn’t fit the narrative people want).

So, if these biomechanically plausible factors do not seem to correlate with posture, what does?

Based on a large, cross-sectional study of over 1,100 teenagers, psychosocial factors may play an important role in development of “postural deviations” (Richards et al., 2016). This study used a 2-dimensional photographic postural assessment in a seated position to cluster subjects into 4 distinct subgroups, which included “upright”, “intermediate”, “slumped thorax/forward head”, and “erect thorax/forward head”. After data analysis, those subjects in the “slumped thorax/forward head” were at higher odds of mild, moderate, and severe depression. Additionally, those in the “upright posture” group exercised more consistently.

To build upon this, Prins and colleagues performed a systematic review investigating the influence of psychosocial and posture as contributors to development of musculoskeletal pain. Once again the most common factors to influence the development of pain to be depression, stress, and psychosomatic symptoms. Whereas, they could not identify specific postures as pain contributors, but they did identify an association between the duration of static sitting and pain.

Before we completely disregard the postural model, lets assume for a second that these models did contribute to static posture… Would altered posture actually impact the prevalence or severity of painful conditions?

The available literature is less than supportive of a direct correlation between posture and the presence of pain. A systematic review performed in 2008, which included 54 studies, found no correlation between kyphosis/lordosis and low back pain, reduced cervical lordosis and neck pain, neck pain and postural deviation, or low back pain and posture (Christensen and Hartvigsen, 2008).

Since this time, several additional studies have been performed and have found similar results. Of the available literature, and take into consideration that these are all systematic reviews, the following was found…

  1. There was strong evidence from six high-quality studies that there was no association between awkward occupational postures and low back pain (Roffey et al., 2010).
  2. No dose-response relationship for work posture exposures and low back pain or frequency of trunk flexion as a risk factor for low back pain (Ribeiro et al., 2012).
  3. Thoracic kyphosis is not be an important contributor to the development of shoulder pain (Barrett at al., 2016).
  4. Posture does not correlate with neck pain or headache symptoms in 1,100 teenagers… Sorry “Text neck” fans (Richards et al., 2016).
  5. No association between neck pain and poor posture while texting (Damasceno et al., 2018). So, about that “Text neck”…

If posture is not the prevailing cause of painful conditions, what is actually important in the management of these patients?

Once again, looking at a systematic review of the available literature, Lin and colleagues tried to identify best practice in the treatment of musculoskeletal pain. After appraising 44 clinical practice guidelines, they determined that the following 11 recommendations were consistent in the literature:

  1. Ensure care is patient centered
  2. Screen for red flag conditions
  3. Assess psychosocial factors
  4. Use imaging selectively
  5. Undertake a physical examination
  6. Monitor patient progress
  7. Provide education/information
  8. Address physical activity/exercise
  9. Use manual therapy only as an adjunct to other treatments
  10. Offer high-quality non-surgical care prior to surgery and try to keep patients at work.

So, in the end, what matters in the management of pain?

Based on the available literature and biological plausibility, postural assessment and interventions do not even come close to the top ten. What we do need to worry about is educating our patients that (in the absence of significant red flags) their body is resilient and adaptable, that we will develop and that we frequently ensure progress towards mutual goals related to recovery, psychosocial factors, and physical factors. A human being’s posture is not akin to the alignment of an automobile and should never be seen as such. Focus on the thing that matter and help to move us beyond the implausible postural models of care.

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This article was originally written for Sam Spinelli,DPT at TheStrengthTherapist.com who also created the summarizing infographics at the bottom of the page.

Interested in learning how to simplify the evaluation and management of hip pain?


  1. I enjoy reading your thoughts on many subjects and this is no exception. However, I have to disagree in part:

    While I agree that psychosocial factors are important, and also that physical activity and exercise can modify these factors, I can’t agree that posture has no effect on painful conditions.

    We know that every passive tissue has a strain or yield point, and we know that moment arms can be modified by joint alignment, orientation, and tissue length and tension. We also know, mechanically, that posture while lifting (or working) both modulates passive tissue load and muscle activation. Biomechanical changes in tissue loads have been measured directly, and muscle activation has been measured directly with intramuscular EMG during different tasks. It simply does not make sense that posture has no effect.

    I would agree, however, that in many cases the demands of the experimental task are met without the need for serious activation of gluteal muscles for instance. In these cases I am of the opinion that a better, more strenuous task is needed for elucidation postural effects. For example, I have seen my colleagues’ longitudinal data of surface EMG measurements and 3D motion capture of athletes under load during sprinting. This is an activity that requires full ROM and a high amount of force to be applied. There is definitely a measurable change in relative EMG activity of the glutes vs. hamstrings and adductors in athletes with “tight hips” before and after specific intervention.

    Keep up the good work.


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