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POSTURAL CORRECTION

What is good posture?

Many people have some idea about what perfect posture is. You probably associate it with
military posture. What most people cannot do, is precisely define why one posture is better
than another. Kritz & Cronin (2008) define perfect posture as follows:
“Optimal standing static posture is when the least amount of neuromuscular activity is required
to maintain body position in space and that which minimizes gravity stresses on the body. The
biomechanical rationale for achieving and maintaining optimal posture is to move efficiently, free
of impairment and dysfunction.”

Perfect posture?

Popular theory in physical therapy states that postural changes occur concurrently with an
imbalance of the associated musculature. Certain muscles get strengthened or weakened over
time, which leads to a different ratio in strength or flexibility of the agonist (the muscle
providing force during a movement) and the antagonist (the muscle opposing the force) muscles
acting over a joint. The agonist muscle group gets strong and tight while the antagonist muscle

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group gets weak and lengthened. Causality can run in both directions, but the common theory
is that strong or overactive muscles pull your posture in a certain direction, away from the
weak or lengthened muscles, and posture is thus the result of your muscular balance.

Upper and lower crossed syndrome

2 Of the most common postural profiles are upper and lower crossed syndrome.
 Lower crossed syndrome is anterior tilt of the pelvis and hyperlordosis in the lumbar
spine (‘belfie posture’). See the left image below.
 Upper crossed syndrome is forward head positioning and forward shoulder rounding.
See the right image below.

Short = strong; weak = long?

The common theory, as implied in the picture above, is that an overactive muscle is short, tight
and strong and an underactive muscle is long, flexible and weak. If you properly understood the
biomechanics you learned in this course about the muscle-tension relation and how muscles
produce force, you should already see that this theory is incorrect. In a shortened muscle the

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actin and myosin filaments generally overlap too much for optimal force production. Optimal
force production generally occurs when a muscle is lengthened, which is the exact opposite of
what common physical therapy claims. So there is no reason why a shortened muscle would
become stronger (poor posture for better bench press gains?) or a lengthened muscle would
become weaker.

There are several more problems with common physical therapy wisdom.

Tight = short?
We are intuitively inclined to conclude a muscle is short when we feel it is tight. However, the
sensation of tightness is just that: a feeling. What we experience as muscle tightness is often a
signal from your muscle (spindles) to your brain to contract a muscle or prevent it from further
stretching. It does not necessarily mean that a muscle is actually short. Consider the following
scenarios you’ve already seen when you generally feel tightness.
 DOMS often makes a muscle feel stiff and tight without any change in its length.
 Heavy eccentric exercise often makes a muscle feel tight while this actually provides a
stimulus to lengthen the muscle.
 Stretching reduces the sensation of muscle tightness without any change in its resting
length.

Many people also experience stiffness when they have a fever and sometimes stiffness can be
purely psychological. In short, you cannot conclude that a muscle is short because it feels stiff.

Postural assessment
The whole idea of looking at someone’s posture from the outside to infer their internal joint
position is questionable. For example, anterior pelvic tilt is commonly diagnosed by looking at
the position of someone’s pelvis from the side as illustrated below (no need to understand the
description fully if you’re not interested in it).

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Schematic diagram of the pelvis illustrating the ASIS-PSIS measure of pelvic tilt and the ischial spine-
pubic symphysis measure of tilt. The ASIS-PSIS measure is defined as the angle between the horizontal
and a line drawn between the ASIS and the PSIS. The ischial spine-pubic symphysis measure is defined
as the angle between the horizontal and a line drawn between the ischial spine and the pubic
symphysis.

Here’s another image to illustrate pelvic positioning. You can see anterior tilt is generally
accompanied with an arched lower back (lordosis); posterior pelvic tilt generally flattens the
spine (lumbar flexion).

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The problem with infering someone’s pelvic positioning from the outside is that you don’t know
what someone’s pelvis actually looks like from within. Variations in pelvic shape can make it
appear someone’s in anterior pelvic tilt when they’re actually not. See the example below for 2
pelvises positioned in their neutral position. The left one actually appears neutral; the right one
appears to be in anterior pelvic tilt due to its shape.

Pathology vs. variation

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Let’s take postural assessment a step further and say you have diagnosed that someone has a
true postural deviation like anterior pelvic tilt based on MRI. Common theory is that you
should correct this, because it’s a pathology.

A pathology, from Greek pathos "suffering" + logia "study", by definition requires symptoms like
pain or dysfunction. However, Herrington (2011) found that many people with anterior pelvic
tilt do not have any symptoms.

Bullock-Saxton (1993) found that women with lower back pain were no more likely than other
women to have anterior pelvic tilt.

Christensen & Hartvigsen (2008) performed a systematic review of cross-sectional studies

looking at low back pain and found no associations between the extent of lumbar lordosis or
even scoliosis and lower back pain.

Mitchell et al. (2008) found that low back pain was not associated with differences in regional
lumbar spine angles or range of motion; however, there was a relation between low back pain
and backward bending range of motion, suggesting that hypermobility in the spine is not
desirable.

A large cross-sectional study from Pope et al. (1985) found no correlation between height,
lumbar lordosis or leg length inequality and lower back pain.

Pregnancy can increase lordosis and anterior pelvic tilt in the third trimester, but this is not
correlated with low back pain.

Another systematic review of longitudinal studies found no relations between back, shoulder or
neck pain and muscle strength, balance, endurance or range of motion.

Not only are postural deviations not commonly associated with pain, they may be beneficial for
athletes.

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Watson (1993) found that athletes involved in running sports such as soccer and football show
marked anterior pelvic tilt (lordosis) compared to other sportsmen. He also studied the
posture of 11 soccer players over 3 years and found the lordosis of 8 of them to be significantly
increased with their participation in the sport. Anterior pelvic tilt may be biomechanically
beneficial for horizontal force production.

Upper-crossed syndrome also does not seem to be inherently associated with any adverse
physical effects. Many boxers and swimmers have forward rounded shoulders and kyphosis
(thoracic flexion) without any corresponding issues; in fact, this posture may be advantageous
to increase stroke rate in the water according to Bloomfield (1998).

It thus seems that the diagnosis of anterior pelvic tilt is often based on abnormality per se, not
the presence of any actual problems and sometimes even when the abnormality may be
advantageous. It is a sad state of affairs if we inherently equate ‘not normal’ with ‘bad’.

And is military posture really normal in the first place? In Herrington’s study, 85% of males and
75% of females had an average of 6-7°of anterior pelvic tilt. In the same study, 6% of males and
7% of females exhibited posterior pelvic tilt, while only 9% of males and 18% of females showed
a neutral hip position. And again, none of these individuals had any symptoms. Let’s emphasize
this: the majority of the asymptomatic population ‘suffered’ from anterior pelvic tilt. So we
can’t even say anterior pelvic tilt is abnormal in the first place.

And remember the course section about structural asymmetries: humans are not perfectly
symmetrical. Knutson (2005) found that 90% of people had a leg length inequality of 5.2 mm ( ±
4.1). A difference in how long both of your legs are is generally not a clinical concern unless the
difference is more than 2 cm (0.78").

It is time to abandon the textbook myth that all humans should have a certain structure and
posture. Nature is messy but beautifully so. The human motor cortex can achieve full
functionality with a wide range of structures and postures. Unless you actually have symptoms,

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there’s little reason to go looking for problems. Trying to fix what isn’t broken can do more
harm than good.

Postural behavior
Resting posture can vary significantly between individuals without any corresponding problems,
but what about active posture? The physical therapy wisdom is that prolonged sitting shortens
the hamstrings and hip flexors and deactivates the glutes, causing anterior pelvic tilt, lordosis
and back pain.

Yet Hartvigsen et al. (2000) found that sitting at work was no more associated with low back
pain than other postures, like standing, driving or bending. Several other review papers have
come to similar conclusions [1, 2, 3]

Another systematic review of prospective cohort studies from 2009 “found strong evidence
that leisure time sport or exercises, sitting, and prolonged standing/walking are not associated
with low back pain. Evidence for associations in leisure time activities (e.g., do-it-yourself home
repair, gardening), whole-body vibration, nursing tasks, heavy physical work, and working with
ones trunk in a bent and/or twisted position and low back pain was conflicting.”

We do know that simple overuse can cause back pain, but that’s a far cry from the theory that
your posture changes your body structure and causes pain or dysfunction.

Postural correction
Suppose you do have an actual problem, i.e. pain or dysfunction, and you associate this with a
postural abnormality. What should you do?

Let’s start with a more basic question: can you change your resting posture with exercise in the
first place? Yes, you can. Strengthening exercises over an 8 week program have been been
shown to decrease forward head and shoulder posture in swimmers compared to a control

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group. Falla et al. (2007) found that a neck strengthening group could over time maintain a
more upright posture during prolonged sitting than a control group. In this case study, a 28-
year-old man with excessive lordosis and severe lower back pain improved his anterior pelvic
tilt angle from 20 degrees to 14 degrees, increased range of motion of the lumbar spine and
decreased lower back pain. In another case study, a 37-year-old man with flat back (posterior
pelvic tilt) and lower back pain completed a similar 2-week strengthening protocol and
increased his anterior pelvic tilt angle, increased lumbar range of motion and decreased lower
back pain.

Stretching programs appear to be effective as well. A 2 week pectoral stretching program has
been found to decrease forward shoulder posture compared to a control group. Harman et al.
(2005) found that after a 10-week progressive pec stretching and shoulder retracting program
the experimental group had significantly less distance between their scapulae, i.e. their
shoulders were "pulled" back more during resting posture.

However, the effect of stretching may be short-lived. A study with 55 adults showed that a
hamstring stretching protocol led to an acute improvement of anterior pelvic tilt and greater
lumbar flexion, but Borman et al. (2011) found that a 4 week hamstring stretching program had
no effect on lumbar flexion range of motion and lumbar curvature, even though hamstring
muscle extensibility increased.

Importantly, the literature is all in individuals with significant postural abnormalities and weak
muscles. And none of these studies show that one type of exercise is more effective than
another. Nourbakhsh and Arab (2002) found that muscle endurance and weakness are
associated with low back pain and that structural factors such as the magnitude of the lumbar
lordosis, pelvic tilt, leg length discrepancy, and the length of abdominal, hamstring, and iliopsoas
muscles are not relevant, suggesting that exercise in itself is the key, not muscular balance.

One of the few studies of combined stretching and strength training came to a similar
conclusion: There was no significant corrective benefit of adding a stretching program to a
strength training program in women with severely abnormal shoulder posture. There was a

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trend for the combined therapy group to experience better outcomes, but the finding that even
in entirely untrained people with severe shoulder abnormalities stretching may not have any
added benefit to very moderate strength training makes the relevance of stretching highly
questionable for someone without clinical postural problems that engages in strength training
with full range of motion exercise.

In support of the primary importance of exercise, regardless of type, for back pain, one of the
most studied forms of pain that is commonly thought to be associated with posture, most
studies of exercise, regardless of type, have noted an overall reduction in back pain intensity,
ranging from 10% to 50% after exercise treatment. Another review likewise concluded: “There
is strong evidence stabilisation exercises are not more effective than any other form of active
exercise in the long term.” The literature about neck pain comes to similar conclusions.

Since the relation between muscle strength, flexibility and endurance and pain are all weak and
many types of exercise seem to be effective with little difference in how effective various
exercise forms are, functionality does not seem to be the primary mechanism of action of why
exercise reduces pain and injury risk. Rather, it may simply be that increased blood flow and
tissue turnover are good for tissue maintenance. There is no evidence that exercise specifically
targeting muscular balance is any more effective to either improve posture or decrease
symptoms than a general full-body strength training protocol. And there is a complete lack of
evidence that a strength trainee can further improve his or her posture with specific exercises.

Take-home messages
 There is no such thing as a universally perfect posture. Humans vary significantly in
structure and many different types of posture are normal.
 You cannot accurately diagnose a postural abnormality from the outside.
 Worry first and foremost about your symptoms, namely pain and functionality. Don’t go
looking for problems or try to fix what isn’t broken.

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 Neither resting nor active posture are inherently associated with any adverse physical
symptoms.
 In so far as you need to change your posture with exercise at all, the type of exercise
may not matter. So when you’re already training your full body with full range of motion
strength exercises, it is highly questionable you can meaningfully change your resting
posture or body structure by targeting your muscular balance.

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