Posture and Pain: Cause and Effect?

In this age of social media and Google, we get a lot of information where some are helpful and some are harmful, and some just plain ridiculous. This is even truer in the area of science, fitness, nutrition and related fields. Search for back pain or neck pain and you will see loads of misinformation regarding “poor” posture and its relation to back and neck pain. And these may all seem and sound legit and right on point since most of this information come from supposed health professionals like doctors, physical therapists, chiropractors, osteopaths, personal trainers and well, so-called wellness gurus. But what does recent studies and more importantly recent research say about this? We who practice a more evidence based protocol to pain science and muskuloskeletal rehabilitation have been spending time debunking this myth and educating the masses. While we see a lot of misinformation citing posture as major cause of not only back and neck pain but also hip and shoulder pains, [and heck, you come with heel pain and they assess your posture]… but there are also a number of articles counteracting these claims based on recent evidences. We just have to know what research say and where to look.

First what is good or proper posture?

My physical therapy textbook in orthopedic assessment describes “ideal” posture if viewed from the side as:

“a straight line [which is the line of gravity] that passes through the earlobe, the bodies of the cervical vertebrae, the tip of the shoulder, midway through the thorax, through the vertebral bodies of the lumbar spine, slightly posterior [behind] the hip joint, slightly anterior [front] to the axis of the knee joint, and slight anterior to the lateral malleolus of the ankle joint.”

So it kind of looks like this…

postural assessment

But is there really such thing as ideal, proper or perfect posture? Aesthetically, yes I may agree so. People wouldn’t want to present themselves with awkward posture. We would want to present ourselves as standing tall, ensuring confidence. But biomechanically, that’s a no. Why?

Perfect posture doesn’t exist… 

Well surprise, surprise – POSTURE like everything else is VARIABLE.

Let’s take a look at this study: Variations during repeated standing phases of asymptomatic subjects and low back pain patients.

This study asked both asymptomatic (353) and LBP patients (83) to repetitively stand 6 times, they found that there was mostly loads of variation between the lumbar curve and position of the sacrum each time they stood.

Study says:

“It can be concluded that standing is highly individual and poorly reproducible. The reproducibility was independent of age, gender, body height and weight. LBP patients and athletes showed a similar variability as the asymptomatic cohort

In the standing position, all investigated cohorts displayed a large inter-subject variability in sacrum orientation (∼40°) and lumbar lordosis (∼53°).

In the asymptomatic cohort (non-athletes), 51% of the subjects showed variations in lumbar lordosis of 10–20% in six repeated standing phases.

29% showed variations of even more than 20%. In the sacrum orientation, 53% of all asymptomatic subjects revealed variations of >20% and 31% of even more than 30%”

This first paragraph alone speaks volumes when it says, ‘An irreproducible standing posture can lead to misinterpretation of radiological measurements, wrong diagnoses and possibly unnecessary treatment.

What does this all mean? 

It means, posture assessments don’t tell much nor do they tell an accurate story about the patient or client.

More evidence indicate that patients with low back pain [or neck pain] and those with no pain have a varied degrees of movement and spinal position in the spine, even when the same subject is evaluated several times.

In other words, if you take one person and do six posture assessments in the same day, you are likely to get six different results. Now multiply that 353 people who are asymptomatic, and 83 people with low back pain, like in this study.

The body is resilient and has many different ways it can adapt. Think dynamic systems theory model. Preaching there is an ideal posture is being dogmatic and quite frankly could create fear of certain movements in certain patients.

We see people with back or neck or shoulder pain with slouched or crooked posture [whatever that means] and we assume right away that it’s the posture causing the aches and pains. But most likely it’s the opposite. The slouching and postural change can be compensatory mechanism for the pain experience.

In short, Correlation does not always imply causation.


posture apes

But my neck hurts whenever I am stuck working on my computer or reading a book for a long period of time! Yes that happens to me, and I have a pretty “good” posture when not slouched facing a book or tablet or phone or computer. Well I think we can suggest that certain actions can be associated with pain. We could simply call them aggravating positions or factors. Same maybe true of sitting at a computer but we can’t suggest it’s someone’s posture but the time spent in a certain position. Also it’s probably got to do with not moving rather than the posture being bad. It could be another posture [position] that could cause the same problem if held for a significant length of time. Even staying in an erect, supposedly ideal position held in a certain period of time can cause the muscles to tense up. Ever experienced standing for a long period of time that our legs starts to ache. You aim for a chair or just sit on the floor. It’s what our body is meant to do. Move.

As my Chilean friend, colleague and a Physio professor have said, ” The postural variability, if we can call it, probably allows better and flexible adaptive responses to unexpected demands. And also allows to distribute load on wider surfaces or in different tissues and structures, reducing risks of tissue over demand”

In short, it’s the amount of time spent in a certain position for a prolonged period of time and the lack of movement and posture variability that’s causing muscles to becomes tensed and the nervous system to be sensitized. It’s a bit more complex than that but that’s a good starting point.

What do we do then?

First off, pain is complex and there is no clear cut, one size fits all, strategy to avoid or manage pain. Many factors come into play in the pain experience – biomechanics, psychosocial and the nervous system’s rule, patient’s previous experience of pain, patient’s belief system to name but a few. Even negative information one gets from the internet or from a clinician can reinforce or add up to the pain experience.

In biomechanics, any positive results you might have had changing one’s or your posture can be because of offloading overly stressed tissues that could be causing pain. You’re bent on your computer, your neck or back muscles start to get tensed, you straighten yourself up, and alas, you feel better! So it must be your posture! Not so fast!

That is why I always preach movement! A good physiotherapist educate their patients on the importance of moving often. I prescribe movement. Movement matters because we are movement beings!

Your best posture is your next posture!

So next time someones says they are going to assess your posture you should ask, “which one?”

Hope you learned something interesting and enlightening from this article.

Much of the contents of this blog is from a recent discussion from among my colleagues as the research material cited in this article was posted and shared among us on facebook, especially from my British colleague Ben Cormack who first posted the study on his timeline and attracted some good and interesting comments from our peers [including me].



Here is an interesting read on one’s experience on being told that her posture is bad and her body broken.. until she knew any better: BS about posture causes pain and suffering.

You can see more articles on topics on pain science, movement and exercises, and a whole lot more on my facebook page: Dynamics Physical Therapy and Performance

For recent research on different topics in physical therapy like effectiveness of certain assessment or treatment, like my page: Evidence Informed Physical Therapy