The ways that we sit and stand and walk are among the strongest of all habits. Changing posture may be as hard as quitting smoking or potato chips. So it had better be worth the effort! After working as a personal trainer and sport massage therapist for many years, I became very confident that poor posture is a “real” thing, a genuine source of partially preventable physical stress and therefore probably a factor in chronic pain, mostly later in life. But it’s not a straightforward business, this posture stuff. There aren’t many “easy wins” for people here. And there’s plenty of potential to waste time and money — or even get hurt. Delving deeper into the topic — much deeper than I ever did as a sport massage therapist, studying the scientific literature and learning more from countless readers and experts — I have developed many reasonable doubts about posture’s importance and the value of trying to change it. I have come to believe that many healthcare professionals pathologize posture, exaggerating its importance to justify costly therapy (all with good intentions, of course).
This doorstopper of an article thoroughly explores strategies for postural improvement that may be helpful, but I also explain why the idea of “poor posture” is mostly much ado about nothing — a problem in theory, but only a minor one in practice. If your main issue is stubborn aches and pains, there are probably much better ways to spend your time than trying to improve your posture.
What is posture?
If you start to tip over, or lose the stability you need for a task, postural reflexes kick in and engage muscles to pull you into a more or less upright and/or functional position again. The biological systems and tricks that keep us upright are nifty, and surprisingly poorly understood. Posture is the embodiment of your comfort zone. At worst, it can be like a cage. The challenges and rewards of trying to change posture are not just musculoskeletal: it can be a profound personal process. Patterns and behaviours that lead to trouble are usually strong.5 This article does not get too “deep” and mostly sticks to the musculoskeletal issues and the relationship between posture and pain, but the psychology of posture also matters. Basically just slouching. Head and shoulders forward, mostly, but UCS comes with some complicated assumptions about its causes and consequences, like your muscles dysfunctional ship’s rigging: some are weak and loose (“inhibited”), while others are too strong and tight (“facilitated”). Viewed from the side, you can draw diagonal lines between these groups that cross. (There’s a Lower-Crossed Syndrome as well, but it’s much less famous.) Dr. Janda was a pioneer. He did good work with the information he had at the time. But he was probably mostly wrong about UCS,6 and the rest of the article substantiates this in many ways. But here’s one quick, fresh, solid example… A good quality 2021 study of hundreds of young folks showed that they actually got less neck pain over five years if they had a classic UCS posture.7 Less! It was good for them. Conversely, an erect posture was linked to more neck pain. The difference wasn’t huge, but it was a difference in exactly the wrong direction for validating Dr. Janda’s idea. The “crosses” of the upper & lower crossed syndromes. Muscle imbalance ideas like UCS have not done well over the last couple decades. Jason Silvernail, Doctor of Physical Therapy, comments: “There is almost no data to support these ideas and to my knowledge there never has been.” Inhibition and facilitation sound technical and specific, but they aren’t: they are pseudo-jargon, words for things that are actually poorly understood and defined. Research has relentlessly shown that professionals have trouble agreeing on muscle balance. The “tightness” of muscles doesn’t seem to have much to do with their strength, or with pain, or really anything that anyone can actually work with. If certain muscles were actually weak in everyone exhibiting a certain posture, and those people tended to have certain problems, then it would make sense to try to strengthen those muscles specifically. But they aren’t, and they don’t, so it doesn’t. Treating people as if they have UCS — with targeted stretching, strengthening, and massage, say — doesn’t work any better than generally getting more exercise. Nor is any of this surprising given where the science has gone. It has become clear that the “behaviour” and condition of individual muscles is mostly trivial compared to the potent role of the central nervous system as the dictator of almost everything about both function and sensation. In short, it’s not messy muscle function that makes people slump and hurt — it’s a brain thing, and UCS is an effect instead of a cause. Or UCS is just a clinical fantasy: it’s most likely that there just isn’t a UCS pattern at all, no “cross” of weak/tight muscles. A bogus narrative. There is just a common posture, plus the panoply of human aches and pains that come and go like aurora borealis, most of which still cannot be specifically explained and probably never will be. The fundamental problems of troubleshooting chronic pain is that there are so many possible causes and chronic pain isn’t a reliable, informative signal. UCS is just a good story Dr. Janda told in the absence of good data. It seemed like a good idea at the time, but it has become quite obsolete. So why is this vision of poor posture still so popular? Jason Silvernail again: “It’s accessible to a wide variety of practitioners. Since it involves muscular assessment, everyone from physicians to personal trainers to physical therapists, chiropractors, athletic trainers, massage therapists and strength coaches could use this approach with their patients or clients. Both clinicians (physicians, physical therapists, chiropractors, athletic trainers) and fitness and service professionals (personal trainers, strength coaches, massage therapists). Those with rigorous academic education at doctoral or postgraduate level (physicians, physical therapists), those with college education (athletic trainers, strength coaches, some trainers) and those with trade school or certification training (personal trainers, massage therapists). Huge numbers of different people in different fields could use this. A marketing dream. It provides a simple solution to a complex problem that leverages deeply embedded cultural ideas that are far more powerful than scientific data. “That’s why these crossed syndrome type things make no sense whatsoever but are not going away any time soon. People will be talking about this brilliant insight for another 50-odd years. I wonder if Janda would [facepalm] if he heard how people were unable to move beyond this idea, and had more fidelity to this particular product/idea than to the process he advocated.” This is what skeptics mean when they say that there is no such thing as bad posture — and I completely agree with the spirit of that position. But there is also more to “poor posture” than UCS. Or perhaps I should say there’s less to it … My definition of poor posture is simple (but took me many tries to settle on): A postural challenge is anything that makes it harder to maintain a comfortable posture, such as “work.” A major source of postural challenges in all our lives is awkward tool use, also known as crappy ergonomics.Sitting for hours with your knees tucked sharply under your chair is a good basic example of a poor posture. No one has to sit like that. The chair isn’t forcing it. It’s an entirely optional arrangement of limbs. And yet it is an actual hazard to kneecaps8 — a completely avoidable hazard, which most people fail to avoid because they just don’t know how knees work.If anyone ever tells you there’s no such thing as poor posture — a popular skeptical perspective — that example is a fine rebuttal. And there are certainly others.9 How much poor posture actually matters on average — not very much, probably — but for sure there is such a thing. What about postural laziness? According to the Puritans, the majority of people genuinely think of slouching when they think of poor posture. Postural fitness declines with time as a result of avoiding postural challenges. In other words, if you avoid postural issues frequently enough, you eventually won’t be able to handle them when you do. we have returned to the original definition. Other than “laziness,” why would anyone respond ineffectively to life’s postural challenges? Weakness, mood, pain, hang-ups, fatigue, fear, stress, and more.Sometimes an effective response to a postural challenge is almost impossible, and that really gets you off the poor posture hook. Many seemingly poor postures are actually just compromises, adaptations to unavoidable stresses. Posture zealots forget this. If the cause of a posture is baked into your anatomy, trying to change it is going to hurt more than help, or it will just be futile. If your posture is caused by adaptation to a shortened leg bone dating back to a motorcycle accident twenty years ago, you aren’t going to have much success changing your posture. The context of posture is important! As often as not, what seems like a poor posture is just a functional adaptation, and sneering at it is ridiculous.For instance, an old man may walk stooped over because he has spinal stenosis and it really hurts to stand up straight. There’s nothing lazy about his stooping. The stooping is creating postural stress, but it’s the lesser of two evils, and it’s the same postural compromise that everyone with painful stenosis chooses. But for a young man, presumably without stenotic back pain, the same posture would be really strange: an unnecessary stress, certainly “poor” and worth fixing, if possible.Of course, for the most part young men do not stoop like old men … Daniel watched Isaac gain a couple of inches in height as he remembered the erect posture that Puritans used to set a better example. a fictionalized Isaac Newton and his Cambridge roommate, Daniel, in Quicksilver, by Neal Stephenson Physiotherapists think that posture matters. In a 2019 study, several hundred of them were asked to rate the importance of optimal sitting and standing posture, and 65% considered it “very” important (and another 28% ranked it just below that). They did not entirely agree on what those postures are, which is a bit embarrassing, but they gave similar justifications for them regardless, which is even more embarrassing.These professional opinions do not appear to be evidence-based.People probably naturally avoid the most ineffective responses to most significant postural challenges. Homo sapiens is allergic to physical stress. We prefer to be comfy. And although postural laziness might seem obviously evil, people also naturally tend to keep up their postural fitness for the things they care about (if you like playing sports, you play them).The “problem” of poor posture is mostly minor and self-limiting. The worst problems are avoided naturally, instinctively. The postural fitness that matters the most is taken care of almost automatically, and what remains is relatively trivial. Doing it the hard way! How long do you think you could work like this without regretting it? That said, we can also be surprisingly self-defeating! In fact, this seems to be a weird feature of “higher” intelligence: we are prone to doing things the hard way and failing to avoid unnecessary stresses. So we probably do make some postural mistakes and develop bad habits, because we are careless, or because our big brains place too much emphasis other priorities, or because don’t even know that we’re doing something stressful (like the knees-tucked-under-the-chair example). Fortunately, the scientific evidence strongly suggests that doing things “the hard way,” posturally speaking, is probably not all that harmful even when we make that mistake. Here are some interesting examples …
Posturology is the cheesy, popular term for the mostly made-up “discipline” of studying the relationship between posture and pain, and even between posture and diseases. Posturologists (I can barely type that word with a straight face) tend to assume their own conclusion: they assume that poor posture causes pain, and then look for confirmation of that. And so there are many, many scientific papers that seem to present evidence of a connection between posture and pain, but most of them suck — here’s a nice appalling example — and “posturology” is mostly a pseudoscientific research backwater. If posturology research was better quality, we might actually learn something from it. But most of it must be chucked or, at best, taken with a huge grain of salt. Posture is only one of many hypothetical factors that contribute to pain problems, but in many cases it probably isn’t contributing at all. This is obvious from a simple observation: there are a lot of people with nice posture who are in terrible pain, and also many people with lousy posture but no pain. The most stereotypical poor posture of them all — a hunched upper back, with the shoulders rolled forward — is widely assumed to be a cause of shoulder and back pain … but the assumption is almost certainly wrong. This has been studied to death (for a posture problem). According to the collective results of ten different experiments it is almost certainly not a cause of shoulder pain. A large 1994 study of kyphosis in older women found no connection either: not even the 10% with the worst kyphosis had “substantial chronic back pain, disability, or poor health.” There’s just nothing there. Hunchers are not wrecking their shoulders and backs. More exotically, I had a truly scoliotic patient, an elderly woman with a blatant S-curve in her spine that she has had since she was a child. Despite this obvious major source of postural stress, she suffered nothing worse than annoying back stiffness in her whole life. Another much younger woman, but with extreme scoliosis, was also amazingly pain-free. Meanwhile, in my ten-year career as a massage therapist, I had a steady stream of people through my office with severe back pain … and perfectly ordinary posture. What’s the difference between these patients? Probably not their posture. Research has shown that abnormal curvature of the cervical spine is actually not closely associated with neck pain. Another good example: a client with a pronounced torticollis (“wry neck”), and who was even little deformed by it. But, once again, this middle-aged patient suffers from no more than irritating chronic discomfort, while many people with much more normal head posture are just about driven nuts by neck pain (including yours truly, which is why I wrote a book about neck pain). There are many better-documented stories like this, like the case of a serious traumatic cervical dislocation reported in New England Journal of Medicine in 2010, notable for being mostly asymptomatic: just torticollis and stiffness, but no pain, weakness, or altered sensation. That such a serious injury could ever have that little impact on a person is quite interesting, and it puts the hazard of “poor posture” in some perspective. Research has shown that abnormal curvature of the cervical spine is not closely associated with neck pain and is probably not clinically significant. A larger 2016 study of 1100 Australian teenagers showed that there was no correlation — none at all — between their neck posture and neck pain, contrary to all the fear-mongering we’ve heard about “text neck” in the last couple years.27 A similar 2018 study of Brazilian youths came to the same conclusion.28 For balance, I’ll acknowledge there are studies that say otherwise29 … but mostly just crappy studies in my opinion,30 and regardless they do not remotely prove that abnormal curvature actually causes pain.31 In general, the story is the same for the low back — the other posture hot zone. For instance, you could hardly ask for a more clichéd notion about posture than the idea that slouching is bad for your back. Teens slouch a lot, and they do get back pain (though much less than adults do), so if posture is an important factor in back pain, it shouldn’t be too hard to find a connection. But a biggish 2011 study did not: “a greater degree of slump in sitting was only weakly associated with adolescent back pain.”32 No smoking gun there. Physical therapists tend to make too much fuss over extremely subtle postural “problems,” which match up even more poorly with pain than the obvious postural problems.33 The popularity of such theories generally suggests to me that posture is often a therapeutic red herring. Both its importance and its “fixability” are routinely overestimated by professionals in a self-serving way. And yet that doesn’t mean there isn’t still something of interest going on. Health problems don’t have to be severe to be of interest. People with less vulnerability to body pain, especially younger people, do not relate well to that kind of story. They may be inclined to underestimate the severity of the pain, dismiss the timing as a coincidence, or to call it a problem with vulnerability rather than a postural problem. (And they may be right! More on this soon.) But it’s quite real for a great many people, especially older ones.The existence of this kind of situation was shown in a large, interesting study of triggers for back pain — what were people doing when they were struck by an episode of acute back pain, basically.34 The results emphasized both that posture isn’t a major risk factor for back pain and that it isn’t nothing either. By far the two biggest risk factors both had something to do with temporary awkward postures: Everyone will be happy to hear that sexual intercourse was not a common back pain trigger, though I imagine it depends on how you do it.So perhaps it’s clear that I’m not tossing the baby out with the postural bathwater. It’s obvious that it’s one of the numerous variables contributing to physical discomfort, even if it’s also obvious that it’s not the only or the dominating one. I’ve observed several instances in which pretty clear and preventable postural and ergonomic pressures did appear to be the source of pain; in many of these instances, the discomfort was quickly and effectively alleviated by avoiding obviously bad posture. However, as opposed to “bad posture,” the majority of these cases actually merely involved an imposed postural stress. This is a persistent source of uncertainty and has to be resolved. There is a big difference between “poor posture” and “postural stress,” but the distinction seems to be absent from most discussions of posture and ergonomics. But sometimes you are the source of postural stress. When the challenge is self-imposed by your own positioning and readily preventable, that is poor posture — it’s just relatively rare, something we easily avoid most of the time. There is some overlap between poor posture and postural stress, of course. Carrying a heavy backpack slung over one shoulder is a good example: it’s technically a self-imposed inefficient use of the tool, not an inherent flaw in the tool, and yet it’s also often convenient and sometimes temporarily necessary. Many postural stresses can be avoided if you recognize the problem, but What if someone is stubbornly unaware of an easily avoidable postural stress? Is that a posture problem? Or is it just cluelessness about ergonomics? I suppose it’s an unholy blend of both.I recall a case of a man with truly awful chronic upper back pain and a nasty computer workstation. I remember my amazement as he described it to me. He was barely aware of it being a problem — I had to tease him about it, it was so absurd — but once the problem was pointed out, he made several easy improvements … and that was the end of his problem. I find it hard to think of that case as a “posture” case.Another good example: the fiddle player who developed terrible pain in his shoulder. Incredibly, he did not tell me that he was a serious fiddle player, but just described himself as a shoulder pain patient and didn’t mention the fiddle at all. It was only after carefully quizzing him that I discovered he was practicing the fiddle for hours every day with his shoulder intensely hunched up, as fiddlers do. If he stopped playing, the pain would fade away over a few days. If he resumed, it would flare back up. He had been doing this for years, but didn’t think to mention any of that to me. And what a terrible dilemma: a clear postural stress required by a beloved activity! Maybe he didn’t mention the fiddle connection because he didn’t want that to be the problem. I’m sure he didn’t want quitting to be the solution. That guy loved playing the fiddle.The science of ergonomics is the arrangement or design of objects for effective usage, specifically to prevent postural stress. Unfortunately, ergonomics is sometimes understood crudely, leading to the misconception among most people that ergonomics is limited to office chair selection and keyboard tilt adjustment. There are many things that can be stated about office chairs and the angle of your keyboard, but those topics just scratch the surface of ergonomics. Humans are always being pulled towards the center of the earth by a gravitational field that never stops working. If we are somewhat crooked on a regular basis, a muscle someplace will have to put in more effort than necessary to maintain us upright. Try it for yourself and see how long you can maintain a slight sideways incline. Extreme unbalance quickly becomes uncomfortable. Yet for at least some people, a slight imbalance inevitably becomes uncomfortable with time. However, discomfort frequently lasts longer than worry. Why? Instead of “muscle imbalance,” why not? similar to everyone else? Because in the field of medicine, equilibrium has a cheesy, snake-oily meaning. Although the imagery may be helpful, it has been tainted by its link with a lot of fraudulent “balancing” quack medicine. It makes an overt suggestion that there is a problem and that therapy is necessary (and expensive!). Like feeling hungry after working out, certain muscular imbalance may simply be a common, occasionally inconvenient aspect of being human. No one really knows, but here’s a theory: Under normal circumstances, muscle works painlessly and effectively; it is a high-performance tissue. Yet, it can become shockingly sensitive, frequently in fairly well-defined patches that are referred to as “trigger spots” or muscular “knots” in the popular press. I’ve written extensively on this mysterious phenomenon, including my doubts that it is actually muscular (though it is very adept at appearing to be muscular). The precise biological factors that lead to this sensitivity are unknown, and it is well known for being unpredictable. Yet uncomfortable postures are a reliable way to bring on trigger point pain. Trigger points seem to be closely associated with a wide variety of other common pain problems. This surprisingly ordinary condition may even be the source many of the (non-arthritic) aches and pains suffered by the human race, especially low back pain. If poor posture contributes to the formation of knots in tired muscles — which is far from proven, but it’s a reasonable hypothesis — then this might be the chief risk of poor posture, and it might be a good idea to try to improve it. Why aren’t we all constantly in pain if it’s so simple to increase muscle sensitivity by defying gravity and adopting unnatural postures? Many humans exist in gravity! (Everyone but these fortunate individuals.) And many people routinely adopt uncomfortable postures without ever experiencing pain. Why me then? Why so many other people? And is bad posture the underlying issue, or are some people just overly exposed? Both are likely involved, but I don’t believe that anything can be directly linked to posture. Although the average healthy individual can probably tolerate “bad posture” with no issues, the range of asymmetry that they can tolerate is likely fairly vast, highly variable, and progressively narrower with age. And if a healthy person isn’t actually harmed by improper posture, People who get pain from trivial postural stress — people like me — do not have a posture problem so much as we have a pain problem.On the other hand, more vulnerable people, people who get pain from trivial postural stress — people like me — do not have a posture problem so much as we have a pain problem. A vulnerability. The greater the vulnerability, the more it’s about the vulnerability and not the posture — awkward postures are just another thing that triggers pain (even if we are quite careful). It doesn’t really seem like posture is what needs troubleshooting there. I’m a bit doubtful that anyone is wandering around in pain as they age because they were sloppy with their posture in the past. It’s possible, but I prefer this story: vulnerability increases with age, and we start to notice that postural challenges we once coped with easily are starting to get tricky. And almost everyone gets there eventually. The “worst” postures become problematic sooner, of course, but I doubt they are the cause — just the messenger, and the message is, “You don’t handle physical stresses like you used to.” “Inflammaging” is the inexorable increase in systemic inflammation as we age, strongly associated with poor fitness, but there are probably many other causes as well. It is the most ubiquitous of many causes of vulnerability to chronic pain all of which seem more likely to cause trouble than posture. Vulnerability to Chronic Pain — Persistent pain frequently has more to do with broad biological weaknesses than with specific tissue issues. Several studies support the logical link between posture and arthritis. For instance, a 2012 study on knee arthritis — a great place to start — revealed that persons with arthritic knees are bigger leaners and have “consistently altered” gaits from those with good knees. These individuals were also likely not walking differently because of pain. That is, rather than arthritis just causing individuals to walk crookedly, the crookedness likely contributed to the pain from the arthritis. On the other hand, we have the previously mentioned evidence as well as a lot more to show that janky biomechanics simply don’t match up with chronic pain very well. In many cases, arthritis is surprisingly painless. The cartilage on the underside of the kneecap will degenerate painfully as a result of uneven control of the kneecap caused by abnormal anatomy and/or posture, according to one of the most well-liked theories in musculoskeletal medicine. This leads to patellofemoral syndrome, a common type of knee pain. Yet, the patellar cartilage might degenerate without any pain. I could argue about the research all day, but the messy evidence is the solution. Although it’s not a significant factor, poor posture may speed up joint deterioration.
What poor posture is not: Upper-Crossed Syndrome (and its likes)
What is “poor” posture?
Postural laziness
Does posture matter?
All of this flies in the face of “posturology”
What are the (physical) risks of poor posture? Part 1
Postural stress versus poor posture
Vulnerability versus “the posture did it”
What are the (physical) risks of poor posture? Part 3: Arthritis
When a tissue’s ability to mend and adapt to stress is surpassed, all tissues begin to deteriorate. Everyone eventually experiences some degree of degenerative arthritis, making it a condition that affects all people. Tissues appear to degrade unevenly when they are loaded, much like how your walk affects how quickly your shoes degrade. This seems like a very logical assumption. Poor posture is undoubtedly a potential candidate in the rapid onset of arthritis in certain people.
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