When it comes to muscle and joint pain, many people ask if their posture has anything to do with it and whether they should get it fixed like using a posture corrector, corrective exercise, or even get “adjusted.” Or they may ask themselves if they need to be sitting or standing straighter.

The obsession with maintaining a “perfect posture” is not new. Some historical evidence indicates that some of the roots came from the European military in the Early Modern Period that eventually permeated throughout the world, including Maoist China.

These types of postures that might see or hear a lot include:

  • Upper cross syndrome
  • Lower cross syndrome
  • Forward head posture
  • Cervical lordosis
  • Kyphosis
  • Rounded shoulders
  • Scoliosis
  • Anterior pelvic tilt
  • Posterior pelvic tilt
  • Lordosis
  • Q-angle
  • Foot pronation

But does what you typically read in the news or hear from your physical therapist or chiropractor actually reflect what the scientific literature says? Let’s take brief look.

Upper Cross Syndrome

women sitting kyphosis

Photo: Nick Ng

Upper cross syndrome consists of protracted shoulders and (sometimes) the head, which may exaggerate the curvature of the upper spine.

The idea proposes that “tight” or “shortened” muscles in the chest and upper trapezius and “weak” or “lengthened” muscles in the shoulder stabilizers, neck extensors,  and other neck muscles are the cause this posture.

The idea behind upper cross syndrome was proposed and popularized by Dr. Vladimir Janda (1928-2002) in the 1970s. As popular as it is today,  scientific research of upper cross syndrome does not support a strong causal relationship between posture and back or shoulder pain.

For example, a review of ten studies on the relationship between the curve of the upper back and shoulder pain found “no association between increased thoracic kyphosis and shoulder pain.”

The researchers could not tell if it’s hunching posture that causes the pain or if it’s an adaptation to pain.


Forward Head Posture

young woman writing with forward head posture slouching

Photo: Nick Ng

Forward head posture refers to sticking your head too far forward, where many manual therapists claim that it can cause neck pain.

This posture also led to many manual therapists and posture correction companies to sell their services and products to “fix” the posture. But scientific evidence fails to find a strong relationship between neck posture and neck pain.

For example, Canadian researchers from Quebec examined subjects with acute neck pain, chronic neck pain, or no neck pain. They found that those with large neck curvatures have no neck pain, and those with chronic neck pain had the least amount neck curvature. Those with acute neck pain, however, are somewhere in between the other groups.

The data doesn’t show a causal relationship because the differences in the cervical angle (about 11 millimeters) “are unlikely to affect the cervical lordosis” and “are unlikely to be responsible for the pain differences between the subjects,” the researchers reported.

More recently, a group of Italian researchers, Bertozzi et al., found “no significant correlations” between the number of hours spent looking at a smartphone with neck pain and disability among 238 young medical students. About half of the sample reported to have no neck pain.

They suggested that there is no justification of spreading text neck fears or an intervention to “treat” this posture.


Cervical Lordosis

man looking at smartphone cervical lordosis

Photo: Nick Ng

Cervical lordosis, which is the lack of a natural neck curve, is often blamed for causing chronic neck pain, causing many people to likely seek treatment to increase the lordotic curve.

Like forward head posture, years of research in the relationship between posture and neck pain found very little association between the two. Therefore, you shouldn’t be too concerned about it.



bruce lee practices sticky hands with Grandmaster Ip man wing chun

Bruce Lee and Grandmaster Ip Man practicing Wing Tsun sticky hands in “upper cross syndrome” posture.
Photo: Uploaded by שילוני on Wiki Commons https://commons.wikimedia.org/wiki/File:Lee_and_yip_chi_sau.jpg

Kyphosis exists in nearly everyone’s upper spine in various degrees, but too much outward curve—sometimes called a “hunchback” or “dowager’s hump”—can reduce your shoulder’s range of motion and increase the risk of some joint disorders and diseases.

Like upper cross syndrome, kyphosis should not be lumped under one umbrella term and assume nearly all treatments and causes are the same.


Rounded Shoulders

Ben Cormack upper cross syndrome

Photo: Nick Ng

Rounded shoulders are caused by the forward tilting of the scapulae. This usually comes with tight chest muscles and can gradually lead to increased tightness in the soft tissue structures in front of the shoulder joint. It’s common to see people with rounded shoulders with their arms and hands turned inwards when they stand.

Like upper cross syndrome, there is almost no evidence that show a cause-and-effect relationship between rounded shoulder and shoulder or neck pain.


Lower Cross Syndrome

young woman with lower cross syndrome

Photo: Nick Ng

Lower cross syndrome is another type of “Janda’s postural syndromes” that also follows the same logic as the upper cross syndrome. Many depictions of lower cross syndrome tend to show a sideway view of someone with an “X” drawn in the middle of the abdominal and pelvic region.

This shows which muscles in the lower back and hips are “tight” and which ones are “weak.” The aim is identify these areas to bring the pelvis and spine as close to “neutral” position as possible.

However, this hypothesis was never validated.

For example, a team of Australian researchers in 2014 pooled data from 43 studies and found no difference between subjects with or without low back pain in terms of the degree of the lumbar spine’s curve (eight studies), hip extension (four studies), and pelvic tilts (three studies).

They also found people with low back pain also have less body awareness, tend to move slower, and have greater movement variability in trunk movement than those with no low back pain.



young man with excessive lordosis and anterior pelvic tilt

Photo: Nick Ng

Lordosis in the concave curvature of the spine, and it often refers to the lumbar spine. Colloquially called “swayback,” it can also refer to the neck curvature.

Not surprisingly, the correlation between lordosis and low back pain is uncertain since most research could not discern whether the posture is a cause of back pain or an adaptation to having low back pain.


Anterior Pelvic Tilt

young woman with lower cross syndrome

Image: Nick Ng

In the anterior pelvic tilt, the pelvis is rotated forward in the sagittal plane, causing an increase of the lumbar spine curve.

This position tilts the buttocks upward, exaggerating its round appearance for some people. Sometimes the pelvic tilt decreases the upper spine curvature, making the person appear to have a flatter upper back.

Like lordosis, there is no clear causal relationship between the degree of the pelvic tilt and low back pain.


Posterior Pelvic Tilt

woman with posterior pelvic tilt

Image: Nick Ng

The posterior pelvic tilt is where the pelvis is rotated back, causing a reduction in the curvature of the lumbar spine and buttocks.

Sometimes the pelvic tilt exaggerates the upper spine curvature, making the person appear more hunched like Shaggy in the old “Scooby-Doo” cartoons.

Again, like other features of the lower cross syndrome, there is no strong evidence that posterior pelvic is a cause of back, shoulder, neck, or hip pain.



young man scoliosis

Photo: Nick Ng

Scoliosis refers to the excessive sideways curvature of the spine, but it can refer to the excessive rotation of the spine.

It may originate in the structure of the bones, and it may present as a single or double curve. While many people attribute scoliosis to back and hip pain, scientific evidence finds that it is more than just the spinal posture alone.

For example, one study found that teenagers with scoliosis who believed their spine is the source of their back pain were more likely to have more pain regardless of the degree of the sideways curvature.

It reflects on their lack of confidence and self-control of their situation. This research reinforces the complex nature of pain and the role of mental health support of scoliosis pain management.


Foot Pronation

foot pronation flat foot man

Photo: Penny Goldberg

Foot pronation, specifically overpronation, has long been considered a risk factor for foot injury. But what does the scientific evidence actually say compared to what you see in advertising and hear what some clinicians say?


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