By Carl Valle
Posture is one of the most debated subjects in sport, and this article will cover the entire spectrum of body alignment factors related to athletes. Posture has always been part of general health and well-being, and today we face even more scrutiny of past beliefs. At the same time, there’s been a rise in interest about posture in some medical circles.
The main goal of this blog is to share my own experience with what I have witnessed working and give scientific explanations for when posture doesn’t affect the outcomes of rehabilitation and performance. If you are a coach or sports medicine professional, this article will cover more than the typical back pain entry we see on websites and in journals. It doesn’t matter if you are just curious about “text neck” or want to get closure on Janda’s lower crossed syndrome, this review covers it all.
Defining Posture and Understanding the Challenge
When the average person says someone has “bad posture,” it’s a very vague and nebulous term. Conversely, when someone has “perfect posture,” be careful, as even that phrase or concept can be misleading. Posture is an ever-changing snapshot in time, so we need to be very precise with our language.
Do we mean static posture—usually when someone is standing at rest? Do we mean a specific activity posture, such as squatting or lifting a load? Are we talking about a choice way to run or jump, such as body lean with acceleration or an athlete jumping with their hips under their center? Even the placement of parts of our body beyond the spine, such as foot positioning, are considered posture. Posture is a wide topic and discussions of it often become very opinionated and controversial.
Posture has always been part of human history, as even the classification of our species, specifically homo erectus, is connected to our body. Over the years, posture has been a nonverbal way to communicate our health and personality. Sometimes our posture changes, like gait, due to our emotional or energy states, but overall, the posture we had yesterday will likely be what we have tomorrow. Posture is a head-to-toe expression and representation of the way our body manages gravity and the response to activities that place demand on the body, and also includes what we express to the outside world.
Coaches and sports medicine professionals need to have better definitions of posture and move away from “good” or “bad” posture, and even evolve past kyphosis and lordosis. The issue with the current vernacular is that it’s usually vague and mainly incomplete, and it has been horribly researched in the past. A fair representation of posture was summarized beautifully by the legendary biomechanist Geoffrey Dyson as the following:
“Posture, a product of heredity, environment and self expression, is acceptable in an athlete if it permits the proper functioning of respiration, circulation, digestion, etc., and involved no unnecessary tensions or restrictions. In consideration, its relation to running efficiently these should be the only criteria.” –The Mechanics of Athletics
This definition is my choice and preference, but feel free to expand or modify it. To me, posture is about orientation, and how it changes based on training, therapy, and life itself. Dynamic actions in sport may connect static posture with testing, but it’s about really knowing how movement is enhanced and impaired by the way the joints stack vertically and horizontally in activity and at rest.
Structure, Alignment, and Symmetry
What becomes really difficult and complicated with posture is the convergence of alignment and structure of the body. The best example of this can be seen with bone architecture and patterns of posture that may seem to interact poorly. For instance, posterior tilt of the spine and pelvis with a very poor arthrokinetic function of the femoroacetabular joint may exacerbate symptoms. Flexion of the spine won’t cause a lot of problems, but under loads and with extreme ranges, the combination could be a pathomechanical danger to some athletes.
Other examples of functional changes from the combination of structure and alignment are the shoulder and spine, where range of motion is linked, and this can be problematic to athletes when performing overhead movements. Athletes who have issues pressing vertically compensate at times, often using extension of the lower spine to complete a task. Regressions, usually exercises that are less demanding with range of motion, are employed because of limitations or contraindications. My own experience is that it’s fine to use an alternative, but you still need to follow up on the causes of athlete’s restrictions to help them in the long run.
Body alignment may change over years or more rapidly, depending on what the change is, the effort by the team involved, and the age of the athlete. A useful example of alignment change is external rotation of the femur, a common uncertainty with coaches and sports medicine. Some athletes will respond symmetrically or asymmetrically to injury and stress, and it’s important to know why symmetry is present, as it could be a risk to an athlete if functional abilities or reserves are low. Sometimes symmetry in sport is typical and even expected, but if it causes a clear and direct problem with output, it’s time to address it, if possible.
A lot of pundits have mentioned that Usain Bolt’s scoliosis may have helped him run faster, but so far, there’s been no explanation of what that mechanism was. Even if it didn’t diminish his speed, does anyone think that his retirement around the age of 30 may have been premature because of injuries? The body is adaptable, but I think Bolt running fast and with some unnecessary wear and tear was likely the reason he left the track injured rather than a world champion.
It’s essential to know the difference between abnormal and primary risk factors with structure, as simple issues like Haglund’s deformity may pose an issue for Achilles and bursa injuries. Research on this is unknown, as the science is unclear at this moment, but when you see smoke, a fire is probable. Structure should be a part of the equation, but not a doomed future or an excuse to not worry about addressing an athlete’s body as best as possible. Pain, posture, performance, and injury are connected—how tight the connection and the magnitude of the relationship are very individual.
Athletes vs. Healthy Populations
The normal activities of daily living for average Joes are not the same as those experienced by pro athletes. One of the most frustrating arguments that medical and performance professionals hear all the time is that athletes are still human. True, athletes are human, but they are also superhuman and sometimes super unique. While they may be prone to diabetes and concussions, and even get the common cold like you and me, what they are doing to their bodies is different than mowing the lawn and gardening.
Heavy training and competition, artificially heavy body types, and even purposeful changes to joints and muscles all come with a cost. Therefore, if research studies use recreational athletes or average populations, extrapolating them to activities that are not done in the design should not be seen as evidence for posture. Even research with sport populations showing little connection may not be representative of the problem, as some athletes don’t train the same or the study may include a different coaching philosophy. When a study doesn’t support a theory, be skeptical but also open to the fact that posture isn’t everything.
Be warned though. Athletes also live normal lives and sometimes experience the same ailments of being uncomfortable in the wrong bed, sitting in an awkward position on the team bus, and other normal activities. They walk around and get blisters when wearing the wrong shoes, and sometimes respond well to a different way of moving when doing recreational activities. Athletes are just like you and me, but they happen to have extra-special physical demands. Being a resilient rugby player won’t solve a wrist problem if they play video games for hours every day. A sane way of looking at all the sports and regular demands of life is to know when research is applicable, and when it’s just not representative of the problem.
What About ‘Text Neck’ or Sleeping and Sitting?
Another area outside of the common athlete versus non-athlete population debate are activities such as sitting in a chair or even sleeping. I do see both sides of the argument, where we can’t be manic about looking down at a phone since soccer athletes look down at the ground, but the absence of range of motion and living with a narrow motion diet are not my idea of a health. Some strong points have been made about creep to the support structures from prolonged sitting, but buying a standing desk may not be the solution if you are not comfortable and prepared for long periods of standing either. A lot of money and research is invested in ergonomics every year, and so far, the conclusions are not rock solid, so don’t put all your eggs into one basket.The way that various athlete postures interact with sleeping positions is complex, but I bet the key is comfort, similar to many other activities of daily living, says @SpikesOnly. Click To Tweet
Sleep is very personal, and assessment is highly dependent on quality data. An athlete should be fitted with the right mattress and use a selected position that gives them the best chance of getting a good night’s rest. Personally, I have seen changes in sleep data when positions are modified and even more results when a mattress is replaced or is a top-of-the line option. The way that various athlete postures interact with sleeping positions is complex, but I bet the key is comfort, similar to many other activities of daily living.
Scientific Evidence and Measurement of Posture
Now comes the deep dive and meat and potatoes of posture and athletes. Regardless of the outcomes or conclusions of the research, if you don’t measure posture properly, false positives and false negatives will surface. Measuring posture is about reference points—mainly how the body aligns compared to a plumb line. Many different body types will be fine during regular activities such as walking the dog, doing chores, raking leaves, and even chasing grandchildren.
When using a posture grid or even technology, static posture is just a starting point, as some athletes are able to move in ways where their static posture does not correlate well with dynamic posture. The same can be said for those who appear perfect in a photo but seem to struggle with movements they may look suited well for. Thus, posture should be seen as a combination of structure, alignment, mobility, coordination, and even physical and mental conditioning. A pelvis that looks neutral standing or walking may radically alter its inclination when sprinting. It’s very frustrating for coaches when they see oppositional sceneries. This means an athlete who has poor posture running but looks great standing, or an athlete who slouches and looks lazy but suddenly performs amazingly well in both speed and poise.
An array of devices, both simple and high tech, exist to help improve the accuracy and validity of testing posture. Such devices range from oversized graph paper against the wall to hardware that resembles protractors and compasses. Digital tools, usually camera-based software solutions, are currently popular in some therapy clinics and research institutions. The primary concern with the devices is their precision and accuracy, but like fat calipers, training and education should take care of the gap. Repeatability will likely be high with any measuring device, but with posture including a live person who may express their positions and orientations differently, force plates and other devices that ensure the center of pressure is consistent are sometimes added to the process.
From head to toe, posture is a sum of its parts or isolated and independent. You can have an appearance of being tall and aligned, but the devil is in the details. We will likely continue to see controversy over the magnitude of impact with some of the more minor positioning and posture measurements, but they are definitely worth exploring. The postures of the head and neck, shoulders, spine and rib cage, pelvis and legs, and even foot alignment, are all shrouded in controversy and even mystery. While this list scratches the surface and there is far more research on the subtopics, it’s good to know if this matters or if it’s just random noise. It’s hard, but at least addressing the design of the body is important.
Take a look at forward head posture and pain and you may see a relationship or no strong connection. But what about negative respiration function changes? As you can see, this is very complex and very specific to the measurements collected. While I am not a huge fan of corrective exercises, good training should rectify most of the problems if they are truly biomechanical. Also, if needed, some isolated neck training may help.
Measuring kyphosis in swimmers with inclinometers and specialized devices is encouraging for reliability, but the connection to shoulder injuries is a coin flip without looking at additional tests of function and training load. Scapular orientation, while great on paper, is also far from perfect, so we can’t assume everything isn’t working just because one or more muscle groups are testing weak or “out of place.” For example, many athletes will have a strong serratus anterior from isolated corrective exercises, but it sometimes fails to fire correctly if they have trained and competed without it working well in the first place.
Anterior tilt has always been a risk factor for hamstrings tears, but only when there’s a true weakness of oblique strength will the theory hold water. I cover this in more detail later in the article, but the reason I think the research is not supportive is because eccentric strength, flexibility, and locomotion speed are too simplified of variables to explain injury patterns. I don’t think the theoretical tension on the hamstrings is the issue—more like a nerve or lumbar injury from high-velocity sprinting. All of this is speculation, as not enough resources have been committed to truly decoding this problem.
The last discussion point is the Foot Posture Index (FPI), a score of the static classification of the foot where some prediction has shown promise and, of course, limitation. Due to the type of motions tested, we can see no value in predicting injuries or relationships to injury patterns using the FPI. All of this is not surprising, but like the rest of joint and posture research cited, it must be taken with a grain of salt.
I’m more impressed with those who use postural restoration in an integrated fashion, as I see the therapy as a catalyst rather than a standalone vehicle for change, says @SpikesOnly. Click To Tweet
My final point is about my thoughts on PRI (postural restoration) and whether the organization is on to something or is just a little too “out there.” I am open to new and old ideas, but I won’t claim that something with promise is a panacea. So far, I am more impressed with those who use PRI in an integrated fashion, as I see the therapy as a catalyst rather than a stand-alone vehicle for change. I do remember seeing the before and after changes online in 1999 and being shocked. I didn’t know whether the changes would create a dramatic improvement in function, but instead of just talking about it, they actually did it.
I am all for therapists bettering themselves with continuing education, but we need to be less tribal and more open to different ideas, as long as the evidence and thinking is strong. I am not endorsing the system, but I am not dismissing it either. I have found some really bright and successful therapists demonstrating positive change using the resources from the Postural Restoration Institute, but I have also seen the wrong people force it on an athlete with little success. The goal is to take the concepts and find a way to create a real outcome that is transferable and measurable with PRI.
Changing Posture and My Experience with Therapists
Now comes my own anecdotal experience with posture, and my personal philosophy. Know when to address it and know when to leave it alone and manage it. I don’t think everything is connected to posture, but I do think it shows up more with ballistic athletes or high-volume endurance sports. True, the human body can cope with a lot and even thrive in bad environments, but let’s not allow resources to be spent unnecessarily on the wrong areas if we can help it.
Changing posture, not necessarily fixing it, requires a lot of effort that sometimes may not be worth it. Again, my own experience watching body workers has made me a believer that speed athletes tend to have more resilience with a combination of capacity and efficiency (alignment changes), but it’s a case-by-case basis. Some of the most beautifully aligned frames can get injured, even when fit and managed well.
Deciding to tinker with an athlete’s structure, especially the alignment, means you need to know what you are doing and have sensible expectations. Soft tissues and the nervous system are very plastic to adaptation, but do have limits. A fair summary is that we should have faith that a sound training program will not increase the failure rate of biomaterial (tendon, ligament, bone, and muscle), but sometimes a repetitive movement, poor recovery, and impaired alignment may decrease the capacity of those structures.
Lordosis in the power athlete is common, and kyphosis in the aquatic athlete is also common. Just like sprinting is seen as the vaccine for hamstring injuries, intense corrective approaches—not low-load exercises—have the potential to address direct injury. The issue with pelvic positions in static stance is that they are far from perfect with correlating to injury, so don’t expect much to change, even if you are able to modify the anterior tilt of a sprinter or team sport athlete. Kyphosis, a theoretical variable with the rotator cuff and other structures of the shoulder, may or may not be the culprit.
Remember: Posture is very visual, but internal architecture is not. Still, even a shoulder type (specifically, acromial type) may not be as problematic as once believed, but it should be a factor with injury rates when all variables are accounted for. The anteriorly tilted athlete can stretch their psoas and tighten their obliques with extreme core training, but if the architectural design of their lumbar spine has an extreme inclination, not much will happen afterwards. This will lead to frustration with some coaches because it may have worked for another athlete with a different “build.” Posture is an example of extreme individualization, as it’s very genetic and very connected to the nature of the athlete.Posture is an example of extreme individualization, as it’s very genetic and very connected to the nature of the athlete, says @SpikesOnly. Click To Tweet
In summary, the younger the athlete and the more versatile their skills and interests in sport, the greater the chance a coach has of keeping them on the right track. There are no guarantees though. Posture may help, but don’t put all your eggs in one basket. Don’t be obsessive—just make posture part of your portfolio, as most of the training that manipulates the body is likely potent enough to help performance overall.
Why not add mobility to the thoracic area? Why not develop a strong core? Why not place emphasis on flexibility and control of the joint systems of the body? Posture training may just be a good approach for athlete development. One warning, though: The ability to see real, measurable changes in posture without comprising training needs is hard, and the entire process takes a long time. Don’t expect a 90-minute massage to change kyphosis or a mobility routine to fix the warped pelvis of an athlete near retirement. Just keep your expectations realistic.
Stand Up Straight or Just Relax?
I don’t want to leave you on the fence about posture, as it’s a complicated topic and it’s not going to be truly solved in the next few years. What I do know is that we can’t be polarized and either just say it doesn’t matter or treat it like a magic bullet. Posture is very individualized and should be supported as a small but noticeable variable in sport, as plenty of athlete have succeeded with different postures.
Unfortunately, some athletes have a lot of variables that may “align” negatively and may be a problem, but focusing on general qualities of ergonomics with a healthy dose of exercise variety and wellness activities should protect athletes from injury. The body can compensate and adapt to challenges, but leaving everything to nature can be a problem if you don’t know where the boundaries are. If you suspect alignment of the body is causing problems, seek a qualified therapist or review the clinical evidence before jumping to conclusions.