The "Perfect Posture" Myth Has Been Costing Patients for 70 Years

In 1952, physical therapists Henry and Florence Kendall published Posture and Pain — the text that established the structural posture assessment framework most clinicians still use today.

Here is what most clinicians don't know: Kendall and colleagues examined over 2,000 healthy people to develop their posture standard. Then they didn't use the data.

Their own words:

"The standard posture as used and described in this text refers to an 'ideal' posture rather than an average posture."

And further:

"It is not probable that any individual can meet the standard in every respect. As a matter of fact, the authors have not seen an individual who matches the standard in all respects."

A standard that no healthy person has ever met. A framework derived not from what people actually look like, but from what the authors believed was mechanically ideal. This is the foundation of postural assessment that millions of clinical hours have been spent on.

What does the literature say?

• Strong evidence from six high-quality studies found no association between awkward postures and low back pain (Roffey et al., 2010 — systematic review)
• Sitting at work is not associated with low back pain, despite persistent clinical belief that it is (Hartvigsen et al., 2000)
• Structural factors including lumbar lordosis, pelvic tilt, leg length discrepancy, and hip flexor length are not associated with low back pain occurrence (Nourbakhsh et al., 2002)
• A systematic review of systematic reviews concluded: "Despite the availability of many reviews, there is no consensus regarding causality of physical exposure (posture) to LBP" (Swain et al., Journal of Biomechanics, 2020)

For context on anterior pelvic tilt — the finding most commonly used to justify posture-focused treatment — 85% of pain-free men and 75% of pain-free women demonstrate it (Herrington et al., 2011). Systematic review evidence confirms anterior pelvic tilt is not associated with back pain (Chun et al., The Spine Journal, 2017).

Clinicians haven't caught up

A 2019 survey of 544 physiotherapists found that 93.9% rated education about optimal sitting and standing posture as considerably or very important. Multiple different postures were selected as "correct" by different practitioners, but all were upright or lordotic (Korakakis et al., 2019).

Clinicians believe it matters. The evidence doesn't support that it does. The gap between those two things has clinical consequences.

The more important question

If we tell clients their pain is caused by how they sit, stand, or carry themselves, what happens when they lift something "incorrectly" and feel a twinge? What happens when their pain returns despite months of postural correction?

The message that the body needs to be held in a specific configuration to avoid harm signals fragility. It increases vigilance. It can generate fear-avoidance behaviours that are, in the evidence, more predictive of disability than the original pain episode.

Perfect posture is not a real construct. Backs like to move. The focus should be on varied movement, not controlled alignment.

If you want to understand the evidence on low back pain myths — posture, core stability, safe lifting, movement screens, and more — our Low Back Pain and BPS Practice course builds a rigorous framework grounded in contemporary research.

→ Explore the course at tkex.org/courses