June 23, 2021 13 min read

Is Your Posture Causing Your Back Pain?

Does your back hurt? Chances are that many of you reading this now have experienced some form of back pain in the past year.

Research shows that each year, 50% of all working adults report back pain symptoms; and that number is growing.

Back pain is one of the most common reasons for missed work and is a leading cause of disability world wide.

According to an analysis by the Journal of the American Medical Association (JAMA), the United States spends $87.6 billion annually on health care related to neck and back pain. (US Spending on Personal Health Care and Public Health, 1996-2013-December 27, 2016).

Orthopedic physical therapists treat patients with back pain due to a number of different reasons.

Patients may present with pain due to sprained ligaments, strained muscles, or injuries to the discs, joints, nerve roots, or vertebrae of the spine.

Some of these cases are attributed to acute traumas such as sports injuries, accidents, or lifting injuries; however, many complaints of low back pain are chronic and not specifically associated with any known trauma.

When patients do not have a clear mechanism of injury and they have been cleared of any red flags for systemic and non-mechanical causes of pain, Physical Therapists will assess posture, ergonomics, and body mechanics as potential drivers of pain.

With a majority of patients working from home and sitting more often than usual this year, the incidence of low back pain from poor posture and impaired body mechanics have increased.

Even if you have a physical job, the way that you sit in your car, at your computer, or in front of your TV can have a significant impact on the health of your spine.

Many people have jobs that involve a combination of physical activity as well as prolonged sitting or standing.

First responders are an excellent example of men and women who must both perform physically demanding lifting and endurance activities in addition to prolonged sitting or standing tasks.

It is not uncommon for paramedics, firefighters, and police officers to encounter on the job injuries. First Responders who attend Physical Therapy for neck and back pain many times report that their pain is exacerbated by sitting in a patrol car for over an hour or standing at a computer completing paperwork.

First Responders are often in peak physical condition, but poor positioning of the spine during prolonged sitting or standing can significantly contribute to muscle strain, joint inflammation, nerve impingement and disc injury.

Most people recognize the importance of 'good posture.' We were often told by our parents, teachers, or coaches growing up to 'stand up straight, lift your head up, pull your shoulders back.'

It is true that posture is important, but it is also true that sometimes our best attempts at creating 'good posture' can contribute to even more problems.

When taking into account the anatomy of the human spine and how it relates to our foot placement, pelvic alignment, and breathing pattern, it is a lot easier to correct our posture in a way that does not lead to over-correction or compensation.

Whether you are sitting or standing, your posture can contribute to pain by placing excess stress or load on the muscles, ligaments, joints, and bones of the spine.

Physical Therapists will sometimes use a plumb line to assess posture and spinal alignment. There are general landmarks that help PTs to identify if a patient has a neutral posture.

The plumb line runs through the ear lobes, the vertebral bodies of the cervical spine, the shoulder joint and then continues to pass through the center of the trunk, the hip joint, the anterior aspect of the lower leg, and the front of the ankle joint.

Stacking the body in this way ensures that the load is evenly distributed across the vertebra of the spine and prevents excess strain to any particular segment.

If you want to find good posture on your own, I recommend doing a quick body scan starting from the ground up. Good posture begins with your base, which is your feet if you are standing or your pelvis if you are sitting.

If you are currently standing, take a moment to assess the feeling of your feet.

Where is your weight most dominant?

Are you on one leg more than another?

Is your weight shifted to the balls of your feet or are you holding much of your weight in your heels?

Take a moment to try to center your weight directly over the arches of your feet.

For many people, this means shifting your weight back into your heels and then anchoring the bones at the base of your big toe and pinky toe in front of you to create a tripod with your foot.

The tripod gives you a stable base and enables you to center your weight over your arch.

From here, check your knees.Your knees should be straight in standing but not hyperextended. Try unlocking your knees if you sense they are resting in their end range joint position. Your knees don't have to be bent to be 'unlocked.'

Next check your pelvic position. If you imagine your pelvic girdle to be a bowl full of water; you want to keep that bowl level in order to avoid spilling water.

Many people who stand on the balls of their feet with their knees hyperextended also have an anterior pelvic tilt (spilling the water to the front of the bowl). This creates excess lumbar extension and places unwanted stress on the lower back.

To correct this, try finding your hamstrings and lower abdominal muscles and use them to perform a slight posterior tilt of your pelvis to achieve a neutral pelvic position. Once you find neutral, relax your muscles. If you can't easily find or activate these muscles, you may want to ask a Physical Therapist to help you.

If you are in a sitting position, it is similarly important to assess both the positions of your feet and your pelvis.

When we sit, gravity places a load on our spine, and it is important for some of that load to be transferred into the floor through the feet. If your feet are not in contact with the floor, then most of the weight of gravity is terminating in your low back and pelvis.

Ideally, if you have to sit for a long period of time, place both feet flat on the floor. If you are unable to reach the floor when you sit, consider using a small foot stool to rest your feet on.

If you are driving, try to be sure to use the foot rest that is located left of your brake pedal in order to keep your feet and your pelvis as symmetrical as possible.

Keeping your pelvis neutral while sitting is just as important as standing.

Unlike standing, most people will tend to sit with a posterior pelvic tilt also known as sacral sitting. If you envision the pelvic bowl again, this time the water would be spilling out to the back.

To correct this, I often recommend that my patients purchase a seated foam wedge that is higher in the back and lower in the front as this helps prevent the pelvis from rolling onto the sacrum leading to excess compression of the spine.

You can also create your own wedge with a towel, pillow, or even a jacket if you need to.

Another tip that helps maintain a neutral pelvis in sitting is placing a pillow or towel roll behind the low back to support the body's natural lumbar curve.

The goal is to be as relaxed as possible with sitting. Using props such as pillows can help give the body feedback while allowing your muscles to stay relaxed and not tense or guarded.

 If you don't have access to any posture props, a good cue for checking pelvic position is to find your 'sitting bones'.

To feel your ischial tuberosities (better known as sitting or sits bones), you may have to untuck your pelvis by pulling the gluteal muscles back with your hands.

As you sit, try to feel the bony prominences of your sits bones beneath you and then shift your weight ever so slightly (no more than a few degrees) anterior towards the direction of your pubic bone.

Keeping your sits bones as a base will create a neutral position for your pelvis and stable position for your spine. Be sure to relax all your back and hip muscles once you are in position and don't over accentuate the curve in your low back.

Excess muscle tension while sitting can contribute to back pain and is not necessary if you are in a neutral and stacked posture.

If you want to recline (whether on a couch or in a car) or lean forward (to eat or work at a desk) try to maintain contact between the front of your SITS bones and your chair while you flex or extend at your hip joint.

If your sits bones maintain contact with the chair beneath you, then the spine will be able to stay relatively 'straight' even if it is at a forward or backward leaning diagonal.

Whether you are standing or sitting, one of the most important concepts for maintaining good posture is breathing.

Humans breath approximately 20,000x/day, but we often don't pay attention to how we breath or where that breath is going in our bodies.

There are many muscles in the body that assist with breathing, but the primary breathing muscle is the diaphragm.

The diaphragm is a dome shaped muscle that is located inside the rib cage where a heart rate monitor or bra line rests on your rib cage.

The diaphragm is responsible for pulling air into your ribs when you inhale.

Ideally, you want to feel your ribs expand 360 degrees (front, back, and sides of your rib cage) when you take a deep inhalation.

Because of stiffness in the thoracic spine and rib cage, many people are challenged to perform a full and effective diaphragmatic breath.

Many people will use their accessory muscles to breath with their neck, excessively elevate their chest, or they will bypass the rib cage all together and the air will expand solely in their abdomen.

Belly breathing alone without rib expansion is not an effective technique as it over elongates the abdominal muscles and leads to unnecessary lumbar extension with every breath.

Breathing is not just essential for human survival, but it also contributes significantly to spinal alignment, posture, and stress management.

Breath work has been shown to help shift a person from 'Fight or Flight Mode' (sympathetic nervous system) to 'Rest and Digest Mode' (parasympathetic nervous system).

It is biologically impossible for the body to heal during the fight or flight mode, so in order to recover from a work out, heal from an injury or trauma, or unwind from a stressful day at work, it is important to have the skills to turn off the sympathetic and turn on the parasympathetic nervous system (PNS).

Because of its proximity to the vagus nerve, the diaphragm is able to stimulate the PNS and bring you in to a more restful and healing state.


The Postural Restoration Institute founded by Ron Hruska, MPA, PT has been the biggest influence on my understanding of how breathing relates to posture. If you are interested in learning more specifics about how the breath influences and informs our posture and what exercises you can do to improve your breathing, I highly recommend you look at the PRI website or find a local PRI certified physical therapist. https://www.posturalrestoration.com/programs-courses

There are many different exercises to practice to improve diaphragmatic breathing form.

One of my favorite exercises to help introduce patients to the concept of 360 degree diaphragmatic breathing is performed in a modified child's pose position.

The patient rests on the floor or on a bed on both elbows and knees with as muscle spinal flexion (rounding) as is tolerated.

From here the patient is instructed to inhale into the nose slowly while trying to feel the ribs expand along the mid back.

I often tell my patients to imagine they are growing wings or inflating a balloon in the back of the rib cage.

Once they have inhaled completely, they are asked to exhale fully from their mouth while maintaining the rounded spinal posture.

If you try this at home and want to feel the breath in the back more fully, try scooting your elbows closer to your knees and round your back more like an angry cat pose and hold this for 5-10 full inhalations and exhalations.

You can also try this exercise in sitting by interlacing your fingers, rounding your back, and reaching your arms in front of you. Inhale into your nose and try to feel the stretch in your mid back and then exhale out of your mouth with a long and loud sigh. This exercise is repeated as often as desired throughout the day.

Once patients improve the ability to breath 360 degrees from their diaphragm, they will be better able to maintain a neutral spine.

Many postural compensations stem from patients wanting to bias their easiest form of breathing.

If a patient is a primary belly breather, they will often stand with an anterior pelvic tilt and lumbar extension in order to give the belly as much freedom as possible to inflate.

The Postural Restoration Institute (PRI) describes that due to the asymmetry of the diaphragm and internal organs, right side dominance, and other factors, many people will tend to breath more easily into the left side of their rib cage.

If someone does find it easier to breath into the left side of the body, you will often find them standing on the right leg or sitting with spine bent to the right in order to allow that left side the ease of expansion.

Patients with this pattern will often drive with their right arm leaning on the middle console and their left leg falling out to the driver's side door. If this pattern sounds familiar to you, I recommend trying the 90/90 Hip Lift breathing exercise explained by PRI founder, Ron Hruska in this video: https://youtu.be/4GoqjoEXaAw.

PRI exercises often include the use of a balloon as this helps with breath control when you are first learning to feel your diaphragm.

Performing an effective diaphragmatic breaths allows the air to expand equally into the front, back, and both sides of the rib cage. This method of breathing will help facilitate a neutral spine and posture whether you are standing or sitting and help to avoid compensation patterns than can contribute to pain and assymetry in the body.

Moving up from the diaphragm, we need to consider the position of the shoulders when assessing posture. If the shoulders are rounded, many people will compensate and 'pull their shoulders back' by extending their lumbar spine, rotating their pelvis anteriorly, and if they are standing, by extending their knees and loading their weight onto the balls of their feet.

Extending the spine to bring the shoulders back is not only ineffective for correcting forward shoulder posture, it also contributes to excess load in the lumbar spine and can be responsible for back and knee pain.

Working on separate and specific exercises that address rib expansion with breathing, thoracic mobility, scapular stability, and muscle flexibility can help reduce the occurrence of forward shoulders.

Forward shoulders need to be addressed independently in order to avoid overcorrecting with excess lumbar extension.

Lastly, it is important to consider head and neck position.

Many people are familiar with the term 'tech neck' which playfully describes the demise of neck posture with the rise of technology use.

Leaning in to computer screens, cell phones, or other devices for long periods of time is reshaping the cervical spine and contributing to neck pain, headaches, and even nerve problems that can cause shoulder and arm numbness, tingling, and weakness.

Similarly to rounded shoulders, forward head is often overcorrected in both sitting and standing by excess lumbar extension. Pulling the head and shoulders back by arching your spine will not correct the underlying problems and only create more pain and tension in the lower back.

It is important to remember that especially in sitting, head and neck position will follow pelvic position. The neck and the sacrum are both a part of the same spine.
When you pelvis rolls into a 'sacral sitting posture, your head will naturally fall into a forward head position.

Constantly trying to pull your shoulders and neck back is a losing battle if you are sitting on your sacrum and not on the front of your sits bones.

There are a few specific exercises that can be helpful to strengthen the neck that has been in a 'forward head position' for too long. Chin tucks or anterior cervical flexion exercises can help build the core of neck and gentle scalene, levator scapula, and upper trapezius stretches can be helpful for elongating muscles that have been in an extended shortened position.

Ultimately, the best way to know if you are at risk for injury or pain because of your posture is to schedule an appointment with your friendly, neighborhood Physical Therapist.

A PT will be able to assess for muscle imbalance and postural asymmetry and give you a home program to strengthen where you are weak, lengthen muscles that may be adaptive shortened, and improve spinal alignment to ensure for optimal nerve flow and oxygen delivery throughout the body.

If you are working from home, you can have a family member take a photo of you at your work station or in your car, and your PT can help address some key strategies for improving your posture, ergonomics, and efficient body mechanics.

Even if you have perfect posture, you were not designed to sit for most of the day. Be sure to take frequent standing, walking, and stretching breaks if possible throughout the day.

A great goal is to set your timer and aim to be out of your chair and moving for 2min every 30min.

When it comes to keeping your back free of posture driven pain, maintaining neutral spinal alignment and diaphragmatic breathing are very important, but in many cases movement is the best medicine!

Moving frequently throughout the day, taking breaks to perform slow diaphragmatic breaths, and maintaining a neutral spinal alignment can help you to avoid becoming one of the many Americans who miss work due to low back pain.

If you are concerned that your posture may be contributing to your back pain or have not fully recovered from a past injury to the lumbar spine or any other area of the body, consider scheduling a consult with an Orthopedic Physical Therapist in your area. It is never too late to make positive changes towards improving posture, preventing pain, and optimizing the health of your spine!

- Brittany Berthelote PT, DPT, OCS

Brittany graduated from Whitworth University with a Bachelor's Degree in Kinesiology in 2009 and from Eastern Washington University's Doctor of Physical Therapy Program in 2012.

After graduation, she returned to her hometown, Wenatchee, WA where she practiced in Outpatient Rehab and the Spine Clinic at Confluence Health.

Brittany also worked as a Traveling Physical Therapist for 5 years and practiced as a volunteer PT in Quito, Ecuador as well as a licensed PT in over 9 different locations across the Pacific Northwest.

She is currently living in Seattle with her husband in a 'tiny-home-on-wheels' and practicing at Lake Washington Physical Therapy in Kenmore.

Her special interests include manual therapy, myofascial release, spine health, breathing mechanics, posture, and prevention and wellness.

She became an Orthopedic Certified Specialist (OCS) in 2017 and is currently studying to become a Certified Nutritional Physical Therapist (CNPT).

She believes healing is a team effort and is passionate about using patient education and empowerment to help her patients achieve their goals.

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