Head up, shoulders back, pain solved. That’s how it’s supposed to go. But what if everything you’ve been told about “good posture” is wrong, and in fact, is only making your pain worse?
This is the question I’ve been asking myself for months now, ever since — after almost a decade of nagging left shoulder pain that wouldn’t go away — a practitioner I found on YouTube finally healed me.
Seeking medical advice on YouTube? I know, I know. But I was at the end of my rope with my body — and my doctors. For years, every expert I consulted told me the same thing: “You hunch over a computer all day. Of course your shoulder hurts.” One doctor told me the problem was my pathetic upper body strength, so I got really into power yoga. I practiced my posture during my commute by closing my eyes and remembering the mantras I learned in class: “Lengthen the spine” and “squeeze the shoulder blades.” I got massages once a month. But alas, no matter how well I could propel myself from downward dog to chaturanga, no matter how much length I gave my spine or how much I was kneaded, when I looked in the mirror, I saw the same slouchy woman. And my shoulder still ached.
Good posture has always been more of a cultural ideal than anything else, “a litmus test for the healthy, modern body of the perfect citizen.”
Most of us take standing up straight for granted as basic health advice. We’re berated about it by our parents and teachers as tweens, and as adults in a capitalist society, we’re bombarded with the same messaging buried in the promises of proper ergonomics, standing desks, and “smart devices” that will ping your phone if you start to slouch. But as I learned the hard way, very little of this has anything to do with actual health or science.
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Good posture has always been more of a cultural ideal than anything else, “a litmus test for the healthy, modern body of the perfect citizen,” as Emory University professor and cultural historian Sander Gilman, PhD, writes in his 2018 book, Stand Up Straight: A History of Posture. The concept of “good” or “bad” posture dates back to ancient times: Hippocrates himself wrote about poor habits being a possible cause of spinal malformation. But to understand why he thought that, you have to know that the ancient Greeks understood posture as the defining character of mankind, Gilman says. Greek myths are rife with postural lessons. There’s Thersites, the hump-backed and dull-witted soldier who gets beat up by Odysseus for causing trouble during the Trojan Wars, and posture and gait is even a recurring theme in the tale of Oedipus. The Greeks believed that man stood upright to face the Gods.
This cultural understanding has followed us ever since, from the 19th-century rise of Swedish gymnastics to the bizarre “Miss Correct Posture” pageants of the 1950s, to the wearable “smart” devices of today. “We have this unspoken language of posture: It affects the way we see other people,” Gilman says. “It affects the way we see our own selves in the world.”
As ridiculous as some of these examples seem now, our assumptions of beautiful posture, or even just an “appropriate” posture, infect our ideas about what makes a “healthy” posture as well. Today, back pain is one of the most common health complaints. “Something like 80% of people will experience back pain at some point in their lives, and it can be debilitating,” explains Charles Kim, MD, a physiatrist at NYU Langone Health. Posture remains among the first things many doctors and physical therapists ask about if you report back pain, despite the fact that multiple recent studies suggest the link between back pain and posture is weak, if not nonexistent. Take this 2016 metanalysis of 10 studies that couldn’t confirm a link between “excessive thoracic kyphosis” (the technical term for slouching) and shoulder pain. Or this 2018 study that found no link between “text neck” (the technical term for looking down at your iPhone) and neck pain in 624 young adults.
This isn’t to say that slouching or looking down at your phone won’t ever lead to pain. Sitting or standing in any one position repeatedly can cause certain stresses on your joints over time. But this idea that there is singularly one healthy posture for everybody — regardless of differences in size or asymmetry or what daily activities you do — is what I’ve found to be dangerously bunk.
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It wasn’t until my left knee also started hurting, making it impossible to run, that the “good” posture myth finally fell apart for me. The discovery was all thanks to a YouTube channel run by Neal Hallinan, a certified strength and conditioning specialist, called “The PRI Trainer.” PRI stands for Postural Restoration Institute, a growing school of thought in physical therapy. In the past 30 years, the institute, led by Ron Hruska, a doctor of physical therapy (DPT), has trained more than 200 physical therapists, athletic trainers, and even dentists in helping people correct what they see as the real troublemaker: poor breathing mechanics.
“When people get in that tall, erect position, they do not have their diaphragm in a position to work appropriately as a respiratory muscle.”
The basic idea behind PRI’s teachings is that human bodies are naturally asymmetrical, and this affects how we move and breathe. Although you are likely pretty symmetrical on the outside (two arms, two legs, two breasts, etc.), internally, your heart sits on your left side, and to make room for it, your left lung is slightly smaller than your right lung. Your main breathing muscle, the diaphragm, is actually two muscles, a stronger, larger right leaflet and a smaller, weaker left leaflet. “Because of this, the left and the right side are not doing the same thing,” says Jennifer Platt, DPT, executive director of the Postural Restoration Institute.
Problems begin when stress and repetitive activities in our lives accentuate this natural imbalance. “Walking, riding the bike, or sitting at the computer, doing any of these repetitive activities, you become very lateralized. You become one-side dominant,” Platt says. And that can wreak havoc on your neck, shoulders, back, and joints. Even worse: The advice to lengthen the spine can aggravate things. “When people get in that tall, erect position, they do not have their diaphragm in a position to work appropriately as a respiratory muscle,” Platt says. “That reinforces the pattern.”
What I learned from PRI training, which consists of targeted breathing and isolation techniques, is that my posture really was terrible — but not in the traditional “up and down” sense. Rather, my posture was terrible because I was tragically uneven left to right. Why didn’t any of the number of professionals I consulted about my pain ever mention this? “Back pain especially, but pain in general, is very poorly taught in traditional medical education,” Kim says.
Physical therapists aren’t always much help, either. “In PT school, you learn the anatomy, but you don’t really learn the whys,” Platt says. “The connection hasn’t been made between the internal asymmetry and the function of the human body.”
Reading the reviews on Neal Hallinan’s website makes PRI seem way too good to be true. “I used to suffer pain literally 24/7,” one reads. “One night I woke up in pain at 2 a.m., found your exercises, and when I did them I felt so good that I finally had a deep sleep.” Normally, I’m a skeptic of miracle fixes. But when I reached out to Hallinan in January of this year, I was ready to try anything.
A few months prior, I had run my first marathon. It didn’t go that well — both my left knee and my left shoulder had locked around 10 miles in, stealing my time goal and twisting me into a pretzel for my finish line photos. After the race, my body simply had it. My shoulder hurt more than ever, and I was diagnosed with IT band syndrome in the left knee and tendonitis in my right Achilles.
Worse, I couldn’t seem to recover no matter how much I rested. After months of physical therapy that didn’t help, I paid $300 for a gait analysis that revealed my left hip didn’t load while I ran. This seemed to explain at least some of my issues: Hip weakness, aha! What I thought I’d get from Hallinan was an exercise program to strengthen that hip. I did not expect him to tell me during our first virtual session that I wasn’t struggling with “weakness” necessarily, but with an inability to connect to the appropriate muscles to actually use my left hip. Even less did I expect him to say that the real issue — the true source of all of my problems — was that I was bad at breathing.
It’s hard to be told you don’t know how to breathe. (Isn’t it, you know, automatic?) But if PRI founder Ron Hruska’s theories are correct, a lot of us are breathing inefficiently. “Most people are breathing with too much compensatory muscle because of the position that they are stuck in,” Hallinan says.
The diaphragm is the main breathing muscle. But we also have accessory breathing muscles in between our ribs, called the external intercostals, as well as certain muscles in the neck. Your diaphragm on both sides contracts as you inhale, pulling down and creating space in your chest for the lungs to expand. It’s like a plunger that pulls air into your lungs. At the same time, your intercostals pull your ribs up and out, creating even more space for air to fill the lungs. During exhalation, everything relaxes.
The key to all of this working is making sure your diaphragm remains in the domed position so it can plunge efficiently. The area where the dome of the diaphragm sits is called the “zone of apposition” or ZOA, and it is heavily influenced by the orientation of the rib cage. If the ribs are off, you can shift into a position where the dome is lost. Maintaining the dome not only helps you breathe efficiently, but the plunging action also helps keep your pelvis, spine, and ribs stable because it, along with the pelvic floor, creates intra-abdominal pressure, explains Leada Malek, DPT, a board-certified sports physical therapist based in San Francisco.
But remember: That left leaflet of the diaphragm isn’t quite as big as the right one. “It’s the weak link, our true Achilles’ heel,” Hallinan says. So what happens is we can very easily lose the dome shape on the left side, which means it can’t create that plunging action. The right diaphragm, intercostals, and sometimes the right-side neck muscles then take over to make sure we can get air into our lungs.
“This can breed compensatory and dysfunctional movement patterns,” Malek says. “A ‘chest breather,’ for example, will move while using accessory muscles of breathing that attach to the upper ribs and can contribute to significant tightness around the neck. This can then cause movement dysfunctions in the shoulder.” If things continue, a cascade of issues can crop up from there.
For me, it started with shoulder pain and escalated to my left knee and right foot. But where pain shows up doesn’t always follow a strict pattern. “I always say the body is so smart. It’s too smart sometimes,” Malek says. “Your body will find one way or another to stabilize you, and over time, that leads to stress somewhere.”
For Cynthia Cook, a personal trainer in New York City, it manifested as dreaded low back pain, a relentless tightness that got so bad on her right side she couldn’t walk for two months. “One would say I have perfect posture. I was doing barre classes. I was in the military,” she says. As a fitness professional, she’s also hella strong. But none of that stopped her from experiencing debilitating low back pain. X-rays revealed nothing going wrong with her spine, and traditional physical therapy didn’t help much, either.
“I was in really severe pain and nothing worked. It never made sense to me that I just needed to strengthen something or stretch something,” she says. Eventually, like me, she found PRI through Google and the rest is history. “I’ve never felt better.”
For the past eight months, I’ve started every day with at least 15 minutes of PRI training. There are a number of different techniques that PRI trainers use based on what’s going on with a person’s body — or how deeply stuck in a certain movement pattern they are. But the key to all PRI exercises is that you exhale slowly, making sure you push all the air out. (This helps you reposition your ribs.) In normal breathing, exhalation requires no effort. But elongating the exhale is itself a kind of workout that activates the internal obliques. Making these specific abdominal muscles stronger helps you keep your ribs on the left side down and your diaphragm and ribs in the optimal position, even during normal breathing.
A good example is the 90–90 hip shift, which is one of the more common techniques in PRI. To do it, you lay on your back on the floor with your feet resting on a wall, so your knees create a 90-degree angle. You place a ball or towel in between your knees and squeeze. Then, you lift your butt slightly off the ground so your pelvis is tilted and your feet are pressing into the wall. Then, you shift your right knee slightly toward the ceiling and begin to lift your right foot so your weight fully shifts to the left side. Finally, while you’re doing all of that, you breathe deeply, trying to make your exhales twice as long as your inhales.
There’s a lot going on here—but that’s because you can’t separate learning to breathe efficiently from learning to move efficiently. “When you try to think about A leading to B leading to C you get into trouble,” Hallinan says. “Everything occurs at once.”
Thanks to consistent practice with these kinds of exercises, I feel amazing — and I’m slouchier than ever. Whenever my shoulder acts up, I know how to take a few breaths and get into the right position to turn off the tension. And what you’ll find doing PRI is that you pretty much have to relax your shoulders to do these techniques correctly.
I look in the mirror today and have a new appreciation for the fact that I slouch, and that my body isn’t exactly symmetrical.
Of course, it’s important to point out that breathing inefficiency isn’t the only thing that causes back pain. Injuries, spinal issues, arthritis, pulled muscles — all of those things can make you hurt, Kim says. But even he admits that something like 60% of people with back pain have no spinal abnormalities or injuries. Could the reason those people’s backs hurt be a breathing issue? Kim puts it at maybe. From his perspective, PRI is an interesting set of theories.
Hallinan and Platt put it at most likely. Malek says she uses PRI in her practice any time a client just isn’t getting better with the regular techniques. “[Posture] is the simple answer. Sometimes sitting up straighter is all you need, but if you keep chasing it and it’s not helping, then what do you do?” she says.
At the end of the day, it’s hard to say who’s right. The natural asymmetry of the diaphragm is well documented in scientific literature, and a growing body of research supports the use of PRI techniques for a variety of frustratingly common pain syndromes, like IT band syndrome and low back pain. But the studies tend to be small. The good news is PRI training is not going to hurt you. And if you’re in pain, anything that won’t hurt you more can be worth a try, Kim says.
Of course I’m glad I found a way to solve my pain. But the best part is that I gained a deeper awareness and acceptance of my body as it is. I look in the mirror today and have a new appreciation for the fact that I slouch, and that my body isn’t exactly symmetrical. Instead of forcing my spine straight and my shoulders back, I revel in the fact that I can move and breathe in this perfectly imperfect body.
The more I look back on how long I spent in pain, the more I realize that I really did believe my pain was the result of some moral failing, like if only I wasn’t so lazy or weak, I’d have learned to straighten it out (literally). “One of the greatest difficulties we have is that posture like many other qualities of the body is also associated with character,” Gilman says.
If this were ancient Greece, I would not be considered a model citizen — and I’m okay with that.