Concept:Postural Considerations

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Poor posture is one of the most powerful activators and perpetuators of myofascial trigger points (TrPs). The relationship is bidirectional: TrPs shorten muscles that distort posture, and distorted posture sustains the mechanical overload that perpetuates the TrPs. Correction of postural faults is therefore not merely adjunctive — for many patients it is the essential prerequisite for lasting treatment success. This page summarises the practical postural guidance from Travell & Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual, Chapter 41, Section C, and provides the clinical content referenced throughout PainWiki muscle pages.

The Core Postural Problem

Excessive forward-head posture (anterior head positioning with posterior rotation of the occiput) and rounded forward shoulders frequently occur together, producing what is commonly called round-shouldered, slumped, or slouched posture. This combination may be initiated from above (occiput and cervical spine driving the rest downward) or from below (loss of lumbar lordosis and posterior pelvic tilt driving the shoulders and head forward).

The consequences are far-reaching:

  • Posterior cervical muscles (suboccipital, splenius capitis, levator scapulae, trapezius) must contract to allow forward gaze — they become chronically overloaded and develop TrPs
  • Humeral range of motion is reduced, particularly elevation and rotation
  • Pectoralis major and minor shorten — they perpetuate the round-shouldered posture which in turn perpetuates their TrPs
  • Adaptive shortening of the pectoralis minor can lead to coracoid pressure syndrome, arm pain, and stretch weakness of the lower trapezius
  • Diaphragmatic breathing is discouraged; restricted thoracic expansion forces recruitment and overload of cervical accessory respiratory muscles
  • Increased pressure on intervertebral discs; decreased lung capacity
  • Temporomandibular joint intra-articular pressure rises from reflexive mandibular contraction under suprahyoid and infrahyoid stretch

A flattened lumbar spine with loss of normal lordosis and excessive posterior pelvic tilt induces anterior head positioning — low back mechanics and head position are linked. What happens from the ground up influences head position whether a person is standing or sitting.

Anterior head position benchmark: When the cheekbone is in the same vertical plane as the sternal notch, the head and neck are in an erect position without muscular overload. Departure from this alignment is clinically measurable; see SCM Postural Assessment for the full protocol including plumb line assessment and anterior head position measurement.

Important: Posture is dynamic, not static. Even in quiet relaxed standing, slight postural sway occurs. Change of position is inevitable and necessary — ligaments, cartilage, intervertebral discs, and muscles all require periodic movement for nutrition. Patients should learn to reposition frequently rather than straining to hold one "correct" position.

Standing Posture

The Problem with "Stand Up Straight"

When a patient stands in a slouched posture with shoulders and head projected forward, the centre of body weight projects on the back of the heels (Fig. 41.4A in T&S). When instructed to "stand up straight and hold the shoulders back," posture may improve slightly but the line of gravity remains on the heels (Fig. 41.4B). Maintaining this straightened position requires constant voluntary effort; the overloaded muscles soon fatigue and the person becomes discouraged.

The Weight-Shift Correction

The effective correction is not to pull the shoulders back, but to shift the body weight from the heels onto the balls of the feet (Fig. 41.4C in T&S). When this occurs:

  • The head shifts back as a counterweight
  • The line of gravity moves forward, anterior to the ankles
  • The normal cervical and lumbar curves are restored
  • The chest automatically elevates and more easily expands
  • The balanced position requires no conscious muscular effort to maintain

Essentially the same result is achieved by actively repositioning the head upward — elevating the back of the head, eliminating the unwanted posterior rotation of the occiput on the atlas. The body then follows the head into good alignment. This is a balanced position that does not require conscious effort to maintain.

"Think Tall"

If there is any one simple thing that makes it easier for a person to develop good posture and movement, it is to think tall — to lengthen oneself. Moving the head upward in relation to the body (away from the body, making oneself taller) causes the body to follow and come into good alignment. The more often this movement is performed with every daily movement activity, the easier it becomes to attain and maintain stress-free balanced posture.

Sitting Posture

Slumped sitting (Fig. 41.5A in T&S) shows: posterior tilting of the pelvis, flattening of the lumbar spine, excessive thoracic kyphosis, round-shouldered posture, anterior head positioning, and a depressed chest. This posture discourages diaphragmatic breathing and, when prolonged, induces muscle and joint stress and pain.

The Ischial Tuberosity Method

Improved sitting posture (Fig. 41.5B in T&S) is achieved by moving the ischial tuberosities toward the front edge of the chair and placing one foot posteriorly. This achieves a relatively effortless balanced position without excessive anterior pelvic tilt — the lumbar and cervical curves approach normal, the thorax and head are erect, and the position can be maintained during work, keyboard use, conversation, and reading.

An alternative is to place a small wedge-shaped pad under the ischial tuberosities (not under the thighs) to achieve the same balanced alignment from a slightly more posterior seat position (Fig. 41.5C in T&S).

Lumbar Roll

When sitting back in a chair, a lumbar roll at approximately belt height (at the thoracolumbar junction) supports the normal lumbar curve and prevents the posterior pelvic tilt that drives forward head posture. Key points:

  • The roll should support the thoracolumbar junction and provide a normal lumbar curve; some individuals benefit more from a lower support that prevents excessive posterior pelvic tilt
  • A bath towel folded to approximately 30 cm (12 inches) wide and rolled to 7.5–10 cm (3–4 inches) in diameter provides the right combination of firmness and resilience for any chair or car seat
  • The roll can be secured with ties around the chair backrest, or with two straps thrown over the top with counterweight sewn into the ends
  • If the lumbar support slips, tying it around the person's waist (rather than the chair) is often more reliable
  • The individual must slide the pelvis and buttocks back to the posterior part of the seat for the roll to be effective

Inadequate lumbar support is a major contributory factor in most patients for whom riding in an automobile aggravates back, chest, or neck pain.

Chair Design Principles

No single chair fits everyone, nor does it fit every situation for the same person. Patients with myofascial pain must learn to distinguish between chairs that promote nonstressful posture and those that cause stressful pain-inducing posture.

Key requirements:

  • Backrest shaped to support the normal lumbar curve — not flat
  • Chair-back slope of 25–30° posteriorly from the vertical for comfort during reading and watching TV (not for meal-times or desk work)
  • Chair seat with sufficient hollow or backward slope at the bottom of the backrest so that the buttocks are not pushed forward
  • Armrests at the height of the half-flexed elbow at rest — supporting the elbows and forearms while keeping the shoulders relaxed. Without armrests (or with armrests that are too low), a person will cross the arms in front of the chest, inducing round-shouldered posture and shortening the pectoral muscles and perpetuating their TrPs
  • The chair must be adjustable; a therapeutic exercise ball can be alternated with a desk chair
  • An inclined board encourages healthy posture for prolonged writing at a desk

Copy Placement and Screen Height

  • Monitor: fingertips should just reach the screen with the arm extended; top third of the screen at eye level
  • When typing from copy: place the copy at eye level and as near as possible to the centre of the line of vision
  • A headset is beneficial to anyone who spends significant time talking or listening on the telephone

Movement Activities

The insight of F. Matthias Alexander is directly applicable: rather than concerning oneself with "doing" the correct posture, the approach is to prevent habitual movement patterns that cause stress. The key movement involves elevating the occiput with a slight anterior rotation of the occiput on the upper spine — letting the head move upward when moving forward, rather than allowing tension and shortening of posterior neck muscles to move the head backward and down, compressing the spine.

The significant aspect of this technique is not posture, but movement. The movement produces a kinesthetic effect of lightness that is pleasurable and thus self-reinforcing.

Walking Up Stairs

The undesirable method: shift weight to the forward foot, then extend the leg with great effort to lift the body weight to the next step. This is accompanied by a posteriorly-rotated occiput, anterior head positioning, shortened pectorals, and a depressed chest.

The efficient method: place the forward foot lightly on the step, deliberately elevate the occiput, let the head move upward and forward, and gradually extend the leg with the body following the head. This provides good head/neck position and chest elevation, with balanced weight transfer and less energy expenditure.

Jogging

Stressful jogging style: shoulders hunched and tense, tense posterior neck muscles inducing a posteriorly-rotated occiput. This activates and perpetuates TrPs in the suboccipital, splenius capitis, levator scapulae, and trapezius muscles.

Efficient jogging: the occiput is raised as the head moves forward, and the body is lengthened by the upward and forward-rocking movement of the head. The shoulders and arms appear more relaxed.

Walking Fast ("Indian Lope")

Shift the pelvis and hips forward, exaggerating the weight shift to the balls of the feet. The rear foot rapidly advances to keep from falling forward. Each step receives a vigorous push-off from the calf muscles, making it efficient for covering long distances quickly.

Reaching Forward

The undesirable method: reach forward over a desk in a way that produces a flattened lumbar spine, upper trunk and hip flexion, and a posteriorly-rotated occiput.

The efficient method (Brügger): extend one hip, placing that foot more posteriorly than the other. This avoids the bent posture with a flattened lumbar spine and posteriorly-rotated occiput.

Rising from a Chair

  1. Shift the hips toward the front edge of the chair
  2. Spread the feet apart with one foot placed posteriorly (to enlarge the base of support)
  3. Lean the body forward at the hips to move the centre of gravity over the base of support
  4. Let the head move upward with the body following (upward in line with the forward torso, not upward in relation to the vertical)

When one lower limb is weak or painful: turn the entire body toward one side of the chair instead of facing straight ahead. The stronger or nonpainful limb should be closer to the chair.

Lifting, Pushing, Pulling

  • Lifting: keep a wide base of support, keep the object close to the body, avoid lifting above shoulder height, do not twist while bending forward
  • Pushing or pulling: keep a wide base of support with feet spread in line with the direction of force; apply force near or in line with the centre of gravity of the object
  • Turning to look at something: turn the entire body, not just the head

Principles for Patients

Patients with myofascial pain due to TrPs should learn to:

  1. Change position often — periodic movement is essential for joint and disc nutrition
  2. Reposition to nonstressful erect posture after each position change
  3. Perform appropriate stretching and postural exercises at regular intervals
  4. In a work setting, use a timer or clock alarm as a reminder to change position and exercise

Rectus abdominis TrPs, because of their forward pull on the thorax, can induce or perpetuate forward-head posture. Upper rectus abdominis TrPs may need to be inactivated before postural correction can be maintained.

Special Situations

For detailed guidance on sitting in a car and at a workstation, see Chapter 48, Section 14 and Chapter 5, Section C.

References

  • Travell JG, Simons DG. Myofascial Pain and Dysfunction: The Trigger Point Manual, Volume 1: The Upper Half of Body. 2nd ed. Baltimore: Williams & Wilkins; 1999. Chapter 41, Section C (pp. 809–817).
  • Travell JG, Simons DG. Myofascial Pain and Dysfunction: The Trigger Point Manual, Volume 1. 2nd ed. Chapter 5, Section C.
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