Why a ‘wonky’ body is often perfectly fine Most of us are used to seeing pictures like this. On the left, a crooked skeleton with a dropped shoulder, a hiked hip, a rotated knee and a collapsed ankle. On the right, the after picture. Everything straight, level and perfectly aligned. The labels are clear. Before […]
Why a ‘wonky’ body is often perfectly fine
Most of us are used to seeing pictures like this.
On the left, a crooked skeleton with a dropped shoulder, a hiked hip, a rotated knee and a collapsed ankle. On the right, the after picture. Everything straight, level and perfectly aligned. The labels are clear. Before treatment the body is imbalanced. After treatment it is balanced. Pain is implied in the first image, comfort in the second.
These before and after skeletons are everywhere in our profession. Posters, websites, leaflets, social media. They suggest that if you are uneven you must be on the road to pain, and that a particular method will line you up and fix the problem.
It is strong marketing. It is not how pain really works for most people.
This blog looks again at three familiar ideas:
The aim is to give massage therapists a clearer, calmer story to share with clients. One that matches current research and keeps people confident in their own bodies.
What do we mean by ‘poor posture’.
Most training programmes include a version of the classic posture lesson.
There is a plumb line and a posture chart. We are shown an ideal side view, with ear, shoulder, hip, knee and ankle stacked neatly. Anything that drifts from this is described as poor posture. Forward head, rounded shoulders, exaggerated curves, flat back.
The difficulty is that poor posture is never really defined. At what point does a natural curve become too much. When does a relaxed slump become harmful. How many degrees of tilt turn a pelvis into a problem. There is no clear cut off.
In reality, posture is simply how someone arranges their body in space at a particular moment. It changes constantly with mood, attention, tiredness, the task in hand, pain, habit and many other factors. No one has one fixed posture. We all move through many postures across a day.
Historically the body has often been compared to a building. If the structure leans, the story goes, the materials will fail. That image has been applied to living bodies, even though we are not static. Muscles, tendons and fascia share load. The nervous system is always making small adjustments to keep us upright with as little effort as possible. We are also not perfectly symmetrical and never have been.
When researchers have tried to link specific spinal postures with low back pain, the simple idea that poor posture causes pain has not been supported well. Reviews that gather many studies together find no clear agreement that a particular posture or sitting style causes low back pain. Some studies show small links, others show none, and the better the study design, the weaker the relationship looks.
More recent work using imaging and wearable movement sensors across full days has found that people with low back pain do not share one recognisable bad posture. In some studies the main difference is that they use less variety. They spend more time in a narrow band of positions and less time exploring their full range.
A useful summary is this:
‘Posture on its own is a weak predictor of who has pain.‘
Posture is still worth noticing, but it is one piece of a much bigger picture.
Normal variation, stress and hypervigilance
This is the part that often gets missed when we talk about alignment.
Different height shoulders, a slightly tilted pelvis, a leg length difference or a flat looking foot may be perfectly normal for that person. They may move well, work hard, exercise regularly and have no pain at all. Their body has adapted around its own structure and is functioning just fine.
Pain can appear when the whole system is under pressure, not simply because a line is not straight.
When someone is stressed, anxious, not sleeping, in a period of big life change or dealing with wider health issues, the nervous system has more to manage. It can become more sensitive and more alert to potential threat. That state of hypervigilance can change how the brain interprets signals from the body. Normal sensations can start to feel threatening. Protective responses, such as muscle guarding and movement avoidance, become more likely. The brain may construct pain as a sensible warning to slow down or change something.
The underlying posture or asymmetry has not suddenly become dangerous. Instead, the whole system has less capacity to cope, so familiar loads begin to feel more threatening.
This is crucial for us as therapists:
For some people, a structural feature such as a large leg length difference or a spinal deformity might be one part of a complex picture. For many others, the shape of their body is not involved at all.
Pelvic imbalance and low back pain
The pelvis often becomes the star of the posture story.
Many of us were taught to look for anterior or posterior tilt, rotations, one side higher than the other or a sacrum that is said to be out. It is easy to link a client’s low back pain to these findings. If the pelvis looks uneven, the assumption is that forces through the lumbar spine must be abnormal and that this is the reason they hurt.
Research does not support this simple chain very well.
Studies that compare pelvic tilt and spinal curves in people with and without low back pain usually find small, inconsistent differences. Larger reviews that look at posture and loading together conclude that there is no clear evidence that particular spine postures or awkward positions cause low back pain across the population.
Movement studies show that people with back pain often stand and move differently, but this does not prove that the position came first. Pain can lead to bracing, leaning, limping and withdrawing from certain movements. These protective adaptations show up as changes in posture, but they are often responses to pain rather than the trigger.
In clinic we see this every week. Some people with a very uneven looking pelvis are comfortable and active. Others with neat alignment are in significant pain. The outward appearance does not tell the whole story.
The key point:
‘Small pelvic asymmetries are common and, on their own, do not reliably explain low back pain.’
We can still use our hands and eyes to understand how a person is using their pelvis and spine. We simply stop telling them that a slightly tilted pelvis is the cause of their pain and start exploring how to increase their confidence, movement options and capacity to cope with daily loads.
Leg length difference
Leg length discrepancy is another familiar piece of the posture picture.
Simple checks with heel positions or pelvic landmarks often suggest that one leg is shorter. From there it is easy to build a story of tipped pelvis, curved spine and overload up the chain.
Imaging studies show that most adults have some true leg length difference, often around a few millimetres. This is normal variation in bone growth and joint shape.
Reviews that examine leg length difference and low back pain tend to agree on two broad points:
Running research adds another angle. In a large study of recreational runners, leg length difference explained only a tiny part of the variation in how symmetrical their gait was. Runners with more gait asymmetry were not automatically more likely to get injured. In some variables they had a slightly lower injury risk.
The practical message is:
‘A small leg length difference is a description, not a diagnosis, and is rarely a good stand alone explanation for pain.’
Large differences after trauma or surgery are a separate case and may need specific management. For most of the differences we see in clinic, explanation, reassurance and sensible loading are more important than trying to correct the skeleton.
Asymmetry and function
Stepping back, a pattern appears.
Asymmetry is normal. Different shoulder heights, slightly rotated ribs, a tilted pelvis, a leg length difference or a pronated foot are all common in pain free, highly functional people. In sport, many asymmetries reflect useful adaptation to a chosen activity.
Pain is not a simple read out of how straight or symmetrical someone is. Pain is constructed in the brain as a protective response when the system judges that something is under threat. That judgement is based on many inputs, including physical load, stress, sleep, expectations and past experiences, not just on joint angles.
Structure can matter, but it is only one part of the story.
What this means for massage therapists
So how do we work with this in practice.
We keep observing posture and movement. We keep using our hands to feel how someone is organising themselves. We simply change the story we attach to what we see.
Some practical shifts:
Updating our narrative about posture, pelvis and leg length does not reduce the role of massage. It strengthens it. We are no longer selling a promise to straighten people into perfection. We are offering skilled touch, time, education and support that help the nervous system feel safer, movement feel easier and life feel more manageable. That is where real change happens.
References
Slater et al. 2019 – posture myth piece
Slater, D, Korakakis, V, O’Sullivan, P, Nolan, D & O’Sullivan, K 2019, ‘“Sit up straight”: time to re-evaluate’, Journal of Orthopaedic and Sports Physical Therapy, vol. 49, no. 8, pp. 562–564, doi:10.2519/jospt.2019.0610. pure.ul.ie
Swain et al. 2020 – umbrella review
Swain, CTV, Pan, F, Owen, PJ, Schmidt, H & Belavy, DL 2020, ‘No consensus on causality of spine postures or physical exposure and low back pain: a systematic review of systematic reviews’, Journal of Biomechanics, vol. 102, 109312, doi:10.1016/j.jbiomech.2019.08.006. PubMed+1
Sugavanam et al. 2025 – postural asymmetry in LBP
Sugavanam, T, Sannasi, R, Anand, PA & Javia, PA 2025, ‘Postural asymmetry in low back pain – a systematic review and meta-analysis of observational studies’, Disability and Rehabilitation, vol. 47, no. 7, pp. 1659–1676, doi:10.1080/09638288.2024.2385070. PubMed+1
Malisoux et al. 2024 – gait asymmetry and injury risk
Malisoux, L, Gette, P, Delattre, N, Urhausen, A & Theisen, D 2024, ‘Gait asymmetry in spatiotemporal and kinetic variables does not increase running-related injury risk in lower limbs: a secondary analysis of a randomised trial including 800+ recreational runners’, BMJ Open Sport & Exercise Medicine, vol. 10, no. 1, e001787, doi:10.1136/bmjsem-2023-001787.
Established in 1992 and officially recognised by the Scottish Government, the Scottish Manual Therapists Organisation (SMTO) is the foremost and longest-standing association for soft tissue, massage, and manual therapy practitioners in Scotland.
