Protocol
Posture Analysis in the Sagittal Plane—Practical Guidelines with
Reference Values
Oliver Ludwig
Department of Sport Science, Rheinland-Pfälzische Technische Universität Kaiserslautern-Landau (RPTU),
67663 Kaiserslautern, Germany; oliver.ludwig@rptu.de
Abstract: Background: The alignment of a person’s body segments depends on their
innate anatomy and neuromuscular status. Sagittal posture assessments provide valuable
information on correctable deficits, which can be used to prevent possible health issues
or injuries. Methods: This article provides practical guidance on how to perform a basic
photometric sagittal posture analysis in a reproducible manner, which reference points
should be used, and which errors should be avoided. For this purpose, based on the
current literature, four important evidence-based parameters for evaluation are defined,
and literature-based reference values are given for the assessment of posture. Conclusions:
When done correctly, the sagittal posture analysis is a valuable tool in the fields of medicine
and sports.
Keywords: posture measurement; reference values; normative values; pelvic tilt; body lean;
craniovertebral angle; head tilt
1. Introduction
Academic Editor: Francesco Fornai
Received: 8 March 2025
Revised: 26 March 2025
Accepted: 28 March 2025
Published: 1 April 2025
Citation: Ludwig, O. Posture
Analysis in the Sagittal
Plane—Practical Guidelines with
Reference Values. Anatomia 2025, 4, 5.
https://doi.org/10.3390/
anatomia4020005
Copyright: © 2025 by the author.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license
(https://creativecommons.org/
licenses/by/4.0/).
Anatomia 2025, 4, 5
Posture assessment is an important diagnostic tool in clinical practice and sports [1–4].
In particular, the lateral view provides information about typical postural defects in several
body segments that may be associated with the onset of complaints. In an extensive review,
Potthoff et al. called for a more detailed investigation into sagittal posture’s status as a
risk factor for the onset of lower back pain in adolescence [5]. In this context, Sugai and
colleagues were able to show that measuring thoracic kyphosis in older adults can predict
future declines in their activities of daily living [6]. Regular posture assessments can,
therefore, help to identify posture deficits at an early stage, enabling preventive measures
to be implemented and can thus be an important tool for promoting public health.
However, determining the points at which posture deviation can still be considered
normal and at which it must be considered a pathological disorder requiring treatment
is difficult [7]. Since posture parameters can change over the course of a lifetime and sexspecific differences exist, it is useful to collect practical reference data to support medical
diagnoses. Apart from radiological methods, which are usually inadequate in the field
of posture prevention [8–10], non-invasive, optically based examination methods such as
photogrammetry are used most frequently [11]. Therefore, only reference values that are
not determined via radiological or 3D-stereophotogrammetric methods are presented in
this article, since these are either invasive or technically demanding and cost-intensive
and are therefore less suitable for preventive medical check-ups. In order to measure
reproducible parameters, whether in the fields of medicine or sport, posture measurement
parameters must fulfill the following conditions in order to be suitable for screening and
preventive examinations of posture in everyday medical, physiotherapeutic or occupational
contexts (see also [12]):
https://doi.org/10.3390/anatomia4020005
Anatomia 2025, 4, 5
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(1)
(2)
(3)
The parameters should be measurable with simple methods, without great effort or
cost-intensive instruments, and in an objective, reliable and valid manner.
The parameters should be able to capture several areas in the sagittal plane since
the transitional areas (lumbosacral transition and thoraco-cervical transition) are
particularly critical in terms of stress [13].
Reference values should be available in order to provide a basis for deciding when
posture parameters deviate from the norm depending on age and sex.
In this context, measurable parameters are helpful because they are superior to subjective assessments, which heavily depend on the experience of the examiner [14]. A large
number of possible parameters are currently available, but they are also defined and measured differently depending on the study. In order to provide those working in the field of
posture analysis with a practical overview, we have reviewed the literature and compiled
analysis parameters that are useful for a sagittal analysis. On the basis of this evaluation,
this article summarizes four global and local parameters that can be easily measured and
have useful, practical applications; descriptions of the required anatomical reference points
are also given.
In the following section, only those parameters are described on the basis of available
studies that have a possible correlation with complaints. Subsequently, four posture
parameters are presented based on the three criteria above, knowing that a large number of
other parameters have been described in the literature (e.g., see [15]).
2. Examination Methodology
2.1. Preparation of the Test Subjects
The procedure for a posture analysis and the preparation of the subject are described
relatively consistently in the literature [16,17]. In order to evaluate posture as accurately as
possible, it is important to visualize as much of the body contours as possible. Simply put,
the less clothing the test subject is wearing, the better. Since it may not be possible to undress
the subject to a certain extent depending on the examination setting, compromises can be
made, although these come at the expense of accuracy. Figure 1 shows the same subject
being examined in different settings (left: workplace; right: doctor’s or physiotherapist’s
office). Most markers can be attached to the skin except for the marker point on the
greater trochanter. However, it is clear that the T-shirt being worn obscures the back
contour, and therefore, no statements can be made about local misalignments in this
body segment. Table 1 summarizes the essential orientation parameters for reproducibly
measuring posture. Ideally, the subject should stand in their underwear.
Table 1. Conditions for reproducible measurements of posture.
No.
Condition
1
2
3
4
5
6
7
8
9
10
As little clothing as possible
Feet shoulder-width apart
Knees pointing forward
Knee joints stretched
Upper limb hanging loosely, palms facing the body
Head straight (Frankfurt plane horizontal)
Relaxed breathing
Posture relaxed, not consciously tense
No talking
No prior muscular exhaustion
Anatomia
Anatomia2025,
2025,4,4,5 x FOR PEER REVIEW
of1717
3 of
Figure
Typical sagittal
sagittalanatomical
anatomicallandmarks:
landmarks:
comparison
of normal
clothing
and minimal
Figure1.1. Typical
comparison
of normal
clothing
and minimal
clothclothing.
ing.
With
Withregard
regardtotopoint
point(3),
(3),ititshould
shouldbe
benoted
notedthat
thatininthe
thecase
caseofofforward-facing
forward-facingknee
knee
joints
(the
examiner
can
grasp
them
from
the
front
to
verify
their
position),
joints (the examiner can grasp them from the front to verify their position),the
theiliofemoral
iliofemoral
ligaments
ligamentsininthe
thehip
hipjoints
jointsare
arenot
notsufficiently
sufficientlytensed
tensedtotochange
changethe
thealignment
alignmentof
ofthe
thepelvis.
pelvis.
As
a
rule,
the
feet
(reference
point:
interdigital
space
1–2)
are
then
rotated
outwards
As a rule, the feet (reference point: interdigital space 1–2) are then rotated outwardsby
by
◦ . The position of the lower legs can be corrected by turning the feet until the
about
5–10
about 5–10°. The position of the lower legs can be corrected by turning the feet until the
knee
kneejoints
jointsare
arestraight.
straight.
The
knee
joints
The knee jointsshould
shouldbe
beextended,
extended,and
andthe
theupper
upperlimbs
limbsshould
shouldhang
hangdown
downloosely.
loosely.
The
forearms
should
be
slightly
medially
rotated
so
that
the
palms
face
the
body
The forearms should be slightly medially rotated so that the palms face the body(neutral
(neutral
zero
zeroposition).
position).AAholding
holdingposition
positionisisoccasionally
occasionallyseen
seenwhere
wherethe
thearms
armsare
arecrossed
crossedininfront
front
ofofthe
chest.
This
changes
the
position
of
the
center
of
gravity,
usually
leading
to an increase
the chest. This changes the position of the center of gravity, usually leading
to an inincrease
thoracic
kyphosis,
and is therefore
not recommended.
The examiner
can easily
correct
in thoracic
kyphosis,
and is therefore
not recommended.
The examiner
can
easily
the
armsthe
so that
do not
thecover
marker
on point
the greater
correct
armsthey
so that
theycover
do not
thepoint
marker
on thetrochanter.
greater trochanter.
The
Thehead
headshould
shouldbe
bestraight,
straight,the
theso-called
so-calledFrankfurt
Frankfurtplane
planeshould
shouldbe
behorizontal,
horizontal,and
and
the
thegaze
gazeshould
shouldbe
befacing
facingstraight
straightahead.
ahead.
InInthe
ofof
nervous
subjects,
it isitimportant
to ensure
that their
breathing
is not is
held
thecase
case
nervous
subjects,
is important
to ensure
that their
breathing
not
back.
it is important
to create
pleasant
and relaxed
for the subject;
held Overall,
back. Overall,
it is important
toacreate
a pleasant
and atmosphere
relaxed atmosphere
for the
only
thenonly
can the
posture
measured
undisturbed.
subject;
thenbody
can the
bodybe
posture
be measured
undisturbed.
2.2. Marker Points and Balls
Table 1. Conditions for reproducible measurements of posture.
Standard adhesive dots with a diameter of 10–15 mm are suitable as marking points.
No.
Condition
For landmarks on the back and pelvis that would
otherwise not be visible from the side,
1
As little
clothing
as possible [18]. They are light and
polystyrene
balls with a diameter of 10–15
mm
are recommended
2
Feet
shoulder-width
apart
can be easily attached to the skin using thin, double-sided adhesive
pads. Beforehand, the
3
Knees
pointing
forward
skin should be cleaned with alcohol and shaved if necessary so that the adhesive dots stick.
4
Knee joints stretched
5
Upper limb hanging loosely, palms facing the body
Anatomia 2025, 4, 5
4 of 17
We recommend using the following landmarks to ensure a meaningful analysis of the
sagittal plane [19]:
•
•
•
•
•
•
Anatomia 2025, 4, x FOR PEER REVIEW
•
Lateral malleolus: This landmark can be easily palpated even through socks. The
marker should be placed at the center.
Greater trochanter: The greater trochanter has a significant spatial extent, and as
such its center point, projected onto the skin, is difficult to palpate in a reproducible
manner. Underwear should be gathered since any point placed on it will shift with
the movements of the test subject. Precise positioning on a pair of trousers, as shown
in Figure 1, requires a lot of experience.
Acromion: The acromion can be easily palpated with a little experience. If problems
arise, it is recommended to palpate from the clavicle toward the acromioclavicular
joint. The marker should be placed on the tip of the acromion process. Here, too,
placement on the skin and not on the clothing is important. T-shirts can be gathered
up at the sleeve and fixed with tape so that the point can be placed securely.
C7: The spinous process of the seventh cervical vertebra is usually easily palpable and
prominently visible. Sometimes, it is difficult to distinguish it from T1, depending
on the individual’s anatomical characteristics. To differentiate them, the spinous
process should be palpated and the subject should rotate their head to the left and
right. The spinous process of C7 moves at the endpoint of the rotation, but T1 usually
remains stationary.
S1: The spinous process of the first sacral vertebra can be easily located by first
identifying the PSIS. It is about the width of a thumb above (Figure 2).
PSIS: The posterior superior iliac spines are located beneath the lumbar dimples. The
level of the dimples approximately corresponds to the level of S2. When placing a
hand on the iliac crest with the index finger to the side, the horizontally spread thumb
points toward the PSISs. When palpating, move the finger you are using to palpate
slightly so that you can feel the roughness beneath the skin (Figure 2).
5 of 17
ASIS: The anterior superior iliac spines are easy to palpate because the iliac crest bends
forward at this point.
Figure
2. 2.
Positioning
onthe
thePSIS
PSIS(posterior
(posterior
superior
spine)
and
S1 sacral
(first sacral
Figure
Positioningofofthe
the markers
markers on
superior
iliaciliac
spine)
and S1
(first
vertebra)
withthe
theassociated
associated anatomical
anatomical structures.
vertebra)
with
structures.
Further instructions on how to palpate the anatomical landmarks accurately can be
2.3. Measuring
Station
found in [20].
If angles and perpendicular distances are to be measured reproducibly and accu-
2.3. Measuring
Station and evenly illuminated measuring station should be set up (Figure
rately,
a standardized
If angles
distances
are on
to be
reproducibly
andtest
accurately,
3). A floor
mat and
withperpendicular
foot silhouettes
printed
it measured
can be used
to place the
subject in a
a
standardized
and
evenly
illuminated
measuring
station
should
be
set
up
(Figure
3). A S1.
defined way. We provide a graphical file for this as Supplementary Materials Figure
floor
mat withwith
foot silhouettes
printed
on it dpi)
can be
used to place
test subject
in a defined
Webcams
HD resolution
(1080
mounted
on athe
tripod
are suitable
for use as
way.
We
provide
a
graphical
file
for
this
as
Supplementary
Materials
Figure
S1.
cameras in the process. For image recording, the tripod should be set to a height that
roughly corresponds to the height of the test subject’s belly button. This minimizes image
distortion.
If the camera is tilted even slightly to the side, all angles that relate to the position of
the test subject in the room (so-called “global” parameters) are inaccurate and can no
longer be evaluated. Slight tilting cannot be seen with the naked eye, so we recommend
Anatomia 2025, 4, 5
ducible manner in the posture photograph. With the help of a self-leveling laser plummet,
an additional vertical line can be projected onto the subject or the calibration wall to correct possible plumb deviations. This is useful if the calibration panel is a mobile roll-up
of 17
instead of being permanently mounted in a lab. In Supplementary Materials Figure 5S2,
we
provide a graphical file for a measuring panel that can be used freely.
Figure 3. Posture measurement station with floor mat, calibration wall, camera on a tripod and
self-leveling laser plummet that projects onto the test subject.
Webcams with HD resolution (1080 dpi) mounted on a tripod are suitable for use
as cameras in the process. For image recording, the tripod should be set to a height
that roughly corresponds to the height of the test subject’s belly button. This minimizes
image distortion.
If the camera is tilted even slightly to the side, all angles that relate to the position
of the test subject in the room (so-called “global” parameters) are inaccurate and can no
longer be evaluated. Slight tilting cannot be seen with the naked eye, so we recommend
the following procedure:
Place the test subject in front of a calibration wall that has vertical and horizontal
reference lines. This allows the global angle reference frame to be determined in a reproducible manner in the posture photograph. With the help of a self-leveling laser plummet,
an additional vertical line can be projected onto the subject or the calibration wall to correct
possible plumb deviations. This is useful if the calibration panel is a mobile roll-up instead
of being permanently mounted in a lab. In Supplementary Materials Figure S2, we provide
a graphical file for a measuring panel that can be used freely.
2.4. Posture Measurement
When taking photographs or video sequences, it is important to ensure that the camera
is positioned at the subject’s belly button height and that the optical axis is perfectly aligned
with the subject to avoid parallax errors. The subject should stand still.
2.5. Analysis
The posture photographs can be analyzed using appropriate video or graphical programs (e.g., Dartfish® , Fribourg, Switzerland; or Kinovea® , www.kinovea.org accessed
on 7 March 2025). When measuring angles, care should be taken to align the vertical
or horizontal reference planes using the reference lines on the calibration wall to avoid
possible camera tilt.
Anatomia 2025, 4, 5
6 of 17
3. Examination Parameters
Posture parameters are divided into global parameters, which indicate the alignment
of the body in relation to the fixed world coordinate system (e.g., body lean), and parameters
that capture the positions of individual segments in relation to each other (e.g., pelvic tilt
and craniovertebral angle) [21]. The suggested parameters provide a good overall view of
posture and are linked to both reference values and specific studies that have been able to
establish correlations with complaints.
3.1. Overview of Lateral Posture
3.1.1. Theoretical Background
With regard to the sagittal plane, it is generally accepted that the head, trunk and
pelvis should be perpendicular to the ground in an upright posture in order to achieve
a state of equilibrium characterized by dynamic stability and low muscle activity [22,23].
Debousset defines the corresponding geometric “conus of economy” [9].
3.1.2. Anatomical Landmarks
The primary anatomical landmarks used for sagittal posture analysis (Figure 1) are
the external auditory canal (meatus acusticus externus), more specifically, the center of the
tragus, the acromion (shoulder height) and the trochanter major (greater trochanter) [19].
The external malleolus or a point located 1–2 cm distal to it (at the calcaneo-cuboid joint)
serves as the reference point for the plumb line, through which the projection of the center
of mass usually runs.
The perpendicular alignment of the body as a normal posture was propagated by the
Kendalls [22] and adopted by other authors with variations in the reference points and
their perpendicular alignment.
3.1.3. Recommendations
When looking at a plumb line projected onto the body from the side, one can obtain
an initial overview of the segments that deviate significantly from the plumb line (Figure 3).
Even though there are no reference values for the magnitude of plumb line deviation, the
following test procedures can be selected on this basis to conduct more in-depth analyses
of postural weaknesses in individual segments that deviate from the plumb line.
3.2. Anteversion of the Pelvis—Pelvic Tilt
3.2.1. Theoretical Background
Since the pelvis is the basis for the alignment of the spine, examining its positioning in
the sagittal plane is particularly important [24]. Anatomically, anterior pelvic tilt (“anteversion”) can lead to an anterior tilt of the lumbosacral transition area and frequently to an
increase in lumbar lordosis [25]. This, in turn, can lead to lower back pain [26,27]. Tilting
the pelvis backward, on the other hand, results in a steep position of the sacrum with a flat
lumbar lordosis.
There is a correlation between a more tilted pelvis and the occurrence of lower back
pain [28,29]. Current research has shown that the anteversion of the pelvis in the sagittal
plane can also influence the incidence of muscle injuries in sports. Bayrak and Patlar
showed that an increase in pelvic tilt beyond a cut-off angle of 13◦ was associated with
a higher incidence of hamstring injuries [30]. Due to its anatomical position, the biceps
femoris muscle is particularly susceptible to increased tension [31], which can be caused
by increased pelvic tilt. Mendiguchia et al. found that tension increased in the proximal
hamstring muscle origin with increasing pelvic tilt [32]. A higher risk of hamstring injury
due to fatigue-related increases in pelvic tilt was also observed by Romero et al. [33].
Anatomia 2025, 4, 5
oris muscle is particularly susceptible to increased tension [31], which can be caused by
increased pelvic tilt. Mendiguchia et al. found that tension increased in the proximal hamstring muscle origin with increasing pelvic tilt [32]. A higher risk of hamstring injury
7 of 17 due
to fatigue-related increases in pelvic tilt was also observed by Romero et al. [33].
3.2.2.
3.2.2.Anatomical
AnatomicalLandmarks
Landmarks
Figure
Figure44shows
showsthe
the marker
marker placements
placementson
on the
the anterior
anterior superior
superior iliac
iliac spine
spine (ASIS)
(ASIS) and
and
posterior
superior
iliac
spine
(PSIS).
The
pelvictilt
tiltisisthe
theangle
anglebetween
between the
the line
line conthe the
posterior
superior
iliac
spine
(PSIS).
The
pelvic
connecting
the
two
markers
and
the
horizontal
plane.
necting the two markers and the horizontal plane.
Figure
onon
thethe
anterior
superior
iliaciliac
spine
(ASIS)
and and
posterior
superior
iliac iliac
Figure4.4.Marker
Markerplacements
placements
anterior
superior
spine
(ASIS)
posterior
superior
spine
(PSIS)
and
the
associated
anatomical
structures,
PT
=
pelvic
tilt.
spine (PSIS) and the associated anatomical structures, PT = pelvic tilt.
3.2.3. Reference Values
3.2.3. Reference Values
Reference values for pelvic tilt have been provided for various populations in several
studies. Table 2 shows an overview of the reported values.
This overview shows how inconsistent the mean values found are, which may be partly
due to the different measurement methods used (inclinometer versus photogrammetry),
the experience of the examiners and the age groups examined (in the studies listed in
Table 2, mostly younger individuals were examined). Nevertheless, the anatomical values
shown for women are greater than those for men.
Based on the results obtained by Bayrak and Patlar [30], values greater than 13◦ should
be viewed critically in athletes.
Anatomia 2025, 4, 5
8 of 17
Table 2. Mean values, standard deviations and 95% confidence intervals (CI) of pelvic tilt from
various studies.
Sex, Number
Mean
Value
Standard
Deviation
95% CI
Method
Bibrowicz et al.,
2022 [34]
W, n = 176
M, n = 170
15.8
14.9
3.5
3.3
15.3–16.3
14.1–15.4
I
I
Yoon, 2020 [35]
W, n = 61
M, n = 44
10.9
8.4
5.4
5.2
9.5–12.3
6.9–9.9
I
I
Krawczky et al.,
2014 [36]
M+W
n = 94
12.3
5.8
11.1–13.5
--
Weighted average of
4 studies
Sinzato et al.,
2013 [37]
W, n = 33
2 subgroups
16.1
13.4
4.1
4.2
14.7–17.5
11.6–15.2
P
P
Initial values of a treatment
and a control group
Glaner et al.,
2012 [38]
W, n = 30
12.6
4.2
11.1–14.1
P
Carregaro et al.,
2012 [39]
W, n = 24
M, n = 13
15.0
9.5
6.3
3.8
12.5–17.5
7.4–11.6
P
P
Herrington,
2011 [40]
M, n = 55
W, n = 41
6.74
6.93
n.r.
n.r.
Moraes et al.,
2010 [41]
W, n = 15
12.4
4.3
10.2–14.6
P
Nguyen & Shultz,
2007 [42]
W, n = 50
M, n = 50
12.2
8.6
5.2
4.2
10.8–13.6
7.4–9.8
I
I
Study
Remarks
I
I—inclinometer, P—photogrammetry, n.r.—value not reported.
3.2.4. Recommendation
Taking into account the measurement inaccuracies that can arise in photometric angle
measurements, we recommend using the following rounded values based on the examinations described in Table 2:
•
•
•
Pelvic tilt (men): 7◦ –15◦ ;
Pelvic tilt (women): 10◦ –17◦ ;
Pelvic tilt (athletes): <13◦ .
3.3. Forward Inclination of the Body—Body Lean
3.3.1. Theoretical Background
The inclination of the body in the sagittal plane is a global posture parameter that
depends on the activity of the stabilizing muscle groups. In the ankle joint area, the activity
of the calf muscles determines the forward inclination of the lower leg [43], while in the
hip joint area, it is determined by the interaction between the hip and trunk extensors
(e.g., the gluteus maximus and erector spinae muscles) and the hip and trunk flexors.
This also results in a correlation between weak back muscles and the occurrence of lower
back pain [5]. Correlations between body lean and back complaints have been shown
in children and adolescents [44–48]. Interestingly, segmental misalignments of the spine
(e.g., hyperkyphosis/hunchback or hyperlordosis/hollow back) are not included in the
calculation of this global parameter.
3.3.2. Anatomical Landmarks
Figure 5 shows the positioning of the marker points on the lateral malleolus and the
spinous process of the seventh cervical vertebra (C7). Body lean is defined as the angle
between the line connecting the two markers and the vertical axis.
3.3.2. Anatomical Landmarks
Anatomia 2025, 4, 5
Figure 5 shows the positioning of the marker points on the lateral malleolus and the
of 17
spinous process of the seventh cervical vertebra (C7). Body lean is defined as the 9angle
between the line connecting the two markers and the vertical axis.
Figure 5.
5. Marker
and
thethe
seventh
vertebra
C7,C7,
BL BL
= body
lean
Figure
Marker placements
placementson
onthe
thelateral
lateralmalleolus
malleolus
and
seventh
vertebra
= body
lean
angle.
angle.
3.3.3. Reference Values
3.3.3. Reference Values
The values found for body lean in other studies are listed in Table 3.
The values found for body lean in other studies are listed in Table 3.
Table 3. Mean values, standard deviations and 95% confidence intervals (CI) of body lean from
Table 3.
Mean values, standard deviations and 95% confidence intervals (CI) of body lean from
various
studies.
various studies.
Study
Ferreira et al.,
2011 [1]
Carregaro et al.,
2012 [39]
Moraes et al.,
2010 [41]
Krawczky et al.,
2014 [36]
Dolphens et al.,
2012 [49]
Standard
Mean Value
95% CI
Mean Standard
Deviation
Study
Sex, Number
Value Deviation
= 22
1.68
0.44
M + W, Ferreira
n = 22 et al., 2011
1.68[1] M + W, n 0.44
1.50–1.86
Carregaro et al.,1.60
2012
M, n = 13
1.60
0.42
M, n = 13
0.42
1.37–1.83
[39]
W,
n
=
24
0.99
0.24
W, n = 24
0.99
0.24
0.89–1.09
Sex, Number
W, n = 15
2.16
1.09
1.61–2.71
M + W, n = 104
1.73
0.94
1.55–1.91
M, n = 639
W, n = 557
0.00
0.60
1.12
1.12
−0.09–0.09
0.51–0.69
95% CI
Remarks
Remarks
1.50–1.86
1.37–1.83
0.89–1.09
Weighted average of
4 studies
Boys, 12.6 ± 0.54 years
Girls, 10.6 ± 0.47 years
In order to establish reference values, Krawczky et al. evaluated data from four studies
in a review [36] and determined the following values, irrespective of sex:
Body lean: 1.73◦ ± 0.94◦ ;
95% confidence interval [1.55◦ –1.91◦ ].
In several scientific publications, Dolphens et al. examined body lean in children aged
10–12 years, among other parameters [21,44,50]. They were able to identify several clusters
of posture types. Children with a more backward-leaning upper body position showed a
Anatomia 2025, 4, 5
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significantly higher prevalence of back pain. The authors provided the following body lean
values for this “sway back” cluster:
Body lean: 1.3◦ ± 0.88◦ ;
95% confidence interval [1.18◦ –1.42◦ ].
3.3.4. Recommendations
Taking into account the measurement inaccuracies that can arise in photometric angle
measurement, we recommend the following values based on the studies outlined in Table 2:
•
•
Body lean (adults): 1.5◦ –1.6◦ ;
Body lean (children): <1.3◦ .
3.4. Forward Tilt of the Head—Craniovertebral Angle
3.4.1. Theoretical Background
The craniovertebral angle, or CVA (also referred to in other studies as the neck inclination angle, cervical angle or head protrusion angle), is a measure of the forward inclination
of the head. The test quality criteria for this parameter (inter-rater and intra-rater reliability)
have been confirmed [17]. For example, Salahzadeh et al. found an ICC of 0.90 for intrarater reliability, 0.92 for inter-rater reliability and 0.96 for intra-subject reliability [51]. In
general, the acute angle is calculated as shown in Figure 6; the smaller the angle, the more
the head tilts forward. Since there is a correlation between a greater forward head tilt and
the occurrence of shoulder and neck complaints [47,48,52], this parameter is useful in the
Anatomia 2025, 4, x FOR PEER REVIEW
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context of posture diagnostics [2]. Likewise, a correlation is suspected between a smaller
CVA and occlusal disorders [53].
Figure6.6.Measuring
Measuringthe
thecraniovertebral
craniovertebralangle
angle(CVA)
(CVA)with
withaamarker
markerplaced
placedon
onC7
C7and
andone
oneside
sideofof
Figure
◦
theangle
anglepassing
passingthrough
throughthe
theexternal
externalauditory
auditorycanal.
canal.Both
Boththe
theacute
acuteangle
angle(57.5
(57.5°)
andthe
theobtuse
obtuse
the
) and
angle
that
thethe
horizontal
side
of the
angle
is aligned
withwith
the horizontal
lineslines
on the
angleare
areshown.
shown.Note
Note
that
horizontal
side
of the
angle
is aligned
the horizontal
on
calibration
panel.
the calibration panel.
3.4.2. Anatomical Landmarks
3.4.2. Anatomical Landmarks
A marker ball positioned on C7 is sufficient; the auditory canal does not need to be
A marker ball positioned on C7 is sufficient; the auditory canal does not need to be
marked. For the most accurate measurement, the leg of the angle should pass through
marked. For the most accurate measurement, the leg of the angle should pass through the
the midpoint of the tragus of the ear. To minimize measurement errors, it is important
midpoint of the tragus of the ear. To minimize measurement errors, it is important that
that the head is straight and the gaze is directed forward (horizontal Frankfurt plane). If
the head is straight and the gaze is directed forward (horizontal Frankfurt plane). If necessary, a marker point can be placed on a distant wall at which the subject focuses their
gaze. The angle to the horizontal is measured. Since the angle is particularly sensitive to
camera tilt, the horizontal leg of the angle should be aligned with a reference line in the
image (Figure 6). A calibration panel (see Supplementary Materials Figure S2) is useful
Anatomia 2025, 4, 5
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necessary, a marker point can be placed on a distant wall at which the subject focuses their
gaze. The angle to the horizontal is measured. Since the angle is particularly sensitive to
camera tilt, the horizontal leg of the angle should be aligned with a reference line in the
image (Figure 6). A calibration panel (see Supplementary Materials Figure S2) is useful for
this purpose.
3.4.3. Reference Values
Table 4 shows the mean values for the CVA (see also [17,54]). Since the definition
of the CVA is not standardized, both the obtuse angle and the acute angle (180◦ —obtuse
angle) are given.
Table 4. Mean values, standard deviation and 95%-confidence interval (CI) for the craniovertebral
angle in the analyzed studies.
Study
Kim et al.,
2018 [52]
Hazar et al.,
2015 [55]
Helmya et al.,
2015 [56]
Coelho et al.,
2014 [57]
Singla & Veqar,
2015 [58]
Salahzadeh et al.,
2015 [51]
Greenfield et al.,
1995 [59]
Raine & Twomey,
1994 [60]
Sex, Number
Mean Value
Obtuse Angle
Mean Value
Acute Angle
Standard
Deviation
95% CI
M + W, n = 22
131.4
48.6
1.99
47.8–49.3
Adults
M + W, n = 30
131.6
48.4
4.9
46.7–50.2
Adolescents, 16 years
M + W, n = 22
131.4
48.6
8.1
45.2–52.0
W, n = 15
M, n = 6
135.6
137.1
44.4
42.9
6.69
2.01
41.0–47.8
41.3–44.5
Adolescents, 12–18 years,
average of 3 raters
Subgroup of children with
normal flexibility, 7–12 years
M, n = 15
129.7
50.3
3.56
48.5–52.1
Adults
W, n = 12
125.0
55.0
3.30
53.1–56.9
Adults
M + W, n = 30
128.0
52.0
4.7
50.3–53.7
Adults
M + W, n = 39
128.1
51.9
4.5
50.5–53.3
Adolescents and adults
Remarks
3.4.4. Recommendations
Kim et al. [52] identified a range of 48.6◦ ± 2.0◦ (95% confidence interval: 47.8◦ –49.3◦ )
for symptom-free subjects. The mean value for subjects with neck complaints was
44.4◦ ± 4.4◦ (95% confidence interval: 42.6◦ –46.3◦ ). Salahzadeh et al. distinguished a normal CVA of 55.0 ± 3.3◦ from a moderate to severe head tilt with a CVA of 41.9 ± 3.9◦ [51].
The following values can therefore be recommended:
•
Craniovertebral angle: 47◦ –50◦ .
3.5. Depth of Lordosis in the Cervical and Lumbar Spine—Fleche Cervicale and Lombaire
3.5.1. Theoretical Background
It is known that a particularly strong structural load is placed on the vertebrae and their
joints, especially the facet joints, at the transition points between lordosis and kyphosis [13].
The posture parameters fleche cervicale and fleche lombaire are particularly interesting in
this context because they are calculated using the differences in the peak points of kyphosis
and lordosis in the sagittal plane (the term “flèche” comes from the French for arrow).
Both parameters were introduced by Stagnara in 1982 [61,62]. Since they can be obtained
quickly, inexpensively and almost without contact with the subject, these parameters are
highly practical.
Anatomia 2025, 4, 5
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3.5.2. Anatomical Landmarks
A plumb line is placed at the point of the most pronounced thoracic kyphosis (apex).
If the apex of the thoracic kyphosis is obscured by the scapulae, a measuring stick can
also be adhered to the skin to precisely locate the position of the apex. The horizontal
distances of the deepest cervical lordosis (fleche cervicale) and the deepest lumbar lordosis
(fleche lombaire) to the plumb line are measured (Figure 7). Since taller individuals have
anatomically more pronounced kyphoses and lordoses, it is recommended to normalize the
fleche values to the trunk height [63]. For this purpose, the vertical distance between C7
and S1 is measured (equivalent to the trunk height), and the fleche values are normalized
according to the following formula:
Anatomia 2025, 4, x FOR PEER REVIEW
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Fleche% = fleche * 100/(distance C7-S1).
Figure7.7.Definition
Definitionofofthe
thefleche
flechevalues
values
(white
horizontal
lines).
X marks
apex
of the
Figure
(white
horizontal
lines).
X marks
thethe
apex
of the
tho-thoracic
racic
kyphosis.
kyphosis.
An advantage of the fleche values is that they can be measured with minimal apparatus.
All that is needed is a plumb line, a ruler (preferably with a spirit level) and a flexible
In a tape.
recent study [63], data from 1150 subjects of different ages were analyzed. Th
measuring
3.5.3. Reference Values
resulting values are summarized in Table 5.
3.5.3. Reference Values
In a5.recent
study [63],
data
subjects
of different
ages
were analyzed.
Table
Normalized
values
of from
fleche1150
lombaire
(FL%)
and fleche
cervicale
(FC%) inThe
different ag
resulting
values
summarized
in Table
groups for
bothare
sexes.
Data adapted
from5.[63] with permission.
Parameter
Age Group
[Years]
10–15
12–16
16–19
17–19
Sex
N
Mean
female
male
female
male
female
44
159
14
29
105
8.99
7.13
7.63
7.29
8.35
25th Percentile 75th Percentile
7.13
5.06
6.45
5.41
6.51
11.27
8.74
8.37
9.50
10.47
Lower 95%
CI
8.14
6.70
6.74
6.21
7.81
Upper 95%
CI
9.86
7.60
8.62
8.44
8.92
Anatomia 2025, 4, 5
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Table 5. Normalized values of fleche lombaire (FL%) and fleche cervicale (FC%) in different age
groups for both sexes. Data adapted from [63] with permission.
Parameter
FL%
[% trunk
height]
FC%
[% trunk
height]
Age Group
[Years]
Sex
N
Mean
25th
Percentile
75th
Percentile
Lower
95% CI
Upper
95% CI
10–15
12–16
16–19
17–19
female
male
female
male
44
159
14
29
8.99
7.13
7.63
7.29
7.13
5.06
6.45
5.41
11.27
8.74
8.37
9.50
8.14
6.70
6.74
6.21
9.86
7.60
8.62
8.44
20–29
female
male
105
126
8.35
7.62
6.51
5.79
10.47
9.31
7.81
7.11
8.92
8.14
30–39
female
male
75
90
8.54
7.85
6.59
5.72
10.49
9.98
7.83
7.24
9.22
8.49
40–49
female
male
97
98
8.22
7.43
6.13
5.37
10.39
9.44
7.62
6.84
8.81
7.97
50–59
female
male
99
144
8.52
7.65
6.69
5.78
10.68
9.59
7.94
7.22
9.12
8.11
60–69
female
male
18
29
8.94
7.41
5.54
5.74
11.34
9.31
7.41
6.51
10.41
8.28
10–15
12–16
16–19
17–19
female
male
female
male
44
159
14
29
12.29
13.04
11.64
12.60
9.77
11.13
8.62
10.76
14.12
15.13
13.97
13.44
11.32
12.57
10.22
11.65
13.31
13.53
13.21
13.51
20–29
female
male
105
126
11.68
12.89
9.53
10.59
13.61
14.86
11.11
12.33
12.24
13.43
30–39
female
male
75
90
10.42
13.11
8.35
11.42
12.44
15.08
9.63
12.54
11.22
13.67
40–49
female
male
97
98
11.30
14.13
9.04
12.45
13.73
16.21
10.59
13.54
12.03
14.71
50–59
female
male
99
144
12.22
14.69
10.06
12.37
14.67
16.65
11.48
14.13
12.97
15.25
60–69
female
male
18
29
11.66
14.68
8.55
12.44
14.47
16.68
9.17
13.40
14.27
15.94
3.5.4. Recommendations
The confidence intervals can be found in the Table 5. As a rule of thumb, the following
can be assumed:
•
•
•
•
Normalized FC for men: 12–15% of the trunk height;
Normalized FC for women: 9.5–14% of the trunk height;
Normalized FL for men: 6.5–8.5% of the trunk height;
Normalized FL for women: 7–9% of the trunk height.
4. Conclusions
Posture analysis in the sagittal plane is useful from a preventative medical point
of view, as there are relationships between deviations in individual posture parameters
and the occurrence of complaints. The parameters presented in this article have all been
scientifically evaluated, and reference values are available that make it possible to assess
sagittal posture from a medical or sports science perspective. Even though photometric
posture analysis is subject to measurement errors, it still allows for sufficiently accurate
measurement and evaluation of posture if the anatomical landmarks are correctly palpated
Anatomia 2025, 4, 5
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and marked. Therefore, sagittal posture analysis should also be increasingly used in the
field of sports for preventive purposes.
Supplementary Materials: The following supporting information can be downloaded at https:
//www.mdpi.com/article/10.3390/anatomia4020005/s1, Figure S1: Floor mat; Figure S2: Calibration panel.
Funding: This research received no external funding.
Institutional Review Board Statement: This study was conducted in accordance with the Declaration
of Helsinki and approved by the Institutional Review Board (Ethics Committee of the Department of
Social Sciences, Rheinland-Pfälzische Technische Universität RPTU; reference number 2023-57) on
25 January 2023.
Informed Consent Statement: The model in the images has given his written consent for the
publication of the images and this article.
Acknowledgments: The author would like to thank Michael Fröhlich for providing the analytical
laboratories.
Conflicts of Interest: The author declares no conflicts of interest.
Abbreviations
The following abbreviations are used in this manuscript:
ASIS
PSIS
C7
T1
S1
FC
FL
CVA
PT
CI
BL
Anterior superior iliac spine
Posterior superior iliac spine
Seventh cervical vertebra
First thoracic vertebra
First sacral vertebra
Fleche cervicale
Fleche lombaire
Craniovertebral angle
Pelvic tilt
Confidence interval
Body lean
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