The Spine Journal - (2013) -

Perspective

Lumbar lordosis
Ella Been, PT, PhDa,b,*, Leonid Kalichman, PT, PhDc
a
Physical Therapy Department, Zefat Academic College, Safed, Israel
b
Department of Anatomy and Anthropology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
c
Department of Physical Therapy, Recanati School for Community Health Professions, Faculty of Health Sciences,
Ben-Gurion University of the Negev, Beer Sheva, Israel
Received 3 October 2011; revised 22 June 2013; accepted 21 July 2013

Abstract Lumbar lordosis is a key postural component that has interested both clinicians and researchers for
many years. Despite its wide use in assessing postural abnormalities, there remain many unan-
swered questions regarding lumbar lordosis measurements. Therefore, in this article we reviewed
different factors associated with the lordosis angle based on existing literature and determined nor-
mal values of lordosis. We reviewed more than 120 articles that measure and describe the different
factors associated with the lumbar lordosis angle. Because of a variety of factors influencing the
evaluation of lumbar lordosis such as how to position the patient and the number of vertebrae in-
cluded in the calculation, we recommend establishing a uniform method of evaluating the lordosis
angle. Based on our review, it seems that the optimal position for radiologic measurement of lor-
dosis is standing with arms supported while shoulders are flexed at a 30
angle. There is evidence
that many factors, such as age, gender, body mass index, ethnicity, and sport, may affect the lordosis
angle, making it difficult to determine uniform normal values. Normal lordosis should be deter-
mined based on the specific characteristics of each individual; we therefore presented normal lor-
dosis values for different groups/populations. There is also evidence that the lumbar lordosis angle
is positively and significantly associated with spondylolysis and isthmic spondylolisthesis. How-
ever, no association has been found with other spinal degenerative features. Inconclusive evidence
exists for association between lordosis and low back pain. Additional studies are needed to evaluate
these associations. The optimal lordotic range remains unknown and may be related to a variety of
individual factors such as weight, activity, muscular strength, and flexibility of the spine and lower
extremities. Ó 2013 Elsevier Inc. All rights reserved.
Keywords: Spine; Posture; Lordosis; Spinal pathology; Spinal measurements

Introduction it difficult for surgeons, researchers, therapists, and patients

to know if they are examining or achieving the same postural
Research studies have shown an increasing recognition
goal [8].
of the functional and clinical importance of lumbar lordosis In this topical review, we determined, based on existing
[1–5]. It is a key feature in maintaining sagittal balance. Sag-
literature, normal and abnormal parameters of lumbar lordo-
ittal balance or ‘‘neutral upright sagittal spinal alignment’’ is
sis and examine the different factors associated with the lor-
a postural goal of surgical, ergonomic, and physiotherapeu-
dosis angle. To accomplish this, we searched PubMed,
tic intervention. However, a wide variety of thoracic and
PEDro, EMBASE, and Google scholar databases (incep-
lumbar spinal curves may correspond with the accepted
tion–2012) for the key words ‘‘spine’’, ‘‘spinal’’, ‘‘lordosis’’,
criterion of sagittal balance (50 mm of C7–S1 sagittal devi-
‘‘lumbar’’, ‘‘posture’’, ‘‘pathology’’, ‘‘measurements’’, and
ation in asymptomatic adults while standing) [6,7], making
combinations of key words. All relevant articles in English
were reviewed. Pertinent secondary references were also re-
FDA device/drug status: Not applicable. trieved. We are aware that this traditional approach to reviews
Author disclosures: EB: Nothing to disclose. LK: Nothing to disclose. has much more potential for bias than systematic reviews or
* Corresponding author. Department of Anatomy and Anthropology,
Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel. Tel.:
meta-analyses; however, we have endeavored to be inclusive
þ972-3-6408287. and open minded. We also consulted experts in spinal surgery
E-mail address: beenella@post.tau.ac.il (E. Been) and radiology to produce this review on lumbar lordosis.
1529-9430/$ - see front matter Ó 2013 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.spinee.2013.07.464
2 E. Been and L. Kalichman / The Spine Journal - (2013) -

Anatomy of lumbar lordosis

Lumbar lordosis is the inward (ventral) curvature of the
lumbar spine formed by the wedging of lumbar vertebral
bodies and the intervertebral disks [9,10] (Fig. 1). Dorsal
wedging of the vertebral bodies and disks (anterior part lon-
ger than posterior) increases the lordosis angle, whereas
more ventral wedging of these structures (anterior part
shorter than posterior) reduces the lordosis angle (Fig. 1).
Lumbar lordosis is similarly influenced by the shape of
the vertebral bodies and the shape of the intervertebral
discs, because each account for nearly 50% of the variabil-
ity seen in lordotic angles of adults [11,12]. Each of the five
lumbar segments (vertebral body and the adjacent disc)
contribute to the lordosis. The last lumbar segment (L5)
contributes almost 40% to overall lordosis. The first seg-
ment (L1) contributes only 5% [13]. The lordosis angle also
correlates with the orientation of the inferior articular pro-
cesses—greater lordosis correlates with more dorsally (hor-
izontally) inclined inferior articular (facet) processes in
relation to the vertebral bodies [14] (Fig. 1).
A close correlation exists between the lordosis angle (the
common measure of lumbar lordosis) and other postural
variables. Many researchers have found a high correlation
between the lumbar lordosis angle and pelvic and thoracic
orientation in space. Greater lordosis angles correlate with
a more horizontally inclined sacrum (increased sacral
slope, more vertical sacral endplate), increased pelvic inci-
Fig. 1. Measurements of lumbar lordosis Cobb’s angle (LA), vertebral
dence, and increased pelvic tilt [15,16]. Most researchers body (B) and intervertebral disc (D) wedging, and facet joint angle (F).
found that greater lordosis usually correlates with higher
thoracic kyphosis, but cases of increased lordosis with re-
angle. Other researchers, however, found that the lordosis
duced thoracic kyphosis have also been reported [15–17].
angle continues to increase during later childhood and pu-
Small lordosis angles usually correlate with a more vertical
berty [22,23] even until the age of 20 [6] (Table 1). For ex-
sacrum, small pelvic tilt, pelvic incidence, and reduced tho-
ample, Cil et al. [22] demonstrated an increase of the
racic kyphosis; however, cases of reduced lumbar lordosis
lordosis angle from 44.3
at 3 to 6 years to 54.6
at 13 to
with increased thoracic kyphosis have also been detailed
15 years.
[15–17].
It can be concluded that lumbar lordosis begins to de-
velop in fetuses. The major increase of the lordosis angle
Ontogenetic development of the lumbar lordosis occurs during the first 3 years of life and continues increas-
ing at least until puberty. There are many gaps in the cur-
Although many authors believe that the spine of the hu- rent knowledge regarding the ontogenetic development of
man fetus shows only one kyphotic curvature from cranial lumbar lordosis. Additional studies are essential to fill in
to caudal [18,19], studies have shown that the fetal spine this gap and to identify the factors that determine lordosis
has lordotic curvature at the lumbosacral junction [20,21]. development. Ascertaining the normal values of lordosis
Choufani et al. [20] in a magnetic resonance imaging in children is essential for early detection and treatment
(MRI) study of 45 fetuses aged 23 to 40 weeks gestation of postural abnormalities.
demonstrated that all fetuses had lordotic lumbar curvature
with a mean radius of 18.7 mm. This lordosis was uncorre-
lated with gestational age, which means that it was not re- Evaluation of lumbar lordosis
lated to growth and, according to the authors, might have
Number of evaluated vertebrae
been genetically determined.
Few researchers have examined the lordosis angle in One of the fundamental questions regarding lordosis
early childhood, with Reichmann and Lewin [21], being evaluation is the number of vertebrae or segments (vertebra
a notable exception. They found that lordosis angles in- and adjacent intervertebral disk) measured. The most com-
creased during the first 3 years of life, claiming that at mon evaluation of lumbar lordosis uses the angle formed by
the age of 3, the child’s spine reaches an adult-like lordosis all five lumbar segments (L1–L5). When employing Cobb’s
 E. Been and L. Kalichman / The Spine Journal - (2013) - 3

Table 1
Data available on lordosis angles in children
Research Method Position Age (y) Sample size Lordosis angle (
)
Cil et al. [22] Cobb’s angle (superior end plate of L1 and S1) Standing 3–6 51 44.3611.0
7–9 37 51.7611.5
10–12 32 57.3610.6
13–15 31 54.669.8
Neuschwander et al. [124] Cobb’s angle (L1–S1) Standing 1162 8 60.263.1
Mac-Thiong et al. [7] Arc between L1 and L5 Standing 12.163.3 341 48611.7
Giglio and Volpon [6] Panthograph (spinous processes L1–L5) Standing 5 16 2269
10 30 3267
15 22 33611
20 17 38610
Willner and Johnson [23] Spinal panthograph Standing 8, boys 48 33.669.3
12, boys 63 3267.1
16, boys 74 33.668.6
8, girls 50 33.368.9
12, girls 64 34.868.5
16, girls 81 36.767.6

method, the upper line is drawn at the superior endplate
of L1, and the lower line at the superior endplate of the
sacrum (S1; Fig. 1). However, some researchers measure
lordosis starting as high as T10*, others finish at L3.
Some researchers do not include the lower lumbar seg-
ment (L5) or only do not include the last intervertebral
disk L5–S1 in their measurements. Significant differences
occur between lordosis angles when different numbers of
vertebral segments are measured (Table 2). Therefore, we
believe that it is crucial to measure exactly the same
number of segments to compare the different studies.
We suggest that measurements should include the verte-
bral bodies and intervertebral disks of L1–L5; in other
words, measurements (Cobb’s method) should be per-
formed between the superior endplate of the first lumbar
vertebra and the superior endplate of the sacrum. The
logic behind our suggestion is based on anatomic consid-
erations, including all of the lumbar segments in the lum-
bar lordosis measurements. In addition, this is the most
popular measurement of lumbar lordosis used today
[22,24–27]; functionally, the five lumbar segments share
a fundamental role in upright functions such as walking
and running [28].
Table 2
Lordosis angle (Cobb’s method) measured in a standing position using
different spinal levels
Modified after
Measurement between Vialle et al. [10]
L1 superior end plateS1 superior 58.5
end plate
L1 inferior end plateS1 superior 62
end plate
L2 superior end plateS1 superior 57
end plate
L1 superior end plateL5 superior 35
end plate
L1 superior end plateL5 inferior 43611.2
end plate
Methods of measurement
Many methods are used to evaluate lumbar lordosis. We
divided the methods into clinical and imaging evaluation.
Clinical examination evaluates the degree of lordosis di-
rectly on the individual’s body. Radiologic evaluation uses
two-dimensional radiographs, three-dimensional (3D) com-
puted tomography and MRI. Each method of evaluation has
its advantages and disadvantages, but the major problem is
that it is difficult to compare the measurements when per-
formed by different methodologies.
Clinical methods for evaluating lordosis angles include
various 3D posture analysis systems and surface topography
systems [29,30]. Most of these methods use the spinous pro-
cesses of the lumbar vertebrae to evaluate the degree of lor-
dosis [6]. The main advantage of these measurements is the
lack of radiation, thus allowing frequent evaluation of the
spinal curves, and better monitoring of the changes in the
lordosis angle. The reproducibility of clinical methods is rel-
atively high (interobserver intraclass correlation coefficient
[ICC] is 0.70–0.85, [31,32]); however, it is not as high as
with radiologic methods (interobserver ICC isO0.87 [33]).
On the other hand, because clinical methods use surface
anatomy to evaluate the lordosis angle, only moderate corre-
lations with radiologic measurements were found. Compar-
isons between the patients are also problematic because of
different paraspinal muscle development, thickness of sub-
Modified after cutaneous fat, and anatomic variations in spinous processes
Been et al. [11] length and orientation. Recently, a few articles have sug-
51.3610.7 gested the use of electronic or laser lordosis angle measure-
ments. Letafatkar et al. [34] showed that using a flexible
54.8 plastic ruler and an AutoCAD (arc) for lordosis angle mea-
surements is a reliable and valid method, and suggested that
49
this method may replace radiography in evaluating lumbar
31.5 lordosis. Celan et al. [35] measured the lordosis and kypho-
sis angles using a laser triangulation method. Although
39.6 there are sophisticated 3D posture analysis systems such as
Optotrak (Northern Digital Inc., Waterloo, Canada), Vicon
4 E. Been and L. Kalichman / The Spine Journal
Fig. 2. Two possible lumbar lordosis curves with the same Cobb’s angle.
(Vicon Motion Systems, Oxford, UK), Motion Analysis
(Motion Analysis Corporation, Santa Rosa, CA, USA),
and surface topography systems, these systems are not
accessible for most clinicians [36]. These sophisticated 3D
systems enable researchers to evaluate the lordosis angle
in different postures and settings. For example, Levine
et al. [37] used motion analysis systems to examine the
lordosis angles during walking and running.
Fortin et al. [36] presented a novel, promising technique
for clinical posture assessment based on calculation of body
angles and distances on photographs. This method has a rel-
atively low cost, is easy to perform in a clinical setting, and
there is no exposure to radiation. Photograph acquisition
showed good inter- and intrarater reliability (ICCO0.991),
but only moderate validity (r50.48) compared with radio-
graphic evaluation of lordosis [36]. We therefore conclude
that utilizing clinical methods for evaluating lordosis angles
can be a useful tool for monitoring patients’ progress. How-
ever, clinical methods in their present form are unsuitable
for research or clinical evaluation when absolute parame-
ters of lumbar lordosis need to be measured.
Many radiologic methods have been used to evaluate the
lordosis angle on two-dimensional radiographs. The Cobb
method (or modified Cobb method) has become the gold
standard in measuring lumbar lordosis [33], using vertebral
endplate lines to measure angles on sagittal radiographs.
This method is very simple to perform, and has been proven
highly reliable [33]. The strongest limitation of the Cobb
method is that, theoretically, two spinal curvatures of differ-
ent magnitudes may result in the same Cobb angle (Fig. 2);
therefore, other methods have been developed in attempt
to overcome this problem. These methods use different
- (2013) -
Fig. 3. Measurements of lumbar lordosis: anterior tangent, posterior tan-
gent, centroid, and best fit ellipse.
anatomic landmarks on the vertebral bodies to evaluate the
lordosis angle. For example, the anterior and the posterior
tangent methods use the anterior or posterior vertebral body
wall to determine the lordosis angle. The centroid method
uses the center of the vertebral body to measure the lordosis
angle. Some methods, such as the best-fit ellipse, construct
a circular geometrical model of the lumbar spine (Fig. 3).
All of these methods were found to be reliable in evaluating
lordosis. A more detailed description of the different lordo-
sis evaluation methods can be found in Vrtovec et al. [33]
Position of measurement
One of the fundamental variables in lordosis measure-
ment is the position in which the measurements were taken,
that is, standing, sitting, or lying down. Most lumbar lordo-
sis studies use X-rays taken in the standing position, stating
that this is the most functionally relevant position [38,39].
However, during the last two decades, more and more spi-
nal clinical evaluations and research has been performed
using computed tomography and MRI technologies that al-
low a much more detailed depiction of spinal anatomy and
pathology. It is therefore important to understand how the
subject’s position influences the lordosis angle. Recently,
several authors [40,41] reported that a horizontal MRI with
the patient supine and legs straight out (supine extended po-
sition) was comparable with a vertical MRI, where the pa-
tient stands. This is in agreement with earlier reports by
Schmid et al. [42], who studied 12 young volunteers using
a positional MRI. All aforementioned authors concluded
that the supine extended position was a functionally rele-
vant position and suggested that it could replace the upright
extended position (Table 3). On the other hand, lordosis
measured in the supine position, with bent hips and knees
(psoas relaxed position), was found to be significantly
smaller than when in a standing or supine extended position
[43]. In an open MRI study, lordosis showed a significant
increase of 6.3
(14%) from supine psoas relaxed position
to a true standing position.
Measuring the lordosis angle in sitting position
All researchers agree that the lordotic curvature in a sitting
position is significantly lower than in a standing position
 E. Been and L. Kalichman / The Spine Journal
Table 3
Average lordosis angle measured in different positions
Research N Modality
Hirasawa et al. [37] 29 MRI
Madsen et al. [38] 16 MRI
Mauch et al. [40] 35 MRI
De Carvalho et al. [41] 8 X-ray
* With flexed hips and knees.
y
Subjects were instructed to lean slightly backwards against the examination bench during the vertical magnetic resonance imaging (MRI) and to rest
their arms on the cross bar to secure immobility.
[26,40,42,44,45] (Table 3). Furthermore, Hirasawa et al. [40]
demonstrated significant differences in lordosis angles be-
tween different sitting positions ranging from 3.1611.8 in
a flexed sitting position to 46.2612.3 in an extended sitting
position. We therefore feel that the sitting position cannot re-
place the standing position as the functionally relevant posi-
tion. However, because sitting is one of the most common
postures used in the modern world, the degree of lordosis ex-
hibited during sitting may has its own significance.
The effect of arm position on lordosis measurements
Arm position in standing lateral radiographs may disturb
sagittal balance and therefore alter the lordosis angle. The
neutral position (arms placed at the sides of the body) is im-
practical because the arm bones overlay the spine and thus
may interfere with the measurements. Several studies have
compared different arm positions with a functional standing
position with arms at the sides [46,47], and found that arm
position in standing lateral radiographs did not significantly
affect the lordosis angle. Although no differences were
found between the different positions, both studies recom-
mended the use of a standard position for repeated mea-
surements of the lordosis angle. Marks et al. [39] used
motion analysis laboratory and found that the lumbar angle
measured from an X-ray taken in a standing position with
the hands supported and shoulders slightly flexed (30
flex-
ion at the shoulder) was comparable with the measurement
taken in a functional standing position with arms at the
side. They concluded that this seems to be the best way
to move the arms, anterior to the spine, with the least effect
on overall sagittal balance.
The wide range of postures (standing, supine extended,
and psoas-relaxed positions) and arm positions used to
measure lumbar lordosis pose a problem when comparing
data and establishing normal values of lordosis. We believe
that a uniform method of evaluating the lordosis angle
should be established to allow comparisons of clinical
and research measurements.
Based on our review, it seems that the optimal position
for the radiologic measurement of lordosis is standing with
arms supported while flexing the shoulder at a 30
angle. If
standing is not possible, the lordotic angle should be mea-
sured in a supine position with straightened legs. In the
clinical setting, there is a strong need to develop a method
- (2013) - 5
Lying with Lying in psoas
extended legs relaxed position* Standing Sitting
53.269.2 53.3613.4 20.5612.7
52 44 43.9y
46.369.9 52.668.9
63615 20
that is reliable, comparable with radiographic measure-
ments, easy to perform, and inexpensive.
Factors associated with lumbar lordosis
Age
The commonly held opinion is that lumbar lordosis ‘flat-
tens’ out with spinal problems and subsequent age-related
degenerative changes [48]. However, most studies did not
find an association between age and lordosis [27,48–51].
Other studies claimed that lumbar lordosis increases with
age [52] or decreases only after the sixth decade [53]. On
the other hand, no association was found between age
and wedging of vertebral bodies and intervertebral discs
[27]. Existing evidence, therefore, does not support the
common opinion of lordosis flattening with age. However,
the question of the lumbar lordosis angle changing with age
is not fully resolved and more research is needed to under-
stand the effect of age on the lordosis angle.
Gender
One study evaluated lordosis in a supine position [27],
whereas others used lateral standing X-rays [14,54–58],
to show that the lumbar lordosis angle does not differ be-
tween the genders. Middleditch and Oliver [59] found no
difference in the lumbar lordosis between males and fe-
males until middle age. However, other studies found that
females have significantly greater lordosis angles (2
–5
)
than males [10,48,50,60,61]. Stagnara et al. [62] suggested
that females apparently had greater lumbar lordosis owing
to their greater buttock size. Mosner et al. [63], who con-
ducted a study of actual and apparent lumbar lordosis in
Caucasian and African-American females, agree with Stag-
nara’s view.
Height and weight
Most researchers agree that obesity, especially central
(abdominal) obesity, increases the lordosis angle. Murrie
et al. [48] found that lumbar lordosis was significantly
greater (p!.01) in individuals with a high body mass index
(BMI). Guo et al. [64] found that a BMI exceeding 24 kg/
m2 might increase the lumbar lordosis angle. Moore and
Dalley [65] suggested that a hyperlordotic lumbar spine
6 E. Been and L. Kalichman / The Spine Journal
found in obese individuals was owing to a compensatory
backward lean to improve balance. Recently, Smith et al.
[66] reported a hyperlordotic or sway posture in children
(3–14 years) with a high BMI. On the other hand, Naseri
et al. [67], who examined 75 Iranian women, Mcllwraith
[68], and Naido [49] found poor correlation between lum-
bar lordosis and BMI.
Naido [49] found a significant association (p5.004) be-
tween the height of the subjects and lumbar lordosis, which
is in agreement with Nourbakhsh et al.’s findings [69]. It is
possible that tall individuals have the increased loading in
the lumbar area, which causes increased lordosis [70].
Pregnancy
In two recent studies, the most significant increase in
lumbar lordosis occurred in the late stages of pregnancy
[65,71]. Nourbakhsh et al. [69] found that previous preg-
nancies and the number of pregnancies were associated
with the lumbar lordosis degree [69]. There are several pos-
sible explanations for this phenomenon: a compensatory
backward lean to improve balance owing to increased ab-
dominal weight [72]; the muscular imbalance caused by
overstretched weak abdominal muscles and strong back
muscles might contribute to increased lordosis found in
women with a high number of pregnancies; and during
the last trimester of pregnancy a significant increase in joint
laxity occurs [73,74]. It is possible that this hyperlaxity al-
lows the increase of lumbar lordosis by softening the para-
spinal ligaments. The new lordosis angle remains after
delivery.
Ethnicity
As early as the end of the 19th century, Cunningham
[75] indicated that differences in lordosis angles were eth-
nically related. Fahrni and Trueman [76] discovered smaller
lordotic angles in a cadaver sample of Native Americans
compared with Caucasians. Patrick [77], using external
flexicurve measurements, found 20% higher lordosis angles
in a Nigerian population compared with Europeans. Hanson
et al. [78] and recently Lonner et al. [79] found that lordosis
angles in African-Americans averaged 4
greater than Cau-
casians. Lonner et al.’s study was the largest study on this
subject. However, the authors used an adolescent scoliotic
population; thus, the results may not be applicable to the
general population. On the other hand, many researchers
found a similarity in the degree of lordotic curvature be-
tween populations. Mosner et al. [63] and Goldberg and
Chiarello [80] found similar lumbar lordosis angles in Cau-
casians and African-Americans. Chen [81] compared the
lordosis angles of 16 healthy Chinese men with that of Eu-
ropeans and found no interracial differences. Mosner et al.
[63] concluded that the clinician’s assumption that African-
Americans have a greater lordosis than Caucasians is based
on an apparent increased lordosis owing to more prominent
buttocks.
- (2013) -
Heritability
Although heritability and genetics of scoliosis has been
extensively studied [82], we found only one study that eval-
uated the familial correlations of normal spinal curves [83],
finding significant positive familial correlations in lumbar
lordosis measurements. All sibling groups showed a greater
correlation of lordosis measurement than unrelated con-
trols. Same-sex siblings had a greater correlation than dif-
ferent sex siblings.
Muscles and lumbar lordosis
It is widely accepted that abdominal and back muscula-
tures affect pelvic inclination and lumbar lordosis while in
a static, upright posture [84,85]. Many researchers
[50,51,86,87] have suggested that lumbar lordosis and ab-
dominal muscle function are related to each other. For ex-
ample, the weakness of the abdominal muscle permits an
anterior pelvic tilt and hyperlordotic posture [18,50,51].
On the other hand, strong abdominal muscles can tilt the
pelvis posteriorly and concurrently reduce lordosis. At the
same time, strong back muscles can tilt the pelvis anteri-
orly, thus increasing lumbar lordosis. Some researchers ex-
amined the association between abdominal muscle strength
and the lordosis angle, but found no conclusive evidence of
a relationship [51,85,88]. It is possible that, in the static po-
sition, the equilibrium between trunk flexors and extensors
influenced the lumbar lordosis and not the strength of the
specific muscle group. Only Kim et al. [46] examined the
relationship between trunk muscle strength (abdominal
vs. back muscles) and lumbar lordosis and found that the
ratio of extensor torque to flexor torque was significantly
related to the lordotic angle (Pearson’s correlation coeffi-
cient50.491; p!.01). Relatively strong spinal extensors
and weak spinal flexors were associated with high lumbar
lordosis and vice versa. The researchers concluded that an
imbalance in trunk muscle strength can significantly influ-
ence the lordotic curve of the lumbar spine and might be
a risk factor for potential low back pain (LBP).
Hip muscles, such as the iliopsoas and hamstring, might
also influence the degree of lordosis in a static upright pos-
ture. These muscles are able to move the pelvis in the sag-
ittal plane—anterior and posterior pelvic tilt. Posterior
pelvic tilt can result from contraction or tightness of the
hamstring muscles, leading to a more horizontal sacral end-
plate and hypolordosis (the smaller lordosis would be nec-
essary to keep the line of gravity close to the acetabulum).
Although theoretically the hip muscles can influence the
degree of lordosis, the evidence in the literature is inconclu-
sive. Some authors found close correlation between tight
hamstring muscles and hypolordosis [89], whereas others
found no correlation between the two [67,90,91]. An ongo-
ing debate exists as to the influence of the psoas major mus-
cle on the lordotic curvature. Some researchers argue that it
acts to flex the lumbar spine and therefore decrease the lor-
dosis angle [92,93]. Others argue that it acts to increase the
 E. Been and L. Kalichman / The Spine Journal
lordosis angle [94]. A third group of researchers claim that
the role of the psoas major is to stabilize the lordotic lum-
bar spine in an upright posture by adapting its contraction
to the momentary degree of lordosis imposed by other fac-
tors outside the lordosis, such as weight bearing [95,96].
Sport
Few researchers have examined the relationship between
the lordosis angle and sports activities. Wojtys et al. [58], re-
porting on a sample of 2,270 children 8 to 18 years old,
found that athletes have a greater lordosis angle than non-
athletes, and that the greater lordosis angle was associated
with greater cumulative training time. The nature of the re-
lationship between sports activity and development of the
lordosis angle is not fully known. Uetake and Ohtsuki
[97] examined the lordosis angle in athletes according to
their sports and found that long distance runners and
sprinters showed greater than average lordosis angles; rugby
and soccer players showed average lordosis angles, and
swimmers and body builders showed lower than average lor-
dosis angles. It has been reported that running is associated
with increased lumbar lordosis and anterior pelvic tilt [98].
Wodecki et al. [99] found increased lumbar lordosis in soc-
cer players. Forster et al. [100] found high lordosis angles in
high ability male rock climbers, whereas Nilsson et al. [101]
reported less prominent lordosis in ballet dancers.
Occupation
Milosavljevic et al. [102] studied the effects of occupa-
tion on sagittal spinal motion and posture. Their sample
consisted of 64 sheep shearers and 64 nonshearers matched
by age and anthropometry findings. Results showed that
sheep shearers had hypolordosis of the lumbar spine and
a flatter compensatory thoracic kyphotic curve compared
with nonshearers. In a sample of 840 randomly selected Ira-
nian subjects, Nourbakhsh et al. [69] reported no difference
in the degree of lumbar lordosis angle between subjects
who utilized tables and chairs versus sitting on the floor,
worked in standing versus sitting postures, or performed
strenuous versus light physical activity. Sarikaya et al.
[103] assessed the incidence of LBP among Turkish coal
miners (surface and underground) and investigated the rela-
tionship between the angles of the lumbar spine and LBP.
They found no differences between the lordosis angles of
the two groups of miners. At the same time, they reported
a significant, negative correlation between lumbar lordosis
and the number of years working as an underground miner.
Lumbar lordosis, spinal degeneration, and low back
pain
Lumbar lordosis and spinal degeneration
Numerous studies have evaluated the association be-
tween lumbar lordosis and spinal degeneration features
- (2013) - 7
[2,4,24,54,104–107]. Most researchers agree that the lum-
bar lordosis angle is positively and significantly associated
with spondylolysis and isthmic spondylolisthesis
[4,24,108–111]. A greater lordosis angle is thought to be
a risk factor for developing spondylolysis and ventral slip-
page of the affected vertebra.
Several investigators have argued that alterations in spi-
nal balance and curvature are implicated in the development
of early osteoarthritis and disc degeneration [112,113]. Two
recent studies explored the association between the degree
of lordosis and spinal osteoarthritis in Greek and American
populations [27,106]. No significant association was found
between the lumbar angle and osteoarthritis in the lumbar
spine in either study. Similar results were found by Lin
et al. [54] in a Chinese population. It is therefore suggested
that lumbar lordosis is neither an outcome nor a contributor
in the development of spinal osteoarthritis.
In a recent study [27], intervertebral disc narrowing was
not found to be associated with the lordosis angle, which is
in accord with Lebkowski et al. [105], who did not find di-
minished lordosis in patients with lumbar degenerative disk
disease. Additional studies are needed to confirm these
findings, which may have potential implications in diagnos-
ing disc pathology and disc replacement surgery.
Lumbar lordosis and low back pain
The question of whether patients who suffer from LBP
have different lordosis angles than nonsufferers is not clear-
cut. It has been claimed that flattening or loss of normal
lumbar lordosis is an important clinical sign of back prob-
lems [114,115]; the patient is thought to keep the spine
straight to reduce pain. This view has been challenged by
several radiologic studies suggesting that patients with
chronic LBP have either no difference [48,52,116,117] or
increased lumbar lordosis compared with controls [118].
These dissimilar results may be explained by different eti-
ologies of LBP in the studies.
Lumbar lordosis and general health
Christensen and Hartvigsen [119] conducted a systematic
critical literature review of epidemiologic (cross-sectional,
case-control, cohort) studies to determine whether sagittal
spinal curves were associated with general health. They
concluded that there is no evidence of an association be-
tween sagittal spinal curves and health, including spinal
pain.
Lumbar lordosis reconstruction
Lumbar lordosis is formed by the sum of bodies and disc
wedge angles. When the intervertebral discs are gone or
when the vertebral bodies are compressed, the lordotic
angle might change. Loss of lordosis can also occur after
instrumented spinal fusion, ‘‘flat-back syndrome’’ [120].
8 E. Been and L. Kalichman / The Spine Journal
The loss of normal lordosis often results in sagittal spinal
imbalance, persistent back pain, and increased muscle fa-
tigue [120,121]; therefore, there is a need for accurate re-
construction of the lordotic curvature. Because the normal
range of lordosis is so wide (30
–80
using the Cobb
method), it is difficult to determine the normal/optimal lor-
dosis angle for an individual. The current knowledge base
is insufficient for accurate reconstruction of the lordotic
curvature, which is very important for spinal surgery
[122]. Recent results showed that facet inclination can ac-
curately predict lordosis [14] in the adult human popula-
tion. Additional studies are needed to confirm these
findings, which in turn might be an important tool in spinal
surgery. Another possible way to speculate what the nor-
mal/optimal lordosis will be is based on pelvic morphology,
especially pelvic incidence. Boulay et al. [123] found that
a low value of pelvic incidence, 44
or less, was associated
with decreases in the sacral slope, thus flattening the lordo-
sis. A high value of pelvic incidence, 62
or more, increases
the sacral slope, thus the lordosis is more pronounced. Be-
cause pelvic incidence does not vary with age and other
postural changes, and because it is highly correlated with
lumbar lordosis in a healthy adult population, it may be
an important tool for lordotic reconstruction. Recently
Chang et al. [121] reconstructed the lordotic curvature in
94 patients with sagittal imbalance owing to lumbar kypho-
sis. The authors used the center of gravity and line of grav-
ity to align the pelvis, and based on pelvic alignment
reconstructed the lordotic curvature.
Conclusions
Lumbar lordosis is an important postural feature of sag-
ittal spinal balance. However, many controversies related to
its evaluation and associated factors exist. First, the number
of evaluated vertebrae varies among researchers. We sug-
gest using a uniform measurement method (Cobb’s
method) to measure between the superior endplate of the
first lumbar vertebra to the superior endplate of the first sa-
cral vertebra. Second, the position of lordosis evaluation:
the most functional and common method are X-rays taken
in a standing position. We believe that this position should
be the position of choice when studying lordosis. However,
recently more and more studies have begun to use com-
puted tomography or MRI to study spinal pathologies. A
majority of studies showed that lordosis of the patient while
in a supine position with legs straight (supine extended po-
sition) is comparable with one measured when the patient
was standing. Therefore, this position should also be ac-
knowledged in future studies. Third, there is still inconclu-
sive evidence regarding the association of the lordosis angle
with age, gender, ethnicity, occupation, and leisure physical
activity. Additional studies are needed to confirm the pres-
ence/absence of such associations. Fourth, the lumbar lor-
dosis angle is positively and significantly associated with
spondylolysis and isthmic spondylolisthesis, but no
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associations have been found with other spinal degenerative
features. Inconclusive evidence exists as to an association
between lumbar lordosis and LBP. We believe that addi-
tional studies are needed to evaluate these associations,
which can help in the understanding of pathophysiology
underlying spinal disorders and LBP, assist in recognizing
individuals at risk for spinal disorders and LBP, and in
the development of prevention and treatment strategies. In
conclusion, the optimal lordotic range remains unknown
and may be related to a variety of individual factors such
as weight, activity, muscular strength and flexibility of
the spine and lower extremities.
Acknowledgments
The authors thank Dr Hayuta Pessah for the illustrations
and Mrs Phyllis Kornspan for her editorial assistance.
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