What Lederman Got Right – and Where He Went Wrong

I want to talk about a paper that changed the way osteopathy is taught in this country, and not entirely for the better. A paper that is often blamed for, or credited with, changing the way osteopathy is taught in this country. Eyal Lederman's 2010 paper, The Fall of the Postural– Structural–Biomechanical Model, didn't change osteopathy. It was read as permission for a change already well underway, and the reason it could be read that way tells us something uncomfortable about the state the profession was already in.

If you trained at a UK osteopathic school in the last fifteen years, you've almost certainly encountered it. It's been read as permission, permission to leave behind the structural thinking that osteopathy was built on, permission to move toward a biopsychosocial, pain-science-led account of what we do, permission to stop worrying about posture and alignment and tissue state and start talking about psychosocial flags and central sensitisation. The educational leaders will tell you this is progress. I want to suggest it's more complicated than that, because the profession had already lost its grip on principles.

Because here's the thing: Lederman is largely right. And the profession has drawn largely the wrong conclusions from him.

The moment I recognised the problem - what was actually lost

Here is the shift, and it happened long before Lederman wrote a word. There was a time when assessment meant meeting a person reading the whole of them, the way they carried themselves, what their tissue expressed. It meant reading the whole person, the way they carried themselves, the story their tissues told, how they had come to be as they were and the configuration their body had settled into and what that configuration was costing them. It was one thread in a clinical picture, never the whole picture. Nobody trained in the osteopathic tradition thought a leg length difference on its own explained a patient's back pain, any more than a single sentence explains a novel.

Then something shifted. The assessments got more specific, more categorical. A positive finding here, a measurement there, a test result that pointed to a diagnosis. Think of the tests you were taught. The leg length difference, the iliac crest height, the sacral base angle and beyond Lederman's list, the stork test sitting right at the centre of undergraduate teaching, a single movement observation elevated to a diagnosis of sacroiliac dysfunction. Single findings generating categorical conclusions.

This is what Lederman looked at. And he was right to be sceptical of it. But it is not osteopathy. It is what osteopathy became once its founding principle that the body is a unity, already whole, had quietly slipped out of the room.

What the evidence actually shows

Lederman's literature review is thorough and the findings are real. Static postural metrics, taken in isolation, do not predict who develops low back pain. Leg length difference doesn't. Lordosis angle doesn't. Pelvic asymmetry, segmental range of motion, multifidus wasting, none of them, on their own, do the predictive work the manual therapy professions assumed they did. The prospective studies are sound. Any honest reading has to acknowledge this.

But look carefully at what those studies are testing. They take a single postural variable, measure it, and ask whether it correlates with a discrete outcome. That is what epidemiology can do. It is not what osteopathic assessment was ever supposed to be doing. The question was never whether any single postural variable, standing alone, predicts pain. Of course it doesn't. The question is what the whole picture tells you. And if that feels harder to answer than it should, that's not a reflection on you, it's a reflection on what your training chose to prioritise.

There is no misalignment, only a configuration

The vocabulary Lederman inherits is worth examining. He talks throughout of "misalignment," and he is right that the idea of correcting structural misalignments doesn't survive contact with the evidence. Manual therapy doesn't reliably reposition bones, doesn't permanently lengthen connective tissue, doesn't restore a normative skeletal geometry the body has deviated from. That isn't what classical osteopathy proposed.

But the word itself already concedes the wrong frame. Misalignment implies there is a correct alignment the body has strayed from, and that the clinician's job is to restore it. That isn't what osteopathy proposed. The body has organised itself into its current configuration for reasons, load history, injury, occupation, habitual breathing patterns, visceral state, emotional life, and that configuration is the organism's current solution to its current circumstances. The clinical question isn't "is this body aligned?" it's "what is this configuration costing, and what purpose is being served?"

Sometimes the cost is low, and the solution is good enough. The biological reserves Lederman rightly describes absorb the load; the person remains asymptomatic. Sometimes the configuration is depleting reserves faster than they can be replenished, and the solution is becoming the problem. That is where osteopathic attention belongs, not in imposing a correct shape from outside, but in helping the organism find a less costly configuration of its own.

This also dissolves Lederman's strongest clinical objection, that we couldn't permanently change these factors even if we wanted to. The aim was never permanent imposition of an external geometry. It was, and is, supporting the organism's own adaptive capacity as a living record of the tissues history. And here is where the current science becomes interesting. The molecular biology now coming into view describes precisely the mechanism by which the body records, holds, and gradually revises its configuration. Mechanotransduction through YAP/TAZ signalling, cellular mechanical memory, fibroblast remodelling under sustained load, this is the substrate of what osteopathy was talking about when it spoke of the inseparability of structure and function. Tissue isn't passive material being deformed. It is living substance writing its loading history into itself. That isn't a refutation of structural thinking. It is structural thinking arriving at the cellular level, where Still and Littlejohn couldn't go and where Lederman doesn't look.

Expansion is not the same as substitution

Lederman is right that pain is poorly predicted by mechanics alone, and that hereditary, psychological, occupational, and social factors carry real predictive weight. The move beyond a purely mechanical account only is necessary but any serious clinical model still has to include it. But here his argument shifts from expansion to substitution. Having shown that singular mechanical measurements doesn't predict pain, he pivots to psychosocial predictors and treats the mechanical as minor, something to acknowledge at the extremes and otherwise set aside. Body unity and mechanics, a lost principle, has been disregarded.

This is also what much of contemporary osteopathic education has done. The "we've moved on from biomechanics" line you hear from educational leaders is the same substitution in different clothes. But the osteopathic position was never pure mechanism, and its answer to the limits of mechanism was never to abandon it. The mechanical, fluid, neural are aspects of one regulating organism. Sustained loading shapes tissue physiology through mechano-transduction. Tissue physiology shapes neural set-points. Neural set-points shape affective state and pain experience. Affective state shapes breathing, posture, and loading patterns. The loop runs in every direction, and you cannot subtract the mechanical from it without losing the substrate everything else operates through.

Lederman throws the baby out with the bathwater. The colleges, in adopting his framing, have done the same.

Palpation, and what reliability cannot see

This brings us to palpation, which Lederman treats almost as an after-thought, but which deserves more careful handling than he gives it.

He is right that many palpatory assessments show poor inter-rater reliability in the published literature, and the more precise the claim, locating an exact vertebral level, identifying a specific tissue texture, judging a pelvic angle, the worse the reliability tends to be. This deserves to be taken seriously. But a significant proportion of these studies use student examiners, trained to brief simplified protocols, tested against criteria that aren't how skilled clinicians actually use palpation. A study showing that final-year students can't reliably agree on the location of L4 tells you something real about the students. It doesn't tell you that experienced palpation is unreliable for the purposes practitioners actually use it for. If our students aren't good enough at it to use it reliably, that is a problem about teaching, not about the modality. The answer is to train palpation more seriously, not to abandon it.

The deeper point is this. Palpation used as a categorical diagnostic test, does this single finding confirm a diagnosis; yes or no, probably does need to meet reliability standards, and probably often fails them. That use of palpation is the reductionist practice Lederman rightly criticises, and which osteopathy never proposed. Palpation as the interface through which the practitioner reads the living tissue in real time, gathering continuous contextual information that feeds an ongoing clinical interpretation, that is doing something different. It isn't producing discrete outputs that reliability studies measure, because it isn't trying to. Reliability is the wrong frame. Skill is the right frame. And skill is what gets built by deliberate practice, by years of refining the hand against the tissue. That is what osteopathic education was organised around, it was once the centre of osteopathic training, nurtured to grow as the students learning developed but has now been left to wither.

What Lederman was actually critiquing

Stand back from all of this and a pattern becomes visible. The clinical practice Lederman describes, the isolated measurements, the categorical diagnoses from single findings, the corrective techniques aimed at restoring alignment, is real. It is taught. It is examined. It is what many graduates of UK osteopathic schools have been trained to do.

But it is not what Andrew Taylor Still proposed, nor what Littlejohn took from Still and taught. They worked from principles, body unity, the inseparability of structure and function, the body's inherent capacity to regulate and heal itself, the integration of mind, body, and spirit. The

reductionist practice Lederman dismantles had left all of them behind. His critique is accurate. His target just isn't osteopathy. It's the shell of a rich practice, stripped of its principles by colleges and institutions that mistook biomedical respectability for progress.

Still and Littlejohn saw that sustained patterns of loading configured the conditions in which the body's self-regulating capacities operated. They identified the question. They lacked the vocabulary to fully answer it. That vocabulary now exists, and it is vindicating their observation, not the framework that replaced it.

What Lederman is dismantling is a practice that adopted the worst of mechanism, the reductionist diagnostic mindset, while losing the best of it, the integrative reading of the physiological effects of the organism under load. What Lederman has dismantled wasn’t osteopathy, it never was.

How the husk was left behind

It is worth saying plainly how this happened, because it wasn't forced on the profession by the evidence. Osteopathy in the UK pursued academic validation, regulatory parity, and professional respectability. The price was a curriculum that looked enough like physiotherapy and biomedicine to be recognised by the institutions awarding the degrees. The colleges didn't move osteopathy on because the science demanded it. They moved it on because the institutional landscape demanded it. Educational leaders will tell you the profession has progressed. What I'd ask them is this: progressed toward what, and on whose terms?

Because here is the uncomfortable timing. Mechanobiology, fascial science, interstitial regulation, the fields now producing the vocabulary the founders lacked, are arriving just as the profession has finished abandoning the framework they would have supported. We are in the strange position of having walked away from the right questions just as the science was beginning to answer them.

Which direction are we moving “on” to?

I am not arguing for a return to a romanticised past. Osteopathy, taken straight from Still or Littlejohn, contains work that needs revising and that needs translating into contemporary terms. The founders didn't have the answers. But they were asking the right questions, in a frame that current science is now equipped to engage with seriously.

Lederman's paper, read carefully, is not the refutation of osteopathy it has been taken to be. It is the refutation of a clinical practice that osteopathy should never have morphed into. The right response is not to retreat further into pain science and psychosocial framing as substitutes for mechanical thinking. It is to recover the integrative clinical reasoning the profession was founded on, equipped now with a biology the founders could only intuit.

If you've read this far, and something in this has felt familiar, something has probably been missing. Not from your clinical ability but from the framework you were given to make sense of it. The ICO exists precisely for this, not to take you back to something old, but to give you back something that has been deliberately omitted. Osteopathy was always heading somewhere richer than this. The question was never whether osteopathy should move on. The question is which direction “on” should be.

Robert Cartwright DO

Institute of Classical Osteopathy Chairman