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Upper Back Pain

Updated: Nov 26, 2020

The thoracic spine—also referred to as the upper back or middle back—is designed for stability to anchor the rib cage and protect vital internal organs within the chest. 

Compared to the neck (cervical spine) and lower back (lumbar spine), the upper back is remarkably resistant to injury and pain. When upper back pain does occur, it is typically due to long-term poor posture or an injury that overpowers the thoracic spine’s sturdiness.

This article explores various symptoms of upper back pain, potential causes, and modern diagnostic methods and treatments.

The Thoracic Spine and What Can Go Wrong

The thoracic spine starts beneath the neck and is comprised of 12 vertebrae, labeled T1 through T12, which go down the back of the torso. Unlike the cervical spine and lumbar spine, the thoracic spine is relatively immobile because each of its vertebrae are connected to a pair of ribs (one on each side), which along with the sternum at the front of the chest combine to form the rib cage. 

If the upper back becomes painful, it is typically for one of the following two reasons:

  1. Muscular irritation. The shoulder girdle attaches by large muscles to the scapula (the shoulder blade) and the back of the rib cage. These large upper back muscles are prone to developing strains or tightness that can be painful and difficult to alleviate. Muscular irritation in the upper back is typically due to either de-conditioning (lack of strength) or overuse injuries (such as repetitive motions). 

  2. Joint dysfunction. Either from a sudden injury or natural degeneration due to aging, joints in the thoracic spine can become dysfunctional and painful. Some examples could include a facet joint’s cartilage or joint capsule tearing

If upper back pain becomes bad enough to limit activities, it usually feels like a sharp, burning pain localized to one spot or a general achiness that can flare up and possibly spread to the shoulder, neck, or elsewhere.

The Course of Upper Back Pain

Few studies have been done to track the frequency of upper back pain. A French study of workers across various professions found about 9% of men and 17% of women reported at least some upper back pain, but other studies have found numbers that range lower and higher.

Upper back pain can appear suddenly, such as from an injury or for no apparent reason. It can also start gradually, such as from sitting with poor posture at work.

In some cases, upper back pain can be managed with self-care, including rest, adjusting posture, or applying heat or ice. If the pain persists, other treatments may be needed, such as medication, physical therapy, or manual manipulation.

When Upper Back Pain Is Serious

Most cases of upper back pain are not due to a serious underlying cause, but rare cases may be caused by a progressing infection or illness, or from spinal instability that has started to affect a nerve root or even the spinal cord. In such cases, it is important to seek medical treatment immediately to reduce the risk of the problem becoming worse.

Symptoms that could indicate a serious underlying cause of upper back pain include radiating pain or pins-and-needles tingling in the chest or abdomen, fever or chills, reduced coordination, problems walking, or severe headache. In addition, upper back pain that follows a high-impact event, such as an auto accident or fall from a ladder, should be evaluated by a doctor urgently.

Upper Back Pain Symptoms

Upper back pain symptoms can differ from person to person. For some, the pain might be mild and go away within a couple days, but for others the pain can worsen and interfere with daily tasks. Upper back pain symptoms and treatment plans can vary greatly depending on the problem’s underlying cause.

Upper back pain can feel like one or more of the following:

  • Sharp pain. This pain is typically described as excruciating and can feel knife-like, burning, or as if being gripped in a vice. It is usually located in one spot instead of spreading across a region.

  • General discomfort. An achy or throbbing pain may be felt in part of the upper back, and it could potentially spread into a nearby area, such as the neck, shoulder, or lower in the back.

  • Stiffness. If either sharp pain or general soreness becomes bad enough, it can contribute to reduced mobility of the upper back’s muscles, ligaments, and/or joints. While reduced mobility in the upper back is typically not significant because that area of the spine is built more for rigidity than motion, it could make certain arm movements, such as rotation or lifting, more difficult or even impossible.

  • Radiating pain. This pain can travel along a nerve from the thoracic spine and potentially go into the arm, chest, stomach, or further down the body. Radiating pain can range from dull to sharp or electric shock-like, and it may come and go or be continuous. It is usually only felt on one side of the body, such as going into the chest on one side.

  • Tingling, numbness, or weakness. Just like radiating pain, these symptoms can also radiate along a nerve from the thoracic spine and are into the arm, chest, stomach, or lower in the body. Pins-and-needles tingling or numbness radiating from the thoracic spine can feel like the shape of a band running along one of the ribs.

If upper back pain becomes bad enough, it can affect normal activities, such as the ability to lift moderately heavy objects, throw a ball, or even comfortably sit or rest.

Onset of Upper Back Pain Symptoms

Upper back pain symptoms could start any number of ways, including:

  • Sudden. Pain could begin immediately after an injury or out of the blue for no apparent reason at all.

  • Delayed. Sometimes pain from an injury takes a few hours or longer before it shows up. The reason for this is not always known, but it could be due to an inflammatory process or how pain might be felt in another area of the body before it is noticed in the upper back.

  • Gradual. Pain may start out mild and slowly worsen over time.

Sometimes upper back pain comes and goes. Intermittent pain may or may not become worse over time, depending on the cause. Pain could feel worse in the morning and get better during the day, or it might be worse in the evening but feel better after rest.

Upper Back Pain Symptoms by Location

At each level of the thoracic spine, two nerve roots (one on each side) branch into networks of nerves that enable sensation and motor functions on that side of the body. If a nerve root becomes compressed or inflamed, such as from a herniated disc, then thoracic radiculopathy symptoms of pain, tingling, numbness, and/or weakness can potentially radiate in different directions depending on the specific vertebral level of the nerve compression.

These thoracic radiculopathy symptoms are typically only felt on one side of the body. Also, adjacent vertebral levels can share overlapping nerve wiring, and these overlaps can vary from person to person.

When Upper Back Symptoms Need Medical Attention

If upper back pain is accompanied by any of the following, it should be checked by a doctor immediately:

  • Problems with balance or walking

  • Difficulty with bladder or bowel control

  • Pins-and-needles tingling, weakness, and/or numbness anywhere in the upper back or below, such as in the chest, stomach, buttock, or down the legs

  • Trouble breathing

  • Fever or chills

  • Severe headache

In addition, upper back pain that lasts for weeks and/or interferes with daily tasks, such as going to work or getting a good night’s rest, warrants a visit to the doctor.

Diagnosing Upper Back Pain

Compared to other regions of the spine, diagnosing upper back pain can be especially complicated because it has more potential sources of pain, including the ribs connecting at each level of the thoracic spine and several internal organs and muscle groups in close proximity. 

While it is sometimes impossible to find the exact cause of a person’s upper back pain, the following three-step process is typically followed to narrow down which causes are more likely.

1. Patient History

A thorough medical history of the patient is taken, including:

  • When the symptoms started. How long has the upper back pain been present?

  • How current symptoms feel. Where in the upper back is the pain located? Does the pain spread anywhere else, such as into the shoulder or lower in the back? How intense is the pain? Does the pain come and go, or is it constant? Do certain activities make the pain worse or better?

  • Injury history. Did the pain start relatively soon after an accident, such as a bike crash or ladder fall? If not, was there an accident or fall from years earlier that was particularly bad?

  • Lifestyle and habits. Does the patient live an active or sedentary lifestyle? Does he or she have a job that involves a lot of heavy lifting, or perhaps most of the day is spent sitting?

  • Family health history. Did a parent, grandparent, or other relative have problems with upper back pain? What about other hereditary health conditions that could be relevant to the current symptoms?

For upper back pain, a patient history is likely to provide the strongest clues as to the underlying cause.

2. Physical Exam

After the patient’s medical history is collected, a physical examination helps to further narrow down what might be causing the upper back pain. This process typically includes:

  • Observation. The back and posture are observed for anything that seems unusual, such as head and shoulders abnormally hunched forward or lesions on the skin.

  • Palpation. The doctor presses against the thoracic spine, going up and down the back while feeling for any tenderness, rib instability, or abnormality.

  • Clinical tests. Sometimes one or more tests is performed in the exam room to see if certain movements exacerbate symptoms. For example, the slump test involves having the patient purposely slump forward while a qualified medical professional gently puts the head and knee (on the side that hurts) in various positions to test if any of the patient’s complaints of radiating pain or tingling can be reproduced.

Based on information collected from the patient history and physical exam, the doctor might decide to collect more information by way of diagnostic tests.

3. Diagnostic Tests

When trying to diagnose upper back pain, or in some cases to confirm a diagnosis, one or more of the following diagnostic tests might be performed:

  • X-ray. An x-ray (radiograph) uses electromagnetic radiation to create an image of the bones. This imaging may show spinal degeneration, fractures, or other bony details.

  • MRI. Magnetic resonance imaging (MRI) uses radio waves and a strong magnet to create cross-section images of soft tissues and bones. In particular, an MRI can be good at detecting compression of spinal nerves or the spinal cord, infections, tumors, or damage to ligaments, muscles, or other soft tissues.

  • Bone mineral density exam (DEXA Scan). This test uses x-rays to measure bone density (based on how much of the x-rays are absorbed into the bones) and is commonly performed to check for osteoporosis, which can occur in the thoracic spine and cause upper back pain.

Several other diagnostic tests could be used, such as electrodiagnostic testing to check nerve and muscle function, CT scan with myelography (typically for patients who cannot have an MRI), or blood tests.

Causes of Upper Back Pain

The course of upper back pain—and how to treat it—depends on the underlying cause of the condition. Even in cases where it seems obvious what started the upper back pain, such as an injury from a fall, the specific source of pain within the body can sometimes remain elusive. 

Regardless of whether the exact source of upper back pain can be determined, it helps to know the various potential causes in order to better narrow down which treatments may be best. 

When the upper back becomes painful, it is mostly likely due to an injury that has resulted in muscular irritation or joint dysfunction. Some of the more common causes of upper back pain are:

  • Poor posture. Living a sedentary lifestyle or routinely sitting for long periods with poor posture can cause structural changes in the back and neck. The muscles can become deconditioned and weak, and thus not hold the spine in neutral alignment as easily as before. As the head and shoulders hunch forward, more pressure is placed on the spine’s bones, discs, muscles, ligaments, and other soft tissues. If a person leans to one side more often, such as while driving or working at a computer, that could also cause an imbalance in the upper back that leads to pain.

  • Improper lifting technique. Lifting a heavy object without keeping the spine aligned can put undue stress on the upper back. In particular, lifting or holding a heavy object above the head, especially more toward the left or right as opposed to centered, can leave the shoulder and upper back susceptible to injury. Lifting an object that is too heavy can also cause upper back pain.

  • Overuse. Putting the upper back through more work than usual, such as by spending a day helping a friend move into a new apartment or painting a ceiling (working above the head), could cause muscle strains, ligament sprains, and inflammation in the upper back.

  • Accident or collision. Trauma from a vehicular accident (car or bike crash), a fall from height (down steps or from a ladder), or sports collision (football, hockey, etc.) can cause upper back pain by injuring spinal bones, discs, muscles, ligaments, nerves, and/or other soft tissues.

Sometimes there can be a combination of causes, such as from both overuse and improper lifting technique. 

Less Common Causes of Upper Back Pain

Some of the less common causes of upper back pain include:

  • Thoracic herniated disc. While herniated discs in the thoracic spine are not uncommon, it is rare for one to cause pain or other symptoms. In general, natural age-related spinal degeneration is much more likely to cause symptoms in the cervical spine and lumbar spine.

  • Compression fractures. Most commonly caused by osteoporosis in older adults, a vertebral bone can weaken and not be able to fully support the weight above it. Small fractures develop at the front of the vertebra as it becomes compressed, causing the vertebra to form more of a wedge shape. If the vertebra loses enough height, it can cause postural changes and become painful.

  • Arthritis. Various types of arthritis can occur in or spread to the thoracic spine, such osteoarthritis (from natural wear and tear) or rheumatoid arthritis (an autoimmune disease).

  • Fibromyalgia. While this rare condition is known for widespread pain and fatigue throughout the body, the upper back is commonly affected.

  • Severe spinal deformity. If a spinal deformity progresses enough, it can cause painful muscle spasms and even stress discs and joints. A few examples include Scheuermann’s kyphosis and scoliosis.

Numerous other causes of upper back pain exist, such as from an infection or a tumor pressing on the spinal cord.

Early Treatments for Upper Back Pain

If upper back pain develops without any signs of an emergency, most people can safely try to alleviate the pain on their own. Several self-care treatments for upper back pain exist. In some cases, a combination of one or more treatments is needed to help reduce the pain.

Self-Care for Upper Back Pain

Some early treatment options to try when upper back pain develops include:

  • Rest and activity modification. If the pain gets worse with certain movements or activities, such as doing household chores or participating in hobbies, a short rest period of a day or two may help. For example, if working in the garden exacerbates the pain, avoid that activity rather than push through the discomfort. After an initial rest period, trying to become active again is advised. Resting for too long can cause muscles in the back to become weaker, which could lead to more pain.

  • Ice and/or heat therapy. Ice may be applied to reduce swelling within the first couple days of the pain starting, and heat is typically recommended after the first 48 hours. Other recommendations simply let patients choose whether they find more relief from ice or heat. Regardless of which temperature is preferred, it is important to limit applications to 20 minutes at a time and check the skin regularly to avoid tissue damage.

  • Over-the-counter (OTC) medications. Various pain medications are available at stores for purchase without a doctor’s prescription. Most of these OTC medications work by reducing inflammation in the body or preventing pain signals from reaching the brain. Common OTC medications that may help reduce upper back pain include aspirin, ibuprofen, naproxen and acetaminophen. Even though these medications do not require a prescription, it is important to read and follow the directions on the label to avoid serious side effects. 

  • Massage. Many people find that a massage can provide relief from back pain. Even if the effects are temporary, a good massage can help loosen tight muscles and get more blood flowing to the painful area. A few options for massaging the upper back include self-massage with a foam roller or ball, having a willing friend or family member provide a massage, or seeking out a professional.

Lifestyle Changes to Reduce Upper Back Pain

Some risk factors from daily routines are known to increase the risk for back pain. Making one or more of the following lifestyle changes could help reduce the risk of developing upper back pain:

  • Exercise and stay active. Going for regular walks or hikes, participating in noncontact sports, strength training, and stretching can all be beneficial for conditioning the upper back. Keeping the back strong and flexible helps maintain spinal function and reduces the risk for developing pain. If trying to transition from a sedentary lifestyle to a more active one, start slowly and gradually build up endurance.

  • Practice better posture. Keeping the head in a neutral position with the ears directly over the shoulders tends to put the least amount of stress on the neck and back. Using good posture throughout the day—such as when sitting, walking, or lifting heavy objects—can reduce the risk for developing pain. Simple changes could include setting up an ergonomic workstation at work, bending with the knees when lifting heavy objects, and placing straps over both shoulders instead of just one when wearing a backpack.

  • Quit smoking. Multiple studies have shown that people who smoke are more likely to have chronic back pain and accelerated degeneration of spinal discs. One of the suspected reasons is that nicotine restricts blood flow, which can reduce the flow of nutrients that go into the discs.

In addition, an overall healthy lifestyle of eating a well-balanced diet, getting the recommended amounts of sleep, and managing stress can help reduce the risk for developing back pain.

Nonsurgical Medical Care for Upper Back Pain

Some of the more common medical treatments for upper back pain include:

  • Physical therapy. A physiatrist, physical therapist, or other qualified medical physiotherapist can design a physical therapy program to meet the patient’s specific needs. Most physical therapy programs for upper back pain focus on strengthening and stretching the upper back’s muscles, as well as neck muscles above and core muscles below. Physical therapy starts gradually and typically progresses over a period of a few weeks or months, at which point the patient can switch to a maintenance program at home.

  • Prescription pain medications. For debilitating pain or severe flare-ups, short-term use of prescription medications may be advised. Common examples include prescription-strength nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, which work by preventing pain signals from reaching the brain; and muscle relaxants, which typically work as a sedative for the neuromuscular system.

  • Cognitive behavioral therapy. A therapist can teach new and better ways to think about challenges. For example, a patient might be able to increase his or her ability to follow a doctor’s treatment plan by becoming more aware of negative thoughts and instead focusing on the positives.

Commonly, more than one treatment is needed to help manage upper back pain. For example, medications might be needed when the pain first starts, but over time the medications might be phased out in favor of physical therapy or other treatments to manage ongoing chronic pain.

Surgery for Upper Back Pain

Suregry may be indicated if one or more of the following conditions are present:

  • Problems with balance or walking

  • Difficulty with bladder or bowel control

  • Pins-and-needles tingling, weakness, and/or numbness anywhere in the upper back or below, such as in the chest, stomach, buttock, or down the legs

  • Trouble breathing

  • Fever or chills

  • Severe headache

In addition, upper back pain that lasts for weeks and/or interferes with daily tasks, such as going to work or getting a good night’s rest, warrants a visit to the doctor and may require urgent surgical intervention.

If surgery is chosen for thoracic spine pain, it is typically one of the following two types:

  • Vertebral augmentation. This minimally invasive procedure involves injecting artificial bone cement into a vertebra’s compression fracture to stabilize it, stop the damaged bone’s painful movements, and prevent further vertebral collapse. Two common types of vertebral augmentation are vertebroplasty and the newer balloon kyphoplasty.

  • Spinal decompression. This type of surgery can relieve pressure on a nerve root and/or the spinal cord in order to prevent worsening damage that could lead to dysfunction or paralysis. For example, a  spinal decompression surgery could remove a structure that has started to press against a nerve or the spinal cord, such as a herniated disc or bony overgrowth (osteophyte), or other structures. In some cases, a spinal decompression procedure is combined with a fusion to stabilize that section of the spine.

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