Upper Back Pain

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.