All about upper back pain

Introduction to the upper back

Although upper back pain is not a very common spinal disorder, it can cause significant
discomfort and pain when it does occur. The most common causes of upper back pain are
muscular irritation (myofascial pain) and joint dysfunction.
There can be an injury to a disc in the upper back (such as a herniated disc or degenerated
disc) that causes upper back pain, but such injuries are very rare.
It is important to note that the thoracic spine (also called upper back, middle back, or midback) is very different in form and function than the cervical spine (neck) or the lumbar spine
(lower back). While the neck and lower back are designed to provide us with mobility, the
thoracic spine is designed to be very strong and stable to allow us to stand upright and to
protect the vital internal organs in the chest. Because this section of the spinal column has a
great deal of stability and only limited movement, there is generally little risk of injury or
degeneration over time in the upper back.
Anatomy of the upper back
The word thoracic means pertaining to the chest, and the thoracic spine (also called the
upper back or mid-back) is the portion of the spinal column that corresponds to the chest area
(Figure 1).

Twelve vertebrae in the middle of the spine with ribs attached make
up the thoracic spine. When viewed from the side, this section of the
spine is slightly concave.
Each vertebra in the thoracic spine is connected to a rib on both sides
at every level and these in turn meet in the front and attach to the
sternum (the breastbone). This creates a cage (the thoracic cage)
that provides structural protection for the vital organs of the heart,
lungs and liver, and also creates a cavity for the lungs to expand and
contract.

The upper nine ribs start at the spine, curve around and are joined at the front of the
chest. Because the ribs are firmly attached at the back (the spine) and the front (the
sternum), they allow for very limited motion in the spine.

The lower three ribs do not join together at the front, but do function to protect the
vital organs while allowing for slightly more motion.

The joints between the bottom thoracic vertebra (T12) and the top lumber vertebra
(L1 in the lower back) allow twisting movement from side to side.

Because there is little motion and a great deal of stability throughout the upper back (thoracic
spine), this section of the spine does not tend to develop common spinal disorders, such as a
herniated disc, spinal stenosis, degenerative disc disease, or spinal instability. These conditions
can cause upper back pain but are exceedingly rare in the upper back.
Because of this stability and lack of motion, in most cases anatomic causes of upper back pain
cannot be found, and an MRI scan or CT scan will rarely image an anatomic problem that is
amenable to any sort of surgical solution for the upper back pain.

Causes of upper back pain

Upper back pain can occur as a result of trauma or sudden injury, or it can occur through
strain or poor posture over time. As an example of the latter cause, in recent years, upper
back pain has become a familiar complaint from people who work at computers most of the
day. Often, upper back pain occurs along with neck pain and/or shoulder pain.
The vast majority of cases of upper back pain are due to one (or both) of the following causes:

Muscular irritation (myofascial pain)

Joint dysfunction

Muscular irritation causing upper back pain

The shoulder girdle attaches by large muscles to the scapula (the shoulder blade) and the
back of the thoracic rib cage. These large upper back muscles are prone to developing
irritation (myofascial pain) that can be painful and difficult to work out.
Often, muscular irritation and upper back pain is due to either de-conditioning (lack of
strength) or overuse injuries (such as repetitive motions). Muscle strains, sports injuries, auto
accidents, or other injuries can all result in pain from muscular irritation.
This type of upper back pain is most amenable to manual treatments, such as:

Exercise/Active and passive physical therapy

Chiropractic or osteopathic manipulation

Deep massage or massage therapy

Acupuncture

Because the upper back pain is related to large muscles in the shoulder area, most
rehabilitation programs will include a great deal of stretching and strengthening exercises.
A conservative care specialist such as an osteopathic physician, a physiatrist/physical medicine
and rehabilitation physician, or a chiropractor would be appropriate to see for treatment of
upper back pain.
If there is a specific area that is very tender, the source of the upper back pain may be an
active trigger point. Trigger points are usually located in a skeletal muscle and can be worked
on by either one or a combination of the following treatments:

Massage therapy
Acupuncture

Trigger point injections with a local anesthetic (such as Lidocaine).

Pain medications can also be helpful. Muscular irritation usually includes some form of
inflammation, so anti-inflammatory medications (such as ibuprofen or COX-2 inhibitors) can be
helpful to reduce the inflammation.
Joint dysfunction causing upper back pain
The ribs connect with the vertebrae in the thoracic spine by two joints that connect with each
side of the spine. Dysfunction in these joints can result in upper back pain.

Treatment for this type of injury usually includes manual manipulation (with an osteopathic
physician, chiropractor or a physical therapist trained in manipulation) to help mobilize the
joint and reduce the discomfort. Lasting relief usually also requires a home exercise program
for stretching the spine and shoulders as well as strengthening. Aerobic conditioning is also
very important to maintain sustained upper back pain relief.
In addition to manual treatments, pain medications can help. Usually the most helpful
medications are the anti-inflammatory medications (such as ibuprofen or COX-2 inhibitors), as
the joint dysfunction can create inflammation.
Injections (e.g. epidural steroid injections) are usually not warranted for thoracic pain other
than local trigger point injection.
Uncommon causes of upper back pain
Because there is little motion and a great deal of stability throughout the thoracic spine, it
does not tend to develop disc herniations, spinal stenosis, degenerative disc disease, or
instability (e.g. spondylolisthesis). As an example, only about 1% of all disc herniations occur
in the thoracic spine. The vast majority of disc herniations occur in the lumber spine, where
there is a lot of motion.
Rarely, upper back pain can be caused by thoracic disc diseasesuch as a degenerated disc or
herniated disc. A correct diagnosis of thoracic disc disease or injury requires diagnostic tests
(such as an MRI scan) and correlation with physical symptoms.
Additionally, significant impact or trauma to the spine can result in a fracture of the thoracic
vertebrae. If this happens, a physician needs to be consulted immediately and diagnostic tests
(such as an X-ray or MRI scan) are required to determine the extent of the damage and
develop a treatment plan.