Upper Back Pain

What is Upper Back Pain?

Upper back pain, also called thoracic spine pain or mid-back pain, is pain in the region between the neck and the lower back, around the thoracic spine, the ribs and the muscles of the shoulder blades. Research on it is much thinner than for neck or low back pain, although it is common across the population.^{[1, 2]}

Common symptoms

The usual symptom is an ache, tightness or sharp pain in the upper or middle back, often between or around the shoulder blades. Many people also notice neck or shoulder tension, and trigger points (tender knots in a tight muscle) can send pain to nearby areas.^[3] Pain may vary with posture, activity or breathing.

Causes and risk factors

Most upper back pain is musculoskeletal, meaning it comes from muscles, joints or ligaments. Thoracic pain has been linked in studies to other musculoskeletal pain, posture, psychological factors, and, in young people, backpack use.^[1] Among working adults, factors include heavy workload, ergonomic problems at work, high mental pressure and other musculoskeletal conditions.^[4]

In postmenopausal women, one study found that weaker upper back extensor muscles were associated with more upper back pain.^[5] Trauma, poor posture and vitamin D deficiency or an underactive thyroid are named as risk factors for myofascial pain.^[3]

The thoracic region is also a site for inflammatory, tumor, infectious, metabolic and degenerative conditions, which is why a physician should evaluate pain that is persistent or unusual.^[6]

How it is diagnosed and treated conventionally

Upper back pain is diagnosed from your history and a physical examination. Imaging is generally not needed for uncomplicated acute pain and may be considered if pain persists despite 6 weeks of conservative treatment, or sooner if red flags are present, such as a history of cancer, infection, weakened immunity or trauma, or signs of spinal cord involvement.^[6]

Initial care is usually conservative. For myofascial pain, this may include anti-inflammatory medicines, muscle relaxants, physical therapy, ergonomic changes and treatment of any underlying problems, with acute episodes often settling on their own.^[3]

Why Upper Back Pain calls for a whole-person approach

Upper back pain seldom has a single cause. Posture and muscle endurance, work demands, mood and general health all show links to it in studies, so care that addresses only one may miss the others.^{[1, 4]}

Evidence on how to prevent or manage thoracic pain is limited, and researchers have called for more prospective studies.^[1]

Muscle tension and trigger points

Tight muscles around the shoulder blades are a common source of upper back pain. Myofascial pain is marked by tender trigger points in taut muscle bands and can be linked to poor posture.^[3]

Posture, work and daily load

In working adults, ergonomic problems, heavy workload and repetitive or tedious tasks were among the factors associated with thoracic pain.^[4] Adjusting the workstation and moving regularly are part of standard care for muscle-related pain.^[3]

Stress and mood

Psychological factors were associated with thoracic pain in the general population, and high mental pressure at work was associated with thoracic pain in employees.^{[1, 4]} Psychological treatment may help people with myofascial pain who also have depression or anxiety.^[3]

Other body systems

Because the thoracic region can be a site of non-spinal disease, new or unexplained upper back pain needs a physician's assessment before any complementary care.^[6]

Acupuncture for Upper Back Pain

What the research shows

The evidence for acupuncture in upper back pain itself is very limited. A PubMed search found no good-quality trials focused on thoracic spine pain, so the research below comes from closely related conditions.

For neck pain, a Cochrane review of 27 trials found moderate-quality evidence that acupuncture relieved pain better than sham acupuncture at the end of treatment and at short-term follow-up, and the benefit did not seem to last long term.^[7] For myofascial pain, a meta-analysis of 10 sham-controlled trials found that manual acupuncture at trigger points reduced pain, while needling at traditional acupuncture points did not show a significant benefit, and the authors called for better-designed studies.^[8]

For chronic pain more broadly, an individual patient data meta-analysis of 29 trials (17,922 patients) found acupuncture was better than sham and than no acupuncture for back and neck pain. The difference from sham was small, which suggests that factors other than needling also contribute.^[9] A network meta-analysis of chronic non-specific neck pain rated the evidence for multimodal non-drug care as low to very low certainty and noted that most of the mild adverse events came after acupuncture or dry needling.^[10]

Dry needling, a related technique that places needles into trigger points, has also been studied. A meta-analysis of six trials (241 participants) in neck and upper back myofascial pain found that dry needling and trigger point manual therapy both improved pain and function in the short to medium term, with neither clearly better.^[11] Physical therapist-delivered dry needling was found to reduce pain in the short term, with evidence of very low to moderate quality and no clear long-term benefit.^[12]

How acupuncture may work

How acupuncture might help upper back pain is not settled, and it has not been studied for this condition. In the meta-analysis of myofascial pain, needling trigger points raised the pressure pain threshold, a measure of muscle tenderness.^[8] In chronic pain trials, the difference from sham was small, which suggests that factors beyond the needling itself also contribute.^[9]

What treatment involves

Treatment uses fine, sterile, single-use needles placed at points along the upper back, shoulders, neck and arms, usually left in place for about 20 to 40 minutes. In myofascial pain trials, a course of about eight sessions was used.^[8] We reassess after a short course of visits.

Serious problems from acupuncture are rare. In prospective studies, about 9 in 100 patients had a minor reaction such as brief bleeding, soreness or redness at a needle site, and serious events occurred in about 1 in 10,000 patients.^[13] Needling over the chest wall carries a small risk to the underlying lungs, so depth and placement matter. Tell the practitioner first if you have a bleeding disorder, take blood thinners, are pregnant, or have a pacemaker (relevant to electroacupuncture).

Ayurvedic medicine for Upper Back Pain

The Ayurvedic view

Ayurveda has no exact counterpart to upper back pain. Pain and stiffness of the back and shoulders are generally described as a Vata disturbance, the principle said to govern movement, and long-standing tightness is sometimes linked to Kapha. These are traditional categories for choosing treatment, not biomedical diagnoses.

Therapies that may be used

Care is chosen for the individual and traditionally combines:

• Diet and daily routine intended to calm Vata, such as warm, regular meals and steady sleep hours
• Warm herbal oil massage of the back, shoulders and neck, with local heat
• Gentle stretching and breathing practices
• Herbs prescribed individually by a qualified practitioner, such as turmeric or ashwagandha, traditionally used for pain, stiffness and stress

Panchakarma procedures are not appropriate during pregnancy, acute illness or frailty, or before red-flag symptoms have been medically assessed. Transdermal medication therapy, an herbal preparation applied to the skin, may be considered for tight areas, but no trial of it for upper back pain was found.

What the research shows

No clinical trials of Ayurvedic treatment for upper back pain were found in a PubMed search, so there is no evidence on whether it helps. A systematic review of 113 studies of Ayush treatments, mostly Ayurveda, Siddha and yoga, for neck and low back spondylosis found that only about one in eight reported any adverse events and noted that these might be underreported.^[14] That review looked at safety reporting and not effectiveness. In one study, about one fifth of Ayurvedic products bought online contained detectable lead, mercury or arsenic.^[15]

Herbal medicine for Upper Back Pain

Herbs and formulas that have been studied

No herbs have been tested in trials for upper back pain. The nearest research covers Chinese herbal medicine for neck pain from cervical disc degeneration, including an oral formula called Compound Qishe Tablet and a topical herbal preparation called Compound Extractum Nucis Vomicae.^[16] Dietary ingredients such as boswellia and ginger have been reviewed for chronic musculoskeletal pain.^[17]

What the research shows

There is no direct evidence for upper back pain, and the indirect evidence is weak. A Cochrane review of four trials of Chinese herbal medicine for neck pain with nerve root signs found low-quality evidence that Compound Qishe Tablet reduced pain more than placebo and that the topical preparation reduced pain more than a diclofenac gel. All the studies were in Chinese and the effect sizes were not clinically relevant, and the authors said further research would likely change the results.^[16]

A review of dietary ingredients for chronic musculoskeletal pain gave no recommendation for boswellia or ginger because the research was low quality or unclear.^[17] These findings are from neck or general musculoskeletal pain and may not apply to upper back pain.

Safety and herb-drug interactions

Herbs are active substances and can interact with medicines. Case reports describe bleeding when warfarin was combined with herbs including dang gui (Angelica sinensis), dan shen (Salvia miltiorrhiza), ginger, ginseng and Boswellia.^[18] People taking blood thinners need a practitioner's review before using herbs for pain. Herbs can also interact with muscle relaxants, antidepressants and anti-inflammatory drugs.

Ayurvedic products vary in quality, and some have been found to contain lead, mercury or arsenic.^[15] Herbs should come from tested sources and be prescribed individually. Tell us if you are pregnant or breastfeeding, or have liver or kidney disease.

Translating traditional medicine into modern biological language

The links drawn here are interpretation, not equivalence. Chinese medicine often describes upper back and shoulder pain as stagnation of qi and blood in the channels of the back, sometimes with wind or cold, or with stress tightening the muscles. Researchers studying this area look at things that loosely parallel the picture: tender trigger points, tight muscle bands, the pressure pain threshold, and the influence of stress and posture.^{[3, 8]}

Ayurveda's aggravated Vata describes stiffness, aching and restricted movement. No study has shown that a dosha corresponds to a specific biological process.

How this care fits with your medical care

Integrative care for upper back pain is complementary. Keep your physician, physical therapist or spine specialist, and do not stop or change prescribed medicines or therapy without your prescriber. We do not diagnose the cause of upper back pain, so pain that is new, severe, persistent or unexplained should be medically evaluated first.

Please bring your diagnosis, any imaging reports, a list of medicines and supplements, and details of any injury, injections or surgery, planned or past.

When to seek urgent medical care

Some upper back pain points to a serious problem outside the muscles and needs prompt assessment.^[6]

• Sudden severe back pain with chest pain, shortness of breath, sweating or fainting
• Back pain after a fall, accident or other trauma
• Numbness, tingling or weakness in the legs, or trouble walking
• New loss of bladder or bowel control
• Back pain with fever, unexplained weight loss, or a history of cancer, infection or weakened immunity
• Pain that is severe at night or steadily getting worse

If any of these occur, call 911 or go to the nearest emergency department.