Upper back pain occurs in the area called the thoracic region of the body, which goes from the back of the neck down to the start of the lower spine at the level of the waist, known as the lumbar spine. It is typically felt in the mid-back between the shoulder blades and the neck.
Pain here can vary in intensity, severity, and character. The area of your upper and mid back is known as the thoracic spines, and consists of 12 small bones called vertebrae that help to make up your backbone. Between each vertebra is a small disc of firm jelly-like material that helps to stop the backbones rubbing together as well as cushioning and protecting the back. Each thoracic vertebra is connected to a pair of ribs that run round to the front of your chest, forming your rib cage. There are also lots of muscles and ligaments in your upper back as well as your backbones and discs, so upper back pain can develop as a result of problems with any of these.
For most people, pain in the upper back is less common than pain in the neck or lower back. This is because the bones in these areas tend to move more and be more flexible than the bones in the upper back, as the thoracic bones and rib cage help to keep your upper body strong and stable.
Upper back pain can feel different to different people, and depends on the underlying cause. For many people, it feels like a burning or pulling discomfort in one particular area that can feel worse on moving or stretching. For others though it may feel like a deep burning pain, pain that travels from the back and round to the side or front of the body, or a tingling type of pain that can also cause numbness or weakness.
In this article we look at some of the most common causes of upper back pain and how they can be treated.
The most common cause of upper back pain is poor posture that puts excessive strain on the muscles and ligaments in your back. This is often due to sitting for long periods in an incorrect position – such as at your desk at work – and slouching in your chair. You may not realise you are slumping in your seat but if you find that your upper back pain is worse at the end of a working day or when you have been sitting for a long time then this may be the reason for it.
If you slump in your seat, or sit in a hunched up position your upper back muscles can gradually start to lose their strength, and this causes increasing pressure on your neck and upper back. Over time, this can cause increasing discomfort and pain as well as reduced mobility in your back and across your shoulders and you may also find it difficult to stand up straight. Carrying a backpack incorrectly or sitting for a long time at a computer are other common reasons for this. Other possible causes of upper back pain include:
Overuse of your back muscles. This is common in people who do an activity – such as at work or with a particular sport – that causes them to repeat the same motion with their back or upper body many times. If this occurs over a long time it can cause muscle tightness, spasm and strain as well as irritation to surrounding nerves. You may also injure the muscles or ligaments of your upper back if you try to lift something that is too heavy, or lift it incorrectly.
Osteoarthritis. Although a less common cause than poor posture or a simple strain, osteoarthritis becomes more common as we get older and so may trigger upper back pain in some people. If the protective cartilage between the upper back bones gradually wears away over time, this can cause friction and inflammation to occur which then causes symptoms such as pain, tingling or numbness.
Disc problems. A herniated or ‘slipped’ disc can often occur in the lower back but may also sometimes happen in the upper back as well. If one of the protective discs that sit between each thoracic vertebrae moves out of line – sometimes because of trauma or moving awkwardly - these can press on the nerves that run next to them, causing symptoms. These include pain (sometimes severe), numbness, tingling and reduced movement.
Osteoporosis. Osteoporosis affects over 3 million people in the UK and is where the bones become more fragile, weak, and likely to break. Osteoporosis is a chronic condition, which develops slowly over years and is usually not painful unless it progresses to a fracture (a break in the bone). Often, it's only after sustaining a fracture that most people find out they have osteoporosis. Because bone thinning cannot be felt or seen, most people with osteoporosis are not aware of any problem until they suffer a fracture, and as such can genuinely be called a ‘silent’ disease. Although X-rays will readily show broken bones, osteoporosis will only become apparent when at least 30% of the bone density has been lost. Sometimes it can cause a fracture of a vertebra called a wedge fracture, where one end of the backbone crumbles, breaks or collapses. Depending on how extensive this is, and where it is this can cause pain in the upper back.
Muscle sprains and strains. A muscle strain is an injury to a muscle or a tendon - the stiff tissue that connects our muscles to our bones. If you have a minor injury it may only pull or overstretch a muscle or tendon, whereas with a more severe injury you may have a partial or complete tear of these. Sometimes called a ‘pulled muscle’ the common places for a strain are the lower back and in the muscles at the back of the thighs. The difference between a ‘strain’ and a ‘sprain’ is that a strain involves an injury to a muscle or to the band of tissue that attaches a muscle to a bone, while a sprain injures the bands of tissue that connect two bones together.
Injury. Although it is often obvious that upper back pain may have been caused by an injury, it may be a day or so until the pain develops in some cases and so the two things are sometimes not linked to each other. Examples of injuries that can cause back pain include slipping, car accidents, incorrect lifting of heavy objects and work-related accidents. If you feel that you have back pain linked to an injury, this should always be assessed by a healthcare professional.
Spinal stenosis. This is a relatively common condition - believed to affect around 10% of the population and which increases with age - where the spinal canal (the gap in the middle of your back bones that your spinal cord runs through) narrows. This reduces the space available for the nerves running through it and so these may progressively become squeezed or pinched. Depending on its severity there may be no symptoms at all or there may be pain, tingling, numbness and weakness. If this happens in the neck or upper spine there may also be pain and weakness in the shoulders and arms. Simple measures such as losing weight, keeping supple and active and taking painkillers may be all that is needed to treat it but occasionally steroid injections or surgery may be required.
Ankylosing spondylitis. This is a type of chronic arthritis that mainly affects the spine and which typically starts between the ages of 20 and 30, with men being twice as likely to develop it as women. About 1 in 1,000 people in the UK will develop this type of arthritis which can cause the affected joints in the spine to fuse together and become fixed. (The word ‘ankylosing’ means joining together, and the word ‘spondylitis’ means spine inflammation). The most common symptoms are back pain and stiffness, and if it is severe your back may become bent over and stooped. Treatment is with exercises, painkillers and sometimes specialist medication.
Upper back pain can also be pain that is referred from another place, such as organs at the front of your body like the pancreas, liver, or lung. Rarer conditions such as bone cancer can also cause this. Back pain that doesn’t have a clear cause is called non-specific back pain.
Fortunately, in many cases upper back pain goes away on its own within a couple of weeks but there are some home treatment methods you can try to help speed along this process;
This is encouraged in all with musculoskeletal back pain. You should avoid complete bed rest with back pain, as it stiffens muscles up and it can set up new problems in surrounding joints. Try to move little and often, with gentle stretches for the back, neck, shoulders, waist and legs, to avoid further stiffness, pain and difficulty recovering.
A good idea in the first few days after a flare-up or injury. A bag of frozen peas wrapped in a towel will help to reduce the initial wave of inflammation and swelling that can add to pain. You should only use a cold compress for a maximum of 20 minutes at a time. Deep Freeze can be applied to the injured area to have the same effect, or creams or gels containing menthol.
Once inflammation has settled, after the first few days, as it helps the muscles relax, prevents stiffness and eases pain. A hot water bottle does the job well – use a towel to avoid causing a skin rash – or certain creams and gels can cause a local heat, such as Deep Heat heat patches or capsaicin cream, the substance that gives chilli peppers their heat. Compare when you would use an ice pack vs a heat pack.
A professional massage or manipulation can help ease aches and pains in the back and improve movement. This is best done by a professional who understands anatomy and injury. A sports therapist, physiotherapist, chiropractor or osteopath are all highly trained, with the latter two working specifically with back problems and alignment. They can also advise on stretches to alleviate pain and rehabilitate, and exercises to prevent future back pain or injury.
A TENS machine (transcutaneous electrical nerve stimulation) can help relieve pain by providing small electrical impulses to the lower back area, giving a mild tingling sensation and reducing pain signals to the brain. It’s a good idea to try if you have long-term back pain.
Acupuncture has evidence to back its role in short-term relief of chronic back pain, and it may allow a little more movement to encourage further rehabilitation and repair. Tiny needles are inserted to the skin and muscles, which is thought to release natural painkillers in the body called endorphins.
CBT and mindfulness may help to treat the brain’s interpretation of pain, if your back pain lasts several weeks or months. Sometimes our bodies malfunction to continue making us think we’re in pain, even after we’ve recovered from the initial injury. So CBT (Cognitive Behavioural Therapy) or mindfulness can be beneficial in reducing your sensitisation to chronic pain and thereby dampening its impact.
Taking care of your mental health is essential with injuries that are slow to recover, as chronic back pain can take its toll. Consider what you enjoy and what helps you relax – music, reading, catching up with friends – and work on releasing those natural painkillers, the endorphins. Be aware that low mood, anxiety and depression can sometimes set in with chronic pain. See your doctor if you think your condition is affecting your mental wellbeing.
Core strength and conditioning using weight training can help with longer term back pain, and help to prevent future injuries. Pilates, yoga and weight training can all help to build up core muscles, including the paraspinal muscles that hug the spine, and flexibility to keep the spine supple. They also improve posture, which helps if you sit at a desk for long periods or have a physical job requiring lots of lifting.
Further treatment may depend on what your doctor thinks the underlying cause may be. They may refer you to a physiotherapist, who can arrange injections and other therapies or involve other specialists such as a rheumatologist or an orthopaedic doctor.
Pain and stiffness can often shortly occur after a muscle injury to the back. Paracetamol is a safe and sensible place to start when reaching for back pain relief, with relatively few risks or side effects, if taken as instructed. It’s well-tolerated and may be sufficient for occasional mild pain that occurs for just a brief time. It’s also safe in pregnancy. It should be avoided by those with a known liver condition who have been told not to use it.
NSAIDs (non-steroidal anti-inflammatory drugs) can help to relieve the swelling and inflammation that causes back pain and loss of function, especially in musculoskeletal injuries. NSAIDs include ibuprofen and aspirin, and stronger versions are available on prescription. Taken regularly for a week or so, NSAIDs can be very effective. They should be taken with food to minimise any irritation to the stomach lining or increasing reflux issues. The anti-inflammatory element of NSAID medications increases throughout the first week, so will continue to give added benefit with regular usage.
NSAIDs should be avoided in pregnancy, and in those with NSAID-sensitive asthma, a long-term kidney condition, on certain medications or those with a stomach ulcer. Aspirin is not suitable for those under 16.
A proton pump inhibitor (PPI) may be recommended by your doctor or pharmacist to protect the stomach lining if recommending regular NSAID medications. These are available on prescription or to buy at the pharmacy, such as Nexium Control (contains esomeprazole) or Pyrocalm tablets (contains omeprazole).
Alternatively, if you want to avoid tablets, you could try creams or gels that contain anti-inflammatory agents, such as Voltarol Back and Muscle Pain Relief 1.16% Gel, containing diclofenac. We should be careful to not take anti-inflammatory topical creams alongside anti-inflammatory tablets, as these can lead to increased risk of side effects and problems.
Most cases of back pain are nothing to worry about and will improve within a few days or weeks. If your symptoms are not improving, worsening or persisting for more than two weeks despite home treatment methods or you are feeling stiff in the morning, it is sensible to speak with your doctor. If you are in the age groups younger than 20 or older than 50 with persistent back pain then seeing your doctor routinely for an examination would be the best next step.There are certain circumstances when you should seek medical attention, and you may need this urgently:
if your back pain started after a significant fall or accident
if you have a history of cancer
if you have back pain together with unintended weight loss, extreme fatigue or night sweats, a chronic cough, a change in your bowel habit or a lump in your breast, or if you are a long-term smoker
if have severe back pain, or intense back pain that wakes you at night
if you have sciatica affecting both legs, numbness around your bottom or problems with your bowel or bladder control
if you are aged under 45 and get severe back pain and stiffness first thing in the morning, every morning, lasting for 30 minutes or more, and this has persisted for 3 months or more
if your back pain has not started to improve after 6 weeks
Because back pain is more likely to be serious if it occurs in the thoracic area rather than in your neck or lower back, your doctor is likely to suggest tests if the pain persists, is severe, or is accompanied by any worrying symptoms. They will ask about your symptoms and examine your back muscles and movement. Depending on what your doctor suspects, they may refer you for further tests including blood tests and scans, and may also refer you to a specialist to carry out these investigations on their behalf.
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