Getting to the heart of upper back pain

People often worry about lower back and neck pain while completely ignoring their upper back. They're having a lot of treatment on their lower backs and necks, but very often, their upper back, also known as the thoracic spine, is the true source of their discomfort. As we get older, we get stiffer and lose mobility in the upper back. That's why it's important to always consider the upper back when assessing spinal pain, because over time, our bodies will no longer let us ignore its presence.
Picture of Jimmy Goulis

Jimmy Goulis

The incidence of upper middle back pain

The global incidence of upper back pain is around 5%. This means it is less common than cervical spine (neck) or lumbar spine (lower back) pain. 

It’s important to note, the incidence of upper back pain is likely to be higher than reported as it is often mistaken for neck or lower back pain. In fact, sometimes pain experienced in the upper back can be the result of an issue relating to the neck or lower back.

Individuals with thoracic spine pain often don’t present as early as they might if they were experiencing lumbar or cervical spine pain. Unfortunately, this can mean they experience a noticeable decline in their mobility.

The most common risk factors associated with upper back pain are:

  • Sedentary lifestyle.
  • Poor or static posture.
  • Heavy workload.
  • Tension.
  • Repetitive bending, lifting, and twisting, motions using the thoracic spine.

How your upper back is put together

The upper back is the central section of the spine, located in the chest region. It starts at your neck and ends at the bottom of your lowest rib.

The functions of your thoracic spine include protecting the spinal cord and branching spinal nerves, providing stability and support for the abdomen and chest, enabling movement in this region of the body, and providing attachments for your ribs.

Although the thoracic spine anatomy is similar to the lumbar and cervical spine, it has a couple of important differences. This is because the thoracic spine supports the rib cage, which encases several of the body’s vital organs. 

Understanding the structure of the upper back, its function, and the basic anatomy is often key to appreciating the reason for thoracic spine pain. 

Bones of the thoracic spine

The thoracic spine comprises 12 vertebrae (T1 to T12), which sit in a vertical column.

A tunnel-like structure, known as the spinal canal, is formed within this column. It aligns with the cervical vertebrae above and the lumbar vertebrae below.  The spinal canal protects the spinal cord as it descends the body.

The thoracic vertebrae are part of the ribcage, which also includes 12 pairs (24 total) ribs and the sternum, which is flat bone at the front of your chest. Its job is to protect the heart, lungs, and major blood vessels contained within it.

Unlike the cervical and lumbar vertebrae, the portion of  bone extending from the back of each thoracic vertebrae known as the spinal process overlaps, which adds support and stability to the ribcage. 

Intervertebral discs of the thoracic spine

Sitting between each of the vertebrae is an intervertebral disc. The discs are spongy, rubber-like structures, which act primarily as shock absorbers. These discs are tough and designed to to minimise the effect of movement and limit the resulting wear and tear on each of the vertebrae that forms the upper back.

Joints of the thoracic spine

Like the other vertebrae of the spine, each thoracic vertebrae has a pair of facet joints. These joints are where the vertebrae connect with the one immediately above (superior facet joint) and below (inferior facet joints). Facet joints contribute to the stability of the upper spine.

In addition, each vertebrae of the thoracic spine has two types of costovertebral joint. These joints are unique to the thoracic spine and are where the ribs and vertebrae connect or articulate. 

  • Costocorporeal joints are where the rib connects with the vertebrae immediately above and below.
  • Costotransverse joints are where the rib connects with the transverse process, which is a wing-like portion of bone on each vertebrae where muscles attach. 

Muscles and ligaments of the thoracic spine and ribcage

The thoracic spine is a complex network of ligaments and muscles. The muscles are divided into extrinsic (superficial) and  intrinsic (deep) muscles, which assist in movement and stabilise the body.

In addition, many of the major muscles that provide the body’s stability attach to the spine in the upper back region.

As well as the muscles of the thoracic spine, the thoracic region includes the muscles that form part of the ribcage.They include the intercostal muscles, subcostal muscles and the transversus thoracis.

These muscles are commonly referred to as the chest wall and are responsible for respiration.

Nerves of the thoracic spine

The spinal cord contains the nerves which control movement and sensations, such as pain, temperature, and touch throughout the body. These nerves are responsible for the communication between the body and the brain.

Each vertebrae has a small hole either side of it, which is where the corresponding spinal  nerve (T1 to T12) exits the spinal column.

Part of the spinal nerves T1 to T11 becomes an intercostal nerve which innervates the space between the corresponding ribs. In addition, each of the thoracic spinal nerves is responsible for communication between the brain and a distinct portion of the body. The areas can vary slightly between individuals, but generally:

  • T1 and T2 innervate the top part of the chest and parts of the arms and hands.
  • T3 to T5 form the nerves of the chest wall and assist with breathing.
  • T6 to T12 become the nerves responsible for parts of the chest wall, abdomen and lower back. They also contribute to balance and posture.

Common symptoms of upper back pain

Each possible upper back pain cause presents with a set of distinct symptoms. Understanding the symptoms of your upper back pain helps the physiotherapist determine what is causing it, as well as the best ways of managing and treating upper back pain.
Some of the common upper back pain symptoms include:

  • Pain between or around the scapulae or shoulder blades.
  • Central, unilateral (on one side), or bilateral (on both sides) pain. 
  • Shoulder pain especially at the cervicothoracic junction, which is where the cervical spine becomes the thoracic spine.
  • Spinal pain that makes it difficult to sleep or where it is hard to get comfortable on either your right or left side.
  • Upper back pain when breathing or taking a deep breath.
  • Decreased sensation in arms or legs.

How your physio should assess your thoracic spine pain

The assessment of thoracic spine pain is divided into subjective and objective parts. 

The questions you should be asked

The physiotherapist will ask a series of  general questions that relate to most types of pain, such as its nature, location, and severity. The goal is to develop a clear picture of the history of your upper back pain.

In addition, your physiotherapist will ask specific questions relating to the onset of the pain and whether it is the result of a specific trauma, or if the onset was sudden or gradual.

These more specific questions help to determine if you are experiencing upper back pain symptoms that occur in common conditions of the thoracic spine and the associated ribcage. This process is key in determining the cause of your thoracic spine pain.

An experienced physiotherapist uses this part of the assessment to consider whether you are experiencing musculoskeletal pain (relating to the nerves, muscles and joints), or a non-musculoskeletal (medical) cause.

Upper back pain red flags that should be considered

The purpose of the subjective questions relating to your upper back pain is not only to better understand the various upper back pain symptoms you are experiencing, but to rule out the red flag conditions that might be associated with thoracic back pain. 

The red flags associated with thoracic spine pain are typically medical conditions and for most you should seek immediate medical attention. They include:

  • Cardiac causes: There is a general rule in medicine that any pain in the chest or thoracic spine region is considered to be cardiac in origin until proven otherwise. This is because cardiac issues can present in a variety of different ways, depending on the individual. Some of the types of questions your physiotherapist might ask to rule out a cardiac cause


  • Peptic ulcer: A peptic or gastric ulcer can manifest as upper back pain. Symptoms commonly include coffee grain like vomit, heartburn, burning stomach pain, intolerance to fatty foods, and bloating, burping, or a feeling of fullness.


  • Cancer or tumour: Back pain is the most common cause of benign and non-benign tumours, with the thoracic spine being the most common spinal location. To rule cancer or tumour out as a possible cause, your physiotherapist will ask about some of the systemic symptoms that are associated with cancer, such as unexplained weight loss, fatigue, general malaise, and loss of appetite. 


  • Infection: A possible infective cause of upper back pain is typically associated with fevers, rigours, generally feeling unwell, tiredness, and night sweats.


  • Inflammatory conditions: Inflammatory and autoimmune conditions are more prevalent in the female population. Inflammatory arthritis, such as ankylosing spondylitis or rheumatoid arthritis can be associated with thoracic spine pain. Questions that help elicit symptoms of inflammatory conditions relate to symmetrical or bilateral (both sides) joint pain, as well as deformations, weakness, and stiffness.


  • Pneumothorax: A pneumothorax is often referred to as a collapsed lung. The types of symptoms that relate to a pneumothorax include one-sided chest pain, sudden onset, sharp pain, and difficulty breathing.


  • Shingles: Shingles is a reactivation of the chicken pox virus, causing a painful blistering rash. Although the rash can appear anywhere, it is most common in the thoracic region. Your physiotherapist is likely to ask about rashes, whether they are symmetrical or the same on both sides of the body, whether you’ve had chicken pox, burning or tingling pain, and other conditions that may weaken your immune system.

The physical tests your physio should do

An objective assessment is when the physiotherapist does a physical exam of your thoracic spine. This involves feeling the vertebrae and other structures of the upper back.

This identifies any obvious deformation. By palpating the different structures in the thoracic spine, any areas of tenderness can also be easily identified.

Assessing your range of movement is another important part of the physical examination, which assists with diagnosing the source of the pain. 

Your physiotherapist will also visually assess your thoracic spine, looking for symmetry, any obvious areas of swelling or visible muscle spasms. They will also look at your gait and posture.

Part of the visual assessment involves looking at the curves of your spine. The lumbar and cervical spine usually curve inward like the letter C. The thoracic spine is the reverse curving outward, meaning the spine curves in an S shape.  

It is important to assess whether the curve in your thoracic region is abnormally rounded. This is known as kyphosis and sometimes results in a hunch back.

As well as assessing the thoracic spine, your physiotherapist will look for uneven heights between the shoulder blades, hips, and waist or  pronounced buttock, which can be indicative of sidewards movement in the vertebrae.

Landing on a diagnosis of musculoskeletal upper back pain

Once your physiotherapist has made a diagnosis that your upper back pain is the result of a musculoskeletal issue, they will then divide your pain into two categories:

  • Traumatic: The pain is the result of a specific event or trauma like a car accident. The thoracic spine is less likely than the lumbar or cervical spine to be injured as the result of a trauma. Most traumatic injuries relate to the ribs.


  • Insidious: There is no one specific event that is responsible for the pain, rather the pain is the result of the accumulation of micro-stressors or repetitive motions over the years.

Common musculoskeletal causes of upper back pain

The most common musculoskeletal upper back pain causes are:

  • Rib sprains: Symptoms associated with a rib sprain include, upper back and shoulder pain, difficulty breathing, and constant pain that worsens on movement. Rib sprains are commonly caused by poor posture, increased loads, poor sleeping position, and accidents involving a whiplash injury. Degenerative conditions that result in weakening muscles can also be a cause of rib sprains.


  • Costovertebral joint sprains: One common type of rib sprain is a costovertebral joint sprain. This sprain occurs when there is increased pressure on the costovertebral joint capsule causing the muscles to tense which can lead to a sprain. Costovertebral joint sprains are common among sportspeople who place external pressure on the thoracic pressure leading to the abnormal twisting and bending of the ribs and thoracic spine, which can result in a sprain to the joint.


  • Facet joint injuries: Facet joint injuries are often the result of degenerative processes that occur as you age or trauma to the facet joint. They lead to thoracic spine and ribcage instability.


  • Paraspinal muscle strain: Paraspinal muscles run the length of the spine and are responsible for its movement. A paraspinal muscle strain can occur when the muscle fibres suddenly contract when stretched. The most common cause is lifting heavy objects. Pain is often exacerbated by twisting the spine.


  • Scheuermann’s disease: Scheuermann’s disease is most common in adolescents and involves thoracic kyphosis (hunched back). It is usually self-limiting, but can be a cause of thoracic spine pain. Scheuermann’s disease affects up to 10% of the population with the incidence in boys double that of girls. Poor posture is a contributing factor.


  • Scoliosis: This condition is most common in children and adolescents. Scoliosis relates to an abnormal curvature of the spine. The usual presentation involves sidewards movement in the vertebrae accompanied by abnormal rotation of the vertebrae. This can lead to muscle and joint pain throughout the thoracic spine.

Less common musculoskeletal causes of upper back pain

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

  • Rib fractures: Generally, rib fractures are the result of trauma. The fracture can cause damage to the structures in the thoracic cavity, such as the heart, lungs, blood vessels, and pleura. This can result in complications, such as pneumothorax, lung contusion or laceration, and injuries to major blood vessels. 


  • Thoracic disc prolapse: A herniated or prolapsed thoracic disc can be the result of a trauma due to force. The force does not have to be huge. Even bending can cause a disc to rupture in older adults. Pain is not always a symptom, with sensation changes, such as tingling or numbness in the legs, paralysis below the waist, muscle weakness in the legs, and increased reflexes common in this type of injury.


  • T4 Syndrome: T4 Syndrome is the result of stiffness in the spine and immobility of the costovertebral joints, which is especially evident at T4. The symptoms include pain between shoulder blades, shooting pain from the shoulder to the hand, radiated pain in the neck, decreased dexterity and numbness in the hands, and headaches.

If you would like your middle-upper back pain diagnosed or treated, reach out to Pollinate Health physiotherapists for an appointment today.

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