It can help you narrow down the possible causes of upper or middle back pain if you are aware of a combination of symptoms:
1. The pain that is aggravated by touch AND the movements of the neck or arms can be from increased muscle tension, spasms or strain, rheumatoid arthritis, fibromyalgia, shingles or a fracture of a vertebra or rib.
2. The pain on the inner side of a shoulder blade that is aggravated by movements but NOT by touch can be from a herniated disc in the neck.
3. The pain in the middle back that is aggravated by touch but NOT by movements can be from kidney disease.
4. The back pain that is aggravated by breathing can be from the overuse of the serratus anterior muscle, pleurisy, pericarditis, rib fracture or pneumothorax.
5. The back pain that is NOT aggravated by touch, breathing or movements can be from the heart disease, kidney stones, upper thoracic (T4) syndrome or tumors in the chest cavity.
|SUDDEN (ACUTE) PAIN||CHRONIC PAIN|
SUDDEN (ACUTE) PAIN
Middle back is the area between the bottom of the rib cage and the bottom of the shoulder blades. Upper back is the area between the bottom of the shoulder blades, shoulders and neck.
1. Pain in the Lower Neck and Upper Back
Muscle Strain (Pulled Muscle)
Overhead sports activities, such as swimming or throwing, reaching for an object on a high shelf or fall on the hands with stretched arms can result in muscle strain or tear in the lower neck or upper back. Symptoms can include :
- Sudden pain in the neck or upper back, which can persist during rest and can be aggravated by bending the neck or moving the arms or trunk and relieved by ice packs
- Local tenderness, cramping, swelling or bruising that can persist for several weeks
Wry Neck (Torticollis)
Wry neck refers to a prolonged spasm of the neck muscles on one side. Causes include sleeping the wrong way, an unusual head movement, neck injury or ear infection. Symptoms can include :
- A painful spasm of the neck and upper back muscles, which makes you tilt your head toward one side; the spasm can persist from few days to several weeks
A sudden back and forth movement of your head (like a whip), which usually occurs in car or motorbike accidents, can cause sprain or tear of the muscles, tendons and ligaments near your cervical part of the spine. Symptoms can include :
- Pain in the neck and upper back that can appear right after an incident or only days or weeks later and can persist for several weeks or months
- Stiff neck
- Dizziness, blurred vision
2. Pain in the Chest and Upper Back
Gastroesophageal reflux disease (GERD, acid reflux) can cause :
- Heartburn (burning pain behind the breastbone, in the throat or upper back), which can be triggered by eating or lying down
- Chronic dry cough
- Metallic or acidic taste in mouth
Acute viral bronchitis, which can be a complication of cold or flu, can cause:
- A dry cough lasting for few weeks
- Pain in the chest and upper back aggravated by coughing
- Low-grade fever
Shingles develops due to a reactivation of a latent infection of one or more spinal nerves by the Herpes zoster virus. Symptoms can include :
- Severe burning pain and tingling, followed by an itchy red rash (fluid-filled vesicles, which eventually crust over) that travels as a stripe horizontally around the chest or down an arm, usually only on one side and can persist for few weeks to a month (Picture 1)
Shingles usually occurs only once but it can recur .
Picture 1. Shingles (Herpes zoster) at the back of the neck
(source: Samuel Freire da Silva, MD, Dermatology Atlas)
Rare Causes of Sudden Chest and Back Pain
- Dissection of the thoracic or abdominal aorta
- Pulmonary embolism
3. Pain in the Upper Abdomen and Back
Stones in the kidneys or upper ureters can cause:
- Sudden, excruciating pain in the right or left flank, radiating down to the lower abdomen or groin, lasting for several minutes to hours (Picture 2)
- Nausea or vomiting
- Blood in urine
Picture 2. Kidney stones — pain distribution
Gallstones or acute gallbladder inflammation (cholecystitis) can cause:
- Sudden, severe, even extreme, pain in the upper right abdominal quadrant that can remain constant for several minutes to hours and can radiate to the middle upper back or right shoulder (Picture 3)
- Nausea or vomiting
- Fever (sometimes)
Biliary dyskinesia including gallbladder dyskinesia and sphincter of Oddi dysfunction is the pain in the gallbladder or bile ducts in the absence of gallstones; it can appear in the upper right abdominal quadrant, right middle back or tip of the right shoulder.
Picture 3. Gallbladder attack — pain distribution
Pancreatitis commonly results from gallstones or chronic alcoholism. Symptoms can include :
- Severe dull pain after meals in the upper middle or left abdomen that can radiate to the middle back and last for several days
- Tenderness or a lump in the upper central or left abdomen
- Nausea or vomiting
4. Right Upper Back Pain
Irritation of the diaphragm (the muscle that separates the chest and abdominal cavity) can cause referred pain in the right upper back. Causes include:
- Gallbladder disease
- Liver cancer
- Pelvic inflammatory disease (due to a recurrent sexually transmitted disease)
- Ectopic pregnancy
5. Left Upper Back Pain
Irritable Bowel Syndrome with Trapped Gas
In individuals with irritable bowel syndrome (IBS), gas trapped in the flexure of the colon near the spleen can cause severe pain in the upper left abdominal quadrant, which can radiate to the left side of the chest and left shoulder and can remain constant for several hours or days. The condition is also known as splenic flexure syndrome.
Heart attack typically includes:
- Sudden, severe pain in the middle of the chest that usually lasts for more than 15 minutes and can radiate into the neck, jaw, left shoulder and arm
- Tingling in the left arm, hand and little finger
- Shortness of breath
- Sweating, nausea and lightheadedness
- Sense of impending doom
6. Back Pain During Breathing
Back pain that occurs only or mainly during breathing (deep inspiration) can result from:
Overuse of the serratus anterior muscle due to repeated sprints, prolonged running, boxing or lifting objects with an extended arm can result in pain on the either side of the trunk, below the shoulder blades and on the inner side of an arm (Picture 4).
Picture 4. Serratus anterior muscle pain syndrome
Pleurisy (an inflammation of the lung membrane, for example, due to pneumonia) can cause scratching, knife-like pain on either side of the trunk or at the bottom of the rib cage, and shortness of breath.
Pericarditis (an inflammation of the heart sac) can cause pain in the middle of the chest and back; the pain may be relieved by leaning forward and aggravated by lying on the back.
A rib fracture can occur during falling or a direct hit; a severe pain on the side of the back is aggravated by deep inspiration; there may also be a bruise and visible bone deformity.
Pneumothorax (a spontaneous or traumatic collapse of the right or left lung) can cause a sharp, stabbing pain followed by discomfort around the chest and back; the pain can be aggravated by moving the trunk or arms.
7. Back Pain When Lying Down
In the following conditions, the pain can be worse after lying down:
- Muscle strain
- Pinched spinal nerve due to a herniated disc in the neck (cervical radiculopathy)
- Gastric reflux
- Acute pancreatitis
- Rib fracture
- Vertebral fracture (due to an injury, osteoporosis or bone cancer)
CHRONIC (CONSTANT or RECURRENT) PAIN
1. Bad Posture and Stress
Examples of bad posture that can result in increased muscle tension in the back, especially if associated with emotional stress:
- Rounded shoulders and poking chin at desk work
- Sitting on a chair that is too high or low or too soft
- Sleeping on a mattress that is too hard or soft
- Carrying a heavy bag or backpack
- Holding a musical instrument the wrong way
Long-term overuse of the upper back muscles (lifting heavy objects, workout, swimming, throwing) can result in myofascial pain syndrome with:
- Tight muscles and muscle knots in the upper back
- Trigger points in the upper back with pain radiating to the neck, face or arm (Picture 5)
Picture 5. An example of pain distribution in myofascial pain syndrome
According to anecdotal reports, some women experience severe upper back pain in the last days before labor.
Lower rather than upper back pain can occur due to hormonal changes, which result in loosening of the ligaments between the pelvic bones in early pregnancy.
Rheumatoid arthritis can cause chronic pain in the neck and upper back and symmetrical pain, swelling and stiffness in the joints (finger knuckles, wrists, shoulders, knees, etc.).
5. Kidney Disease
The following chronic kidney diseases can cause constant dull pain in one or both flanks, at the bottom of the rib cage, few inches away from the spine:
- Recurrent kidney infections (chronic pyelonephritis)
- Kidney inflammation (interstitial nephritis or glomerulonephritis)
- Polycystic kidney disease
- Kidney cancer
- Other causes of kidney pain
6. Angina Pectoris
Angina pectoris is recurring pain behind the breastbone caused by coronary heart disease. The pain lasts for less than 5 minutes and can radiate to the neck, jaw, upper back and down the inside of the left arm; it can be triggered by exercise, stress, heavy meal or cold environment and relieved by rest or the oral drug called nitroglycerin.
7. Pinched Spinal Nerve
Either an injury of the neck spine or cervical spondylosis (osteoarthritis due to age-related wear and tear) can result in bulging or herniated discs or bone spurs in the neck spine and a subsequent compression of a spinal nerve; symptoms include:
- Burning, shooting pain and tingling or numbness in the neck, shoulder, arm, hands, fingers or along the medial border of a shoulder blade (Picture 6); the pain can be triggered by bending or twisting the neck, lying down, sneezing or coughing
- Weakness in an arm
Picture 6. Pinched spinal nerve — pain distribution
Fibromyalgia refers to chronic musculoskeletal pain and symmetrical tenderness in various parts of the body, including the upper back (Picture 7). Other common symptoms include fatigue, insomnia and mood changes. No abnormalities can be detected by the laboratory and imaging investigations (X-ray, CT, MRI).
Picture 7. Fibromyalgia — typical locations of tender points
9. Muscle Spasms
Recurring muscle spasms along in the middle or upper back can appear as a reaction to painful underlying conditions, such as a bulging or herniated disc or rheumatoid arthritis.
Common cancer symptoms include nausea, loss of appetite and unintentional weight loss.
Esophageal cancer can cause pain in the middle of the chest and neck; the pain can be aggravated by swallowing.
Stomach (gastric) cancer can cause pain in the upper central abdomen and middle back; the pain can be worse during eating; other symptoms can include vomiting blood and black stools .
Liver cancer can cause constant dull pain in the upper right abdomen, the right side of the back and right shoulder, and jaundice.
Pancreatic cancer can cause pain in the upper central abdomen, which can radiate to the middle back or left shoulder; other symptoms and signs can include jaundice and a palpable lump in the upper abdomen.
Hodgkin lymphoma that affects the lymph nodes in the chest can cause pain in the middle of the chest and upper back, low-grade fever, dry cough and hoarseness.
Lung cancer can cause right or left middle or upper back pain before causing any other symptoms, such as coughing up blood.
Multiple myeloma develops in the skull, pelvic bones and vertebra, mainly in older people; it can result in the fracture of the vertebra, which causes pain between the shoulder blades.
T4 or upper thoracic syndrome, which is caused by the irritation of the nerves near the chest spine, can cause pain between the shoulder blades and abnormal sensations in the forearm, hand and fingers, on one or both sides (Picture 8). The pain may or may not be aggravated by touch and upper body movements.
Picture 8. T4 or upper thoracic syndrome
12. Transverse Myelitis
Transverse myelitis (an inflammation of the spinal cord, for example, in Lyme disease or multiple sclerosis) can cause shooting pain and tingling in the neck and upper back and weakness in the arms; the pain can be triggered by light touch.
13. Rare Causes of Chronic Upper Back Pain
- Scoliosis (a sideways curvature of the spine) rarely causes pain in the upper back.
- Dermatomyositis and polymyositis (an autoimmune disease that affects the muscles and skin) can cause pain and weakness in the shoulder and pelvic girdle muscles, and rash.
- Lung tuberculosis symptoms can include pain on the either side of the chest or middle or upper back, low-grade fever and coughing up blood.
Treatment and Prevention of Upper Back Pain
The treatment of back pain depends on the cause.
Stress can arise from wrong attitudes in the relationships and at work. Doing the things in the way you personally believe are right to do, which means being at peace with yourself, can greatly reduce the stress and back pain. If you work too much you may consider taking a break.
Cold compresses or ice packs can partially prevent the development of a bruise and reduce the pain caused by a direct hit or muscle strain.
Sleeping on a semi-hard mattress can be optimal for middle and upper back pain. Sleeping on a very hard or soft mattress can actually cause back pain.
An office chair with a low back support that allows you sit straight but not lean back is probably the optimal chair for upper back pain. A chair should allow your feet, thighs and forearms to be in a horizontal position.
Stretching exercises can help prevent pain in myofascial pain syndrome and rheumatoid arthritis .
Physical therapy, which can include massage, dry needling, steroid injections and exercises, may help in myofascial pain, bulging disc or rheumatoid arthritis, for example.
Over-the-counter (OTC) painkillers, such as aspirin or ibuprofen, can be used to relieve mild to moderate pain, for example, after a muscle strain.
Acupuncture is a widely used but unproven method for relieving pain in the back.
Examples of conditions in which surgical treatment can relieve upper or middle back pain include pinched nerve in the neck, whiplash, broken vertebra, gallbladder inflammation, coronary heart disease and cancer.
- Bowles MJ et al, 2001, Cancer of the stomach and pancreas PubMed Central
- Cooney JK et al, 2011, Benefits of Exercise in Rheumatoid Arthritis PubMed Central
- Sprains, Strains and Other Soft-Tissue Injuries OrthoInfo
- Torticollis Patient.info
- Whiplash symptoms Mayo Clinic
- Understanding Gastroesophageal Reflux Disease (GERD) — Symptoms WebMD
- Shingles – topic overview WebMD
- Acute pancreatitis causes and symptoms The National Pancreas Foundation