Upper Back and Chest Wall Pain

What is it?

Upper back (thoracic) pain is felt between the neck and the lower back, particularly between the shoulder blades. Chest wall pain comes from the structures that make up the rib cage: the ribs, muscles and joints, and the nerves that run between the ribs. Because the thoracic vertebrae are joined to the ribs, this part of the spine moves less than the neck or lower back, so pain here more often comes from muscles, joints and nerves than from the discs.

Pain in this area usually comes from muscles and joints and does not point to a serious illness. However, chest and upper back pain can also be a symptom of heart, lung, major blood vessel or digestive problems. That is why the first step with any new chest pain is to rule out these urgent causes.

What causes it?

The main muscle, joint and nerve causes are:

• Posture and muscle strain: long periods bent forward and desk work can cause pain between the shoulder blades.
• Myofascial pain: tender trigger points in the back muscles (myofascial pain syndrome).
• Facet and rib joints: irritation of the joints of the thoracic spine can cause pain that worsens with twisting and deep breathing.
• Costochondritis: inflammation of the cartilage where the ribs join the breastbone, causing chest pain that is worse when pressed.
• Intercostal neuralgia: irritation of the nerves that run between the ribs, causing band-like pain around the rib cage.
• Pain after shingles: nerve pain that persists in the same area after shingles (herpes zoster) (neuropathic pain).
• Pain after surgery: pain that can last for months after chest or breast surgery.
• Vertebral fractures: compression fractures that can occur after minor strains, especially in people with osteoporosis.

Disc herniations are much less common in the upper back than in the neck or lower back. New back pain in someone with a history of cancer is always investigated, because of the possibility of spread to the spine (cancer pain).

How is it diagnosed?

With chest pain, heart and lung causes are assessed first; an electrocardiogram (ECG), blood tests and chest imaging are arranged where needed. Once these causes have been ruled out, the examination looks at whether the pain is coming from muscles, joints or nerves.

The examination covers spinal movement, tenderness where the ribs meet the breastbone, trigger points in the muscles and changes in sensation around the rib cage. After shingles, pain that matches the area where the rash appeared supports the diagnosis. X-rays, MRI or a bone density scan are requested when needed. When the source remains unclear, diagnostic nerve blocks can help.

Treatment options

Once urgent causes have been ruled out, treatment is planned around the source of the pain.

Conservative care

• Posture and ergonomics: adjusting your workspace, taking regular breaks and paying attention to posture.
• Exercise and physiotherapy: programmes that strengthen the back and shoulder girdle muscles and improve the mobility of the rib cage.
• Medication: short courses of painkillers; for nerve pain, medicines aimed specifically at that type of pain.
• Treating the underlying cause: for example, treatment for osteoporosis, or antiviral treatment started in the first days of shingles.

Interventional pain treatments

• Trigger point injection: may support an exercise programme when clear trigger points are present in the back muscles.
• Facet joint injection: for pain thought to come from the joints of the thoracic spine, used to confirm the source and to reduce pain.
• Radiofrequency treatment: can be applied to the joint nerves when a diagnostic block has confirmed joint pain, or to the relevant intercostal nerve in long-standing intercostal neuralgia.

In suitable patients these methods can provide a meaningful reduction in pain; results vary from person to person. Procedures in the chest area carry specific risks, such as the closeness of the lining of the lung, and these are discussed in detail beforehand.

When is surgery considered?

For a disc herniation pressing on the spinal cord, an unstable fracture or a tumour, treatment is planned together with a neurosurgeon or an orthopaedic spine surgeon.

When should you see a doctor?

See a doctor if your upper back pain is not easing after a few weeks, gets worse at night, or if burning pain around your rib cage persists. Once heart and lung causes have been ruled out, an algology (pain medicine) specialist will assess where the pain is coming from and plan treatment with you; you can request an appointment through our contact page.