By: Dr. Stephanie Duffey, PT, DPT
Upper middle back pain is one of the most overlooked areas of spine health, often dismissed or temporarily managed with massage and stretching that never addresses the root cause. This post breaks down why that pain keeps coming back and what is actually driving it beneath the surface.
The thoracic spine sits between two of the most discussed pain regions in healthcare, and that middle position means it is frequently undertreated. From postural strain and core weakness to nervous system dysregulation and referral patterns from the neck, the causes go far deeper than a muscle knot.
Physical therapy is one of the most effective tools for identifying and treating the specific underlying cause of upper middle back pain. Understanding what is actually happening in your body is the first step toward lasting relief.
You’ve tried all the things…massage, stretching, heating pad, having your significant other rub your back at the end of the day. It helps for a day, maybe two. Then it’s back.
That upper middle back pain, tension, and muscle knot can really wreak havoc on your focus, concentration, comfort, and ability to get through the day.
If muscle tension were the whole story, it would’ve stayed gone. A massage or stretch session would have actually fixed the problem and you wouldn’t be reading this blog post.
It’s what is actually under the muscle tension and knots, the thing that is driving the tension, that is the key.
Once you can identify what is driving the tension, you can address it, and actually get lasting relief.
I am going to break it all down for you today and tell you everything you need to know.
Here’s what we are going to talk about in this blog post:
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Why the upper middle back gets neglected
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Common upper middle back pain causes
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What helps upper middle back pain and what does not
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How physical therapy helps upper middle back pain
Why the upper middle back gets neglected
In healthcare and on the internet, upper middle back pain (aka pain in the thoracic spine) often gets neglected. So much focus and attention is put on the neck and lower back, and the mid back becomes like the middle child of the spine.
Yes, there is a lot going on in the neck and back regions, and pain in these areas are very common. But so many people have come to me with upper middle back pain, confused and worried about what is actually going on and how they can feel better.
My honest opinion is that there aren’t a ton of high revenue-generating treatments for upper middle back pain, so less attention is given to it. It sucks, I know. That’s why I’m here to share the truth with you.
Upper middle back pain is very fixable with conservative care. There is hope and I’ve got you!
Common upper middle back pain causes
The spine is all connected, so it is worth talking about the neck, low back, and nervous system when addressing upper middle back pain causes. We will address all of it right now.
Common upper back pain causes are:
Postural strain
This one is usually pretty obvious for people. Almost everyone comes through our doors saying they think their posture is causing their pain. Sometimes this is the case! Optimizing posture, especially for desk workers, dentists, aestheticians, and nail technicians can go a very long way in improving upper middle back pain.
Spending lots of time in a forward head posture puts increased demand on the muscles of the neck and upper back to hold up the head and torso. This strain compounded over the hours spent in a forward position can really cause a lot of pain and tension. Yes, it can manifest as muscle knots, but the underlying reason is too much muscle demand (and potentially not enough strength). These muscles are working harder than they ever were intended to work.
Core and back muscle weakness
The core and back muscles are super important for supporting your body through movement and sustained postures every day. However, they work in different ways.
Think of the back muscles as marathoner muscles. They are designed to hold you upright all day, every day. Weakness in the back muscles that run up and down the spine can make you feel like it is hard to hold yourself upright, especially for long durations of time. Over time, this can cause pain anywhere in the spine, including the upper middle back.
In contrast, the core is a sprinter muscle. While it does help support upright posture, it is also designed to help you lift and move heavy loads. So if it seems like working out or heavy, repetitive activities (think gardening, mulching, heavy cleaning, lifting and carrying small children, etc) trigger your upper middle back pain, your core is probably not stabilizing you well.
When your core isn’t stabilizing you well, your body will find that stability elsewhere. The path of least resistance is the back and neck muscles. But remember, those are marathoner muscles…not sprinter muscles. If you try to make a marathoner into a sprinter, it’s not going to work well. The end result? Upper middle back pain, tension, and muscle knots.
Stiffness in the spine
The thoracic spine is an area of the spine that can get stiff over time. It inherently is more stiff than the neck and low back because of the ribcage. But with chronic forward posture and core or back muscle weakness, these joints can become more stiff.
Motion is lotion here! Doing mobility and strength drills to actively move the mid back can make a big improvement in upper middle back pain.
Carrying high amounts of stress
Carrying high amounts of stress and overwhelm, especially over months or years, can manifest as muscle tension and knots. The most common areas to hold stress in the body are the neck, shoulders, and jaw as well as the hips and low back. What is right in between these areas? You got it, the middle back. Stress can absolutely be held here. Plus, the mid back will feel the effects of tension, strain, and tightness in the parts of the spine above and below.
Additionally, chronic stress puts your nervous system in a heightened state. In this heightened state, your nervous system is trying really hard to protect you. One of the ways your nervous system protects your body is through stiffening the muscles. This is a protective mechanism that works well if you’ve broken a bone or sustained trauma, however it does not work well when you’re trying to live your daily life.
Referral from the neck
One of the most common causes of upper middle back pain that I see is a referral from the neck. This is called a Cloward’s referral. If there is irritation in the neck, usually at the disc level, it refers pain to the upper middle back and inner part of the shoulder blades.
So many times, clients have come to me with knots in the muscles right along the shoulder blades. All they’ve been doing is addressing those knots. But what actually works for them is focusing treatment on the neck. Once we do this, they get immediate relief.
Unfortunately, this Cloward’s referral is very often missed in traditional medical exams. At Empower Physio and Wellness we know to screen for this pattern and recognize it quickly so that you can feel better in the most efficient way possible.
Other
A less common cause, but one worth mentioning, is referred pain from the organs. I’ve seen a few cases where we helped upper middle back pain a bit, but couldn’t get it to totally go away. If your pain is tied to eating, is worse at night, or really doesn’t follow any pattern, it is worth exploring if this pain is referred from an organ like the gallbladder, liver, stomach, or heart.
What helps upper middle back pain and what does not
It is very important to address the underlying upper middle back pain causes in order to experience lasting relief. Simply stretching or massaging tight muscles only scratches the surface and keeps you on the frustrating cycle of pain.
While the things that will work best for you are highly individualized, here are common strategies that help our clients with upper middle back pain.
Posture optimization
Optimizing your workplace setup can really go a long way in improving spine pain. For all the details on this, check out our blog Posture, Neck Pain, and Headaches: How Physical Therapy Can Break the Cycle.
Remember that your best posture is your next posture…it’s a posture that is always changing. Our bodies are made to move, so even the most “perfect” posture will only last for so long. Aim to get up and move every 45-60 minutes throughout your workday.
Strengthening the core and back muscles
Solid muscle strength is so important for literally everything in life. Having a good exercise routine where you strength train two to four days a week can really improve spine pain.
Whether you have a strength routine already or not, here are some of our favorite exercises:
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Core breathing– This is a foundational breathing and core activation drill that is great for both beginners and experienced lifters alike.
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Chin tuck swimmer– This is a great drill to specifically target upper back strength.
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Dead bug– This is a great beginner to intermediate core strengthening drill.
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Bear plank– This is a great intermediate to advanced core and upper back strengthening drill.
Improving thoracic spine mobility
There are two parts that are important for improving mobility and also keeping this mobility. First, start with this open book drill. It will target stiff areas of the spine and get those joints moving better. Then follow it up with a side plank thread the needle to build strength through the mobility you just gained from the open book.
Nervous system regulation techniques
Productively processing stress is a great way to reduce pain from muscle tension, especially in the spine. We love using breathing to help regulate the nervous system and get you in a coherent state to productively process stress. Try this Quick Coherence® Technique from the HeartMath Institute, then spend 5-10 minutes journaling or brain dumping your stress onto paper. This is a super powerful combination of techniques!
You can also take our Nervous System Quiz to see how much your nervous system is contributing to your pain. You’ll receive our free 3-week Empowered Nervous System Recalibration Method after you take the quiz! It is an amazing resource to support your nervous system in an accessible, genuine way.
Improving neck mobility
The most effective way to improve upper middle back pain that is referred from the neck (aka a Cloward’s referral) is with these two drills: chin tucks and neck rotation SNAG. Do these drills two to three times per day in the beginning, then just once a day or every other day for maintenance.
How physical therapy helps upper middle back pain
Like I mentioned, addressing the specific underlying cause of your upper middle back pain will allow for the most efficient recovery. The best way to do this is to have an expert on your team!
Physical therapists are specifically trained to identify the root cause of pain and efficiently help you fix it. We are the experts so you don’t have to be.
We first determine the primary underlying cause(s) of your upper middle back pain, whether it be postural strain, muscle weakness, mobility problems, nervous system dysregulation, or a referral from another part of the body.
Then we can curate a customized plan for you to feel better as quickly and efficiently as possible. This can include any combination of manual techniques, dry needling, cupping, mobility drills, lifestyle modification, strength training, and nervous system regulation techniques.
Feeling better is not only possible, it is extremely attainable! Nothing is broken, you just need the right support.
