Mid Back Pain: Causes, Symptoms, and Treatment Options

What is Mid Back Pain?

Mid back pain refers to pain felt between the shoulder blades or anywhere along the thoracic spine. It may be dull and constant, or sharp and worsened by specific movements such as deep breathing, rotation, or bending.

Because the thoracic spine is stabilised by the ribcage, it moves less than the cervical or lumbar spine and is less prone to disc herniation. However, the facet joints between vertebrae and the joints where ribs meet the thoracic spine (costovertebral joints) are frequent sources of pain that often go undiagnosed.

Mid back pain can also be referred from internal organs, including the kidneys, gallbladder, and lungs. A thorough assessment rules out these sources before targeting spinal structures.

Symptoms of Mid Back Pain

Common symptoms include:

1. Pain between or below the shoulder blades on one or both sides
2. Pain that worsens with twisting, bending, or extending the spine
3. Pain that increases with deep breathing, coughing, or sneezing
4. Tenderness along the spine or at the rib junction when pressed
5. Radiating pain around the rib cage following an intercostal nerve distribution
6. Stiffness after prolonged sitting or on waking in the morning
7. In severe cases, weakness, numbness, or altered sensation in the torso or legs

See a specialist promptly if mid back pain is accompanied by weakness in the legs, bowel or bladder changes, or pain after a fall or trauma, as these can indicate serious spinal pathology.

What Causes Mid Back Pain?

The most common causes are:

1. Thoracic Facet Joint Arthropathy: Wear and tear of the facet joints between thoracic vertebrae causes paraspinal pain that worsens with extension and rotation. It is the most common interventionally treatable cause of mid back pain.
2. Ankylosing Spondylitis: In younger patients, thoracic facet joint pain is frequently caused by ankylosing spondylitis, an inflammatory disease affecting the facet and sacroiliac joints of the spine. Unlike degenerative arthropathy, it is immune-mediated and typically presents with morning stiffness improving with activity. Early recognition is important as it requires specific medical management alongside interventional pain treatment.
3. Costovertebral Joint Dysfunction: Each rib attaches to the thoracic spine at two small joints. Inflammation or degeneration of these joints causes unilateral mid back pain that typically worsens with deep breathing and lateral movements.
4. Thoracic Disc Herniation: Less common than lumbar disc herniation but can cause nerve root compression producing sharp radiating pain around the chest wall (intercostal neuralgia) or, in severe cases, spinal cord compression.
5. Intercostal Neuralgia: Irritation or damage to an intercostal nerve causes burning or sharp pain that wraps around the chest from back to front. Common causes include post-herpetic neuralgia (after shingles) and post-thoracotomy pain, which is persistent pain following chest surgery where intercostal nerves are stretched or damaged during the procedure.
6. Osteoporotic or Metastatic Vertebral Fractures: Compression fractures in the thoracic vertebrae from osteoporosis or bone metastases cause acute, severe mid back pain, often occurring with minimal or no trauma.

Risk factors include poor posture, sedentary work, prior thoracic surgery, osteoporosis, and age-related degenerative changes.

Thoracic Facet vs Costovertebral Joint Pain

These two conditions are the most common interventionally treatable causes of mid back pain and are frequently confused with each other, as both produce paraspinal and lateral thoracic pain.

Thoracic facet joint pain is typically felt close to the midline, worsens with extension and rotation, and is reproduced by pressing on the paraspinal muscles adjacent to the involved levels. A thoracic medial branch block precisely diagnoses and treats this.

Costovertebral joint pain is more lateral, often felt at the rib angles, and characteristically worsens with deep breathing or coughing. This is because the rib-vertebra joint is stressed whenever the ribcage expands. A targeted costovertebral joint injection confirms and treats this source.

Correctly distinguishing these two conditions ensures the injection is placed in exactly the right structure, maximising benefit.

How is Mid Back Pain Diagnosed?

Diagnosis begins with a detailed clinical history and physical examination. Dr. Ashu Kumar Jain assesses spinal movement, palpates specific joint levels, and checks for neurological signs before recommending imaging.

1. Clinical examination assessing spinal movement, paraspinal tenderness, and rib cage expansion
2. X-rays to assess vertebral alignment, disc height, and any fractures or structural changes
3. MRI for disc, nerve root, and spinal cord assessment, and to exclude referred sources
4. CT scan for detailed bony anatomy when vertebral fracture or instrumented fusion is relevant
5. Diagnostic medial branch block or costovertebral joint injection to confirm the pain source and guide definitive treatment