Upper back pain is common—especially for people who spend long hours in front of a desk or computer screen. Interestingly, there is a great deal of research published on lumbar and cervical pain complaints, but nowhere near as much focusing on thoracic spine pain (TSP). The orthopedic literature that does focus on TSP emphasizes structural issues associated with the spine and doesn’t put as much emphasis on soft-tissue problems. The emphasis on bony, structural causes of TSP is common in orthopedics; however, massage therapists often find that clients report soft-tissue pain in the upper thoracic region with this condition.
TSP is more common in women than men,1 and TSP also appears to be occurring with increasing frequency among adolescents. It is correlated with heavy load, like a backpack full of books. Other factors that play a prominent role in adolescent TSP include the frequency of physical activity, daily time spent watching television, studying in bed, sitting postures when writing, and computer usage.2 Ergonomics literature and research offers insights into developing workstations that help decrease back pain, yet rarely discuss good ergonomic workstations for adolescents. Young people often get last picks on work locations for their studies at home.
In this article, I will focus on the soft-tissue elements of TSP that don’t get as much attention in the research literature but are common for our clients. We’ll review some of the key anatomical issues in this region and then explore how anatomy, biomechanics, and other factors contribute to upper back pain. Then, we’ll look at some key treatment strategies.
Anatomical Background
The upper back is the area between the lowest cervical vertebra and the uppermost lumbar vertebra. Essentially this area of the back corresponds with everything adjacent to the 12 thoracic vertebrae. The majority of soft-tissue TSP complaints seem to be within about the T1–T7 region.
One of the main reasons for the high incidence of upper back pain is the mechanical stress in this region from sedentary postures. There are layers of muscles in this region that must manage these loads. Some of these muscles are quite deep, so it is easy to gloss over them when working on the thoracic region. For that reason, it is helpful to use a specifically targeted technique, most likely with a small contact surface (fingertip, thumb, or pressure tool).
Another key anatomical factor to consider in the upper back is the costovertebral articulations where the ribs connect with the thoracic vertebrae. The costovertebral articulations are not very stable joints. And, like other synovial joints, the articulation is surrounded by a richly innervated joint capsule, so mechanical stresses, subluxations, or dislocations of rib heads can produce significant acute thoracic pain. A former rib injury can also set the individual up to have recurrent pain in this region long after the initial injury has resolved. In the next section, we’ll explore some of the key biomechanical stresses that overload these muscles and lead to pain in the upper thoracic region.
Causes of Upper-Back Pain
A key cause of upper back pain is biomechanical overload. There is a limited amount of movement between adjacent vertebrae in the thoracic region. The structure of the rib cage allows very little torso flexion, as this motion would compress the rib cage. There is also minimal spinal extension in this region. The majority of flexion and extension movement in the back is in the lumbar region.
More of the rotational movement of the spine occurs in the thoracic region. A primary role of the muscles in this region is to maintain and stabilize the torso or scapula so the upper extremity can generate large forces. Also, many of these muscles must hold the head and upper back in static positions for long periods.
Frequent sedentary postures and forward-head tilt to look at monitor screens puts a significant biomechanical strain on the thoracic extensor muscles. These postures require the muscles to work with long periods of isometric contraction to offset the pull of gravity on the head.
When attempting to determine a cause of pain with TSP, it is helpful to consider key theories about posture and pain that have developed from both research and clinical experience. One of the most prevalent theoretical concepts regarding posture and upper back pain is the upper-crossed syndrome model popularized by Vladimir Janda. You can find references to this model in physical therapy, orthopedics, chiropractic, massage therapy, and almost any other manual therapy practice.
In this model, there is proposed tightness and subsequent strength in the neck extensors and anterior upper thoracic muscles. Their opposing muscles, the neck flexors and posterior upper thoracic muscles, are then thought to be weakened through reciprocal inhibition. The “cross” comes from a hypothetical line being drawn between the tight/short muscles and between the overlengthened/weak muscles. When the two lines are superimposed on each other it produces a cross pattern, which is where this postural distortion gets its name (Image 5).
The idea is relatively simple and mechanically seems to make sense. However, in the years since this original idea was proposed, it has come under greater scrutiny. For example, there isn’t any strong research to support the idea that shortened muscles are strong while their opposing muscles that may be held in a more lengthened position are weak. If that were true, you wouldn’t see the incredible strength in dancers, gymnasts, and other athletes where muscular strength is combined with extensive flexibility.
In her excellent book on stretching, Jules Mitchell reminds us that “muscles don’t get stronger by being held in a shortened position. They get stronger from progressive loading.” In addition “. . . muscles don’t necessarily become weak from stretching. They become weak when loads are insufficient.”3 In the upper-crossed syndrome model, the idea is that anterior neck flexors and upper thoracic back muscles are functionally weak from reciprocal inhibition. Supposedly this weakness, along with continual postural stress, causes upper back pain.
There may be something to the idea of reciprocal inhibition generally, but we have drastically oversimplified movement mechanics with this idea. Movement and muscle control are not limited to just one plane with exactly opposing muscles. Muscles have multiple actions, which makes the idea of reciprocal inhibition much more complicated.
There is another misapplication of the concepts of upper-crossed syndrome commonly proposed. Supposedly working on the rhomboids of a person with the postural pattern of upper-crossed syndrome exacerbates the condition as these muscles are already overstretched. Treating these muscles is thought to increase this lengthening.
First of all, there is no significant evidence that massage can manually lengthen muscle tissue in this way, especially in any kind of permanent way. So, we don’t “pathologically lengthen” muscle tissue with our manual work. There is a benefit to working on muscles that seem hypertonic and maintained in a shortened position, like the anterior chest muscles and cervical extensors. But we will not exacerbate a postural disorder from treating the upper back muscles.
We must also remember that upper back pain may be caused by factors other than mechanical overload and postural strain. TSP may result from bony disorders and degenerative conditions of the vertebral column, rib articulation problems, as well as various systemic disorders that may affect the gastrointestinal, cardiopulmonary, and renal systems.
In one of ABMP’s recent podcast episodes, pathology instructor Ruth Werner highlighted a case in which a client reported upper back and shoulder pain that at first seemed like a common musculoskeletal disorder. However, further investigation indicated that the problem was originating from gall bladder disease (Episode 18 – Shoulder Injury—Or Is It?—“I Have a Client Who …” with Ruth Werner, www.abmp.com/podcasts/ep-18-shoulder-injury-or-it-i-have-client-who-ruth-werner).
We should remember that not all seemingly musculoskeletal-related problems are in fact that, and may be related to other issues.
Primary Layers in the Upper Back
Starting superficially, the upper back is dominated by the trapezius and latissimus dorsi muscles (Image 1). Deep to the trapezius in the upper back lie the rhomboid major and minor (Image 2). These muscles frequently hold myofascial trigger points that refer pain to other regions. Rhomboid pain is probably one of the most frequent complaints that brings people to see their massage therapist.
The next layer down holds the serratus posterior superior running parallel beneath the rhomboids. In addition, the long expanse of thoracic erector spinae muscles lie against the rib cage as they extend toward the cervical region (Image 3). At the deepest level are the intrinsic spinal extensor and rotator muscles that lie close to the spine, the multifidus, and rotatores (Image 4).
Treatment Strategies
While there are several potential conditions involving structural dysfunction in the thoracic spine, the vast majority of upper back pain complaints involve the soft tissues. As a result, massage is an excellent strategy for these complaints. There are some key considerations for this region that will make your treatments more effective.
The upper back has numerous tissue layers
Your knowledge of anatomy comes in handy as you address your client’s soft-tissue pain. Generally, like in other treatments, start the session using a broad contact surface, like the palm or backside of the fist. Then, get more specific by using a small contact surface, like a fingertip, thumb, or pressure tool. This is what produces the best results for chronic tightness and soft-tissue pain in the upper back. It is most effective to work through the layers of back muscle from superficial to deep. Your deep longitudinal stripping techniques applied parallel to the muscle fibers will start in one direction as you work the most superficial tissues. They will then change direction as you focus on the next layer of muscle. It is helpful to visualize the muscle layers as you are treating them, so be well-versed in the region’s anatomy.
Clients often have myofascial trigger points in the upper back
These trigger points refer pain or other sensations into the neck, head, or upper extremity. The small contact surface techniques (especially those that go parallel with the muscle fiber direction) allow you to identify and deactivate these tissues.
Active engagement techniques encourage shoulder girdle flexibility
These techniques incorporate motion during the treatment. Have the client lie in a prone position on the table so the upper arm can be brought as far as possible into horizontal abduction, swinging the arm toward the face cradle. Have the client pull the upper arm into full horizontal abduction and attempt to squeeze the scapula together. Instruct the client to slowly release the contraction and move the arm through horizontal adduction as far as possible. As they perform this movement, apply a deep stripping technique with a small contact surface to the mid trapezius and rhomboid region. Make sure to stay medial to the vertebral border of the scapula so you don’t put uncomfortable pressure on the edge of the scapula. You can see a video of the technique applied by scanning the QR code above.
Home-Care Suggestions
Offering clients home-care options can play a helpful role in reducing the pain from soft-tissue tightness in the upper back. A curved self-massage tool is a great way to address these muscles, particularly when lying supine on the floor. However, a great substitute is two tennis balls placed between the scapula, with one on each side of the spine (placing the balls in a sock is helpful). These are also used when supine on the floor.
Instruct the client to pull their knees to their chest to apply the appropriate amount of pressure to the upper back as they lie on the tennis balls. They can then move the tennis balls around and focus on the most sensitive areas, which are those likely to house myofascial trigger points.
The popular phrase that “motion is lotion” is true in this region. Encourage the client to engage in upper extremity and upper back movements that help increase range of motion and decrease the chronic tightness that results from the long periods of immobilization. When you can combine simple movements with the soft-tissue treatments, it is far more effective than either one of them done alone.
As long as people are sitting for long periods in front of screens, there should be no shortage of work for massage therapists. There are few treatment strategies as effective as massage for addressing most of the soft-tissue complaints in this region. Our best results come when we encourage our clients to gain greater freedom of movement while providing pain relief through our hands-on work.
Notes
1. Andrew M. Briggs et al., “Thoracic Spine Pain in the General Population: Prevalence, Incidence and Associated Factors in Children, Adolescents and Adults. A Systematic Review.” BMC Musculoskeletal Disorders 10, no. 1 (June 2009): 77, https://doi.org/10.1186/1471-2474-10-77.
2. Matias Noll et al., “Back Pain Prevalence and Associated Factors in Children and Adolescents: An Epidemiological Population Study,” Revista de Saude Publica 50 (May 2016): 1–10, https://doi.org/10.1590/S1518-8787.2016050006175.
3. Jules Mitchell, Yoga Biomechanics: Stretching Redefined (Pencaitland: Handspring Publishing, 2019).
Whitney Lowe is the developer and instructor of one of the profession’s most popular orthopedic massage training programs. His text and programs have been used by professionals and schools for almost 30 years. Learn more at www.academyofclinicalmassage.com.