Upper back pain: causes, red flags and when to see a GP

The upper and mid back is formed by the thoracic spine, the ribs that attach to it and the muscles that hold the shoulder blades in place. It is stiffer and less mobile than the neck or lower back, so mechanical strain is more often the problem of long hours at a desk, a phone held low, a new activity, or sleeping awkwardly than of lifting injuries.

Arthritis UK, which was formerly Versus Arthritis, says back pain often has no single cause and may reflect lack of exercise, muscle strains or ligament sprains, poor posture and a poor work or home set-up. It also lists spondylosis, slipped discs and, less commonly, fractures linked to thinning bones, infection, tumour and inflammation in or around the spine.

The pattern of pain, rather than the label, is what helps most. The table is a general guide drawn from NHS and NICE descriptions.

The NHS says to call 999 or go to A&E when back pain comes with chest pain, pain, tingling, weakness or numbness in both legs, loss of feeling around the genitals or anus, bladder or bowel changes such as difficulty passing urine or leaking urine or stool, or sexual changes such as being unable to get or keep an erection. It also applies if the pain started after a serious accident such as a car crash.

For a pulmonary embolism, a blood clot in the lungs, the NHS lists chest pain or upper back pain, sudden severe breathlessness, a very fast heartbeat or someone passing out as reasons for 999 or A&E, and coughing up blood or sudden breathing difficulty as reasons for an urgent appointment or 111. The NHS page on cervical spondylosis, a neck condition that can refer pain to the shoulders, lists severe neck pain that starts suddenly or worsens quickly, heaviness or weakness in the arms or legs, and pins and needles in an arm as reasons for an urgent appointment or 111.

The NHS asks for an urgent GP appointment or 111 if back pain comes with feeling hot, cold, shivery or generally unwell, or if severe pain starts suddenly or gets worse quickly.

• Chest pain, breathlessness or a racing heartbeat alongside the back pain.

• Weakness, numbness or pins and needles in both legs.

• Numbness around the genitals or anus, or new problems passing or controlling urine or stool.

• Fever, shivering or feeling generally unwell.

• Weight loss without trying, a lump or swelling on the back, or pain that is worse at night or does not ease with rest.

• Pain that began after a serious accident.

NICE says a clinician assessing back pain asks about onset, type, site and pattern, any spread of pain, how long it has lasted, associated symptoms and red flags, effect on daily life, and treatments tried. They examine posture, walking, tenderness over the spine and range of movement, and carry out a neurological examination.

For upper back pain the examiner will often also think about the chest, heart and lungs, and may check blood pressure, pulse and breathing. Arthritis UK points out that doctors often start with a watch-and-wait approach and that most back problems can be diagnosed from the history and examination without tests.

Arthritis UK says you may be sent for a scan if you have had an injury such as a bad fall, if your doctor suspects an underlying cause, or if the pain has lasted unusually long. It adds that X-rays are rarely used for back pain because many causes are in soft tissues that do not show on them.

If something other than a muscle problem is suspected, tests are chosen to match: blood tests for infection or inflammation, imaging of the spine, a chest X-ray or an ECG when the heart or lungs are in question, and referral to a rheumatologist when inflammatory back disease is suspected, as the NHS describes for ankylosing spondylitis.

The NHS advises staying active and carrying on with daily activities, and not staying in bed for long periods. It suggests an anti-inflammatory such as ibuprofen if suitable, notes that paracetamol on its own is not recommended for back pain, and recommends checking with a pharmacist or GP if unsure which painkiller is suitable.

An ice pack or a heat pack wrapped in a tea towel may help, and the NHS suggests walking, swimming, yoga and pilates, plus back stretches. Stop any exercise that makes the pain worse. Changing position often, setting up a desk so the screen is at eye level, and breaking up long periods of sitting are practical measures consistent with the posture causes listed by Arthritis UK.

A GP is the right starting point for upper back pain that does not improve after a few weeks of home care, stops you doing daily activities, or comes with any of the NHS features: unexplained weight loss, a lump or change of shape in the back, pain that does not improve with rest or is worse at night, or pain that is worse when sneezing, coughing or passing a stool.

In many areas people can refer themselves to NHS community musculoskeletal services for physiotherapy without a GP referral. Persisting pain may lead to group exercise, physiotherapy, manual therapy or cognitive behavioural therapy for pain, as the NHS lists for back pain generally. Anyone wanting to pay can see a physiotherapist privately.