Upper Back Pain Over 60

Of the eight guides I have written, this is the one where being properly examined matters most.

The upper back is where pain from internal organs is most likely to be felt. It is the commonest part of the spine for a fracture caused by thin bones. And it is the commonest part of the spine for other serious problems to show up in.

None of that means your pain is likely to be serious. The vast majority of upper back pain is muscle and joint pain, and completely harmless. It does mean this is not a part of the body to make assumptions about.

With that said, the rest of the picture is mostly reassuring. Upper back pain is not a normal part of being your age. The changes on your scan are almost certainly not the reason it hurts. And there is a great deal you can do.

This guide is not saying your pain is in your head. Your pain is completely real.

If nobody has examined you yet, read section 5 and section 14 first.

The short version

• Pain is an alarm. It protects you. It does not measure damage.
• There is a gate in your spinal cord. It controls how much of the warning signal reaches your brain.
• When pain lasts a long time, the alarm gets more sensitive. That is learned, so it can be unlearned.
• Sudden upper back pain after a trivial event, or after nothing at all, can be a fracture from thin bones. These are common, often missed, and worth diagnosing. See section 5.
• Exercise is safe and good for you with osteoporosis, including after a spinal fracture. Stopping is the risk. See section 10.
• Becoming more rounded is not entirely inevitable, and back strengthening genuinely helps.
• The scan evidence here is genuinely poor, and I will not pretend otherwise.

1. Pain is an alarm, not a damage meter

It feels obvious that pain comes from your upper back. It does not, quite.

Your back has danger sensors. They fire when tissue is stretched, squashed or irritated. They send warning signals to your spinal cord, and then to your brain. None of that is pain yet. It is just information.

Then your brain weighs that information against everything else it knows. What were you doing? What happened last time? What do you think this means? How stressed are you? Did you sleep?

Then it decides: how much danger am I in, and how much pain does this person need to feel to keep them safe?

Pain is the answer. Your brain produces it.

That is why damage and pain match up so badly:

• A paper cut really hurts. There is almost no damage.
• Soldiers get badly hurt and feel very little until they are safe.
• People who have lost a limb can still feel pain in it.

So how much pain you feel does not tell you how much damage there is. It tells you how protective your body is being right now.

2. The pain gate

In 1965, two researchers called Ronald Melzack and Patrick Wall came up with an idea that changed pain medicine. It is still one of the most useful pictures we have.

Picture a gate in your spinal cord. Warning signals from your back have to pass through it to reach your brain. When the gate is open, lots get through and you feel more pain. When it is closed, fewer get through and you feel less. Your back has not changed at all. Only the gate has.

What closes the gate

• Touch, rubbing, heat and hands-on treatment. Touch signals travel on bigger, faster nerves than danger signals, and they crowd them out. It is why you rub your elbow after you bang it.
• Moving and exercise. They release your body's own painkillers.
• Slow, easy breathing. See section 8.
• Feeling safe and calm.
• A decent night's sleep, and company.
• Understanding what is going on. Reading this counts.

What opens the gate

• Stress and worry, especially about your independence.
• Shallow, held or braced breathing.
• Broken sleep.
• Low mood, and feeling written off because of your age.
• Being afraid to move, particularly afraid to bend, if you have been told you have thin bones.
• Being told frightening things about your spine. Crumbling and collapsing are words that do real harm.

3. When the alarm gets too sensitive

When a pain system has been busy for months or years, it does not wear out. It gets better at its job.

Think of a car alarm. When it was fitted, it went off if someone tried to force the door. Years later it goes off when a cat walks past.

The alarm is not broken. It is not lying. It is just set far too sensitive for the actual level of threat.

And because your body learned it, your body can unlearn it. There is no age limit on that.

4. Why the upper back is different

Your upper back has twelve bones in it, and every one is attached to a pair of ribs. That gives this area a job the rest of your spine does not have: protecting your heart and lungs, and letting you breathe. Three things follow.

It moves less, on purpose. Your upper back is built for stability, not range. That is a design feature, not a fault.

It moves every time you breathe. Around twenty thousand times a day, every rib joint in your upper back moves. That is why an irritated rib joint announces itself when you breathe, cough, sneeze or laugh. It is also why it can feel alarmingly like a heart or lung problem when it is not.

Pain here often wraps round. The nerves follow the ribs around your body. So an irritated joint in the middle of your back is often felt as a band or stripe round your side, or even at the front.

Rib joint irritation is common and often responds well. It is also easy to mistake for something more serious, which is exactly why it should be checked, not assumed.

5. The one to know about: a fracture from thin bones

This is the section I would most like you to read carefully. These are common, they are frequently missed, and spotting one changes what happens next in a way that really matters.

As bones thin with age, a bone in the spine can squash down and lose height. This is called a vertebral fragility fracture. It is the commonest fracture caused by osteoporosis. It is not the dramatic event the word fracture suggests.

Why it is easy to miss:

• It often happens with little or no injury. Bending to make a bed. Lifting a kettle. A heavy cough or sneeze. A small stumble. Or nothing you can identify at all.
• The pain is usually in the middle or lower back rather than the neck.
• A large share, often quoted as around two thirds, never come to medical attention. They get put down to a pulled muscle, or to simply getting older.

What to look for:

• Sudden back pain, often quite severe, clearly worse when you stand and move, and better lying down.
• Pain that is worse when you cough, sneeze or strain.
• Losing height. More than about four centimetres, an inch and a half, compared with your height as a young adult is worth checking.
• Your upper back becoming visibly more rounded, especially if it has changed noticeably over a year or two.
• Clothes fitting differently. Trousers getting longer. A growing gap between the bottom of your ribs and the top of your pelvis.
• Feeling full quickly when eating, or getting more breathless, if the change has been big.

Why spotting it matters. A fracture in the spine is the single strongest warning sign of having another one, and it raises your risk of a hip fracture too. It is also the point where treatment to protect your bones becomes clearly worthwhile. Every fracture dismissed as a bad back is a missed chance to prevent the next one.

What happens if you have one. Most settle over roughly six to twelve weeks, with pain relief and a gradual return to moving. Long bed rest is avoided, because it costs bone and muscle you cannot afford to lose. Your GP would usually arrange a bone density scan and consider treatment to strengthen your bones.

If you get sudden significant upper back pain, and you have thin bones, take steroids long term, or have broken a bone from a minor fall since you were fifty, please contact your GP rather than assuming it is muscular.

6. Bones, strength, and becoming more rounded

Two things happen to a lot of people over sixty. Bones thin, and the upper back becomes more rounded. Both get treated as inevitable. Neither entirely is.

On bones. Bone is living tissue that responds to load throughout your life. Weight bearing activity, some impact suited to you, and strength training all stimulate it.

Calcium and vitamin D matter. Vitamin D is worth knowing about specifically. In the UK, adults are advised to consider a daily 10 microgram supplement through autumn and winter, because we cannot make enough from sunlight between October and March. If you rarely get outside, that applies all year.

Smoking and heavy drinking both work against bone. If you have broken a bone from a minor fall since you were fifty, ask your GP about a bone density scan.

On becoming rounded. More curve in the upper back has several causes. Fractures. Disc changes. And simple weakness of the muscles that hold you upright.

That last one is the part you can do something about. Strengthening those muscles has been shown to help, and it does more than change your outline. A very rounded upper back shifts your centre of gravity forwards, which affects your balance and raises your risk of falling. In more marked cases it also reduces the room your lungs have to expand.

You are unlikely to get back the posture you had at thirty. You can meaningfully improve your strength, your steadiness, and how far the change goes. That is worth having.

7. What scans show, and how little is known

I want to be straight with you here, because this differs from what I can tell you about the neck and low back.

For the low back, big studies have counted how many pain free people have wear at each age. About 9 in 10 at sixty, and nearly everyone at eighty. For the neck, a study of over 1,200 people with no symptoms found nearly 9 in 10 had disc bulging. Those numbers are solid.

For the upper back, they do not exist.

A review published in 2024 gathered every study it could find on degenerative MRI findings in this area. It concluded that no firm conclusions could be drawn. Not about how common the findings are, and not about whether they relate to pain at all. The estimates ranged from under 1 per cent to nearly 90 per cent, depending mostly on how each study defined it.

So the honest position is: wear findings here are common, they are almost certainly a normal part of ageing, and there is no good evidence that they explain upper back pain. If your report uses words like degeneration or wear, nobody can currently tell you that this is why it hurts.

The important exception is section 5. A scan that finds a fracture is telling you something real and useful. That is a completely different thing from a scan that reports wear.

8. Breathing, stress and the upper back

This is not filler, and it is not a polite way of saying the pain is psychological. There is a direct physical link between how you breathe and how your upper back feels.

Under stress, almost everyone breathes higher in the chest, faster, and using the neck and shoulders more than the diaphragm. Those muscles were not designed to do the bulk of the work of breathing, and using them twenty thousand times a day is exactly the kind of constant load this area does not enjoy. At the same time we brace, and stop the ribcage moving freely.

In practice:

• Two or three times a day, spend sixty seconds breathing slowly, with a longer breath out than in. Let your lower ribs move rather than the top of your chest. That is enough.
• Notice the shoulder shrug. Most people holding tension here have no idea they are doing it.
• If you have a long term chest condition, breathing work is worth more than just your back, and your GP practice may be able to refer you for proper support.

9. What turns your pain up and down

• Sleep. Poor sleep is one of the strongest signs of a bad pain day ahead.
• Stress. Bereavement, caring for a partner, health worries.
• Mood. Low mood and pain feed each other. Depression is often missed in older adults, and it is very treatable.
• What you believe. Believing your spine is crumbling and nothing can be done is linked to worse outcomes. It is also not true.
• Being afraid to move. Very common after a diagnosis of osteoporosis, and usually based on advice that was never quite right. See section 10.
• Activity. Too much too soon turns it up. So does too little for too long.
• Staying still. Long drives, long stretches in one chair, hours of reading or television.
• Being isolated. This genuinely matters.

10. Moving is safe, and how to exercise with thin bones

If you have been told you have osteoporosis, you may have come away thinking you should be careful with your back for the rest of your life. That is not what the evidence says, and the confusion has done real harm.

The UK expert consensus on this is called Strong, Steady and Straight. It is clear that people with osteoporosis, including people who have already had spinal fractures, should exercise. The risks of exercising are small. The risks of not exercising are considerable.

Its three headings are worth remembering:

• Strong. Strength training for the major muscle groups, working up to around three sets of eight to twelve repetitions, two to three days a week. Plus weight bearing activity with a level of impact matched to you. If you have had spinal fractures, that means lower impact activity such as walking or marching on the spot, around twenty minutes, built up gradually. Not jumping and running.
• Steady. Balance and coordination work, to reduce falls. Falls, not thin bones alone, are what break bones.
• Straight. Strengthening the muscles that hold your spine upright, two to three days a week. This helps your posture and it helps your pain.

The one real change to make: find alternatives to sustained, end of range or heavily loaded forward bending. Sit ups are the classic example.

This does not mean you cannot bend. Bending to put your shoes on, load the dishwasher, or pick something off the floor is ordinary life, and you should carry on doing it. It means avoiding repeated, deliberate, loaded curling forwards as an exercise. The most important message in this section is that worrying about exercise leads to doing nothing, and doing nothing costs you bone, muscle, balance and independence. Being cautious is not the safe option here. Being gradual is.

If you would like this set up properly, we can build a programme together, and I can work alongside your GP where treatment for your bones is part of the picture.

11. Pacing and flare-ups

A good day comes. You seize it. Then you pay for three days. Over months the trend quietly goes down.

• Work out what you could manage on almost any day, including a bad one.
• Do that amount every day, good and bad.
• Once it feels easy, add about a tenth more each week.
• Break big jobs into chunks. Take breaks before you need them, not after.

When a flare-up comes, it does not mean new damage. Keep moving gently, do less rather than stopping, drop back to your baseline for a few days, and use whatever settles it.

If breathing deeply is sore, keep breathing normally anyway. Holding your breath shallow to avoid the pain tends to drag it out, and at your age it also raises the risk of a chest infection.

Get in touch if it is not settling as it normally does, or if anything in section 14 applies.

12. A word about painkillers

I am not your prescriber, and this is not prescribing advice. But one thing is worth knowing.

Anti-inflammatory tablets like ibuprofen and naproxen carry noticeably higher risks after sixty. Stomach bleeding, kidney problems and raised blood pressure. They interact with several medicines commonly taken later in life. Anti-inflammatory gels rubbed into the skin carry much less risk.

Anything that makes you drowsy or light headed feeds straight into falls risk.

If you are taking painkillers regularly rather than now and then, talk to your GP or pharmacist. A pharmacist medicines review is free and genuinely useful.

13. What treatment does, and what it does not

Hands-on treatment works through everything above. It closes the gate. It calms the sensitivity. It relaxes muscles that have tightened to protect you. It gives you a spell where moving feels easier and breathing feels freer. That is a real effect and it is worth having.

What it does not do is put ribs or bones back in, or reverse changes in your bones. Nothing is out.

The clicks and pops you sometimes hear are gas moving inside a joint. Same as cracking a knuckle. Not the sound of anything being moved back.

I will adapt what I do to you, and in this area that matters more than anywhere else. Technique, positioning and force all change depending on your bone strength, and I will always ask.

Please tell me if you have osteoporosis or osteopenia, have taken steroids long term, have had a fracture of any kind, or have had a bone density scan. These genuinely change what is right for you. There are plenty of effective, gentle approaches, and there is no reason for you to go without treatment because your bones are thin.

One note on progress. A better question than your pain score is: what can I do now that I could not do three months ago? Can you get through a car journey? Sleep on your side? Reach a high shelf? Take a deep breath without thinking about it? Do the garden?

14. When to get urgent help

This section is longer than in my other guides, deliberately.

The upper back is the one part of the spine where pain from internal organs is genuinely common, and a few problems get more likely with age. Almost all upper back pain is muscle and joint pain, and completely harmless. The list below is not a list of what is likely. It is a list of things worth acting on quickly if they turn up.

Call 999

• Upper back or chest pain with chest tightness or pressure, breathlessness, sweating, feeling sick, or light headedness. Or pain that comes on with effort and eases with rest. Heart problems can be felt between the shoulder blades, and can happen with no classic chest pain, especially in women, people with diabetes, and people over seventy.
• Sudden severe tearing or ripping pain between the shoulder blades or in the chest. Especially if it moves, or comes with faintness, breathlessness, or a difference between your arms. This can mean a tear in the wall of the main artery, and the risk rises with age and blood pressure.
• Sudden breathlessness, sharp pain worse when you breathe in, coughing blood, or a racing heart. Especially after a long journey, recent surgery, or time off your feet.
• Severe upper back pain straight after a bad fall or crash, especially with weakness, numbness or trouble walking.

Contact your GP or NHS 111 today

• New or worsening weakness in the legs, unsteadiness, numbness in both legs, or any change in bladder or bowel control. Pressure on the spinal cord at this level is uncommon but time critical. Mid back pain with leg symptoms should never wait for a routine appointment.
• Sudden significant upper back pain after a minor knock, a fall, a cough or a sneeze, or with no cause at all. Especially with osteoporosis, long term steroids, or a previous fracture from a minor fall. See section 5.
• Upper back pain with weight loss you cannot explain, night sweats, or a past history of any cancer. The upper back is the commonest part of the spine for cancer to spread to, so this is always taken seriously.
• Upper back pain with fever, shivering, or feeling generally unwell.
• Pain that is much worse at night, wakes you every night, or is not helped by any change of position.
• Severe tummy pain with back pain. Pain under the right ribs spreading to the right shoulder blade. Pain boring through to the back that is worse after eating or lying flat.
• A band of blistering rash, or burning skin pain in a stripe round one side of your chest. This may be shingles, and treatment works best started early.
• Pain when you wee, or pain in your side spreading round to the front.

Worth mentioning at a normal appointment

• Any loss of height, or your upper back becoming noticeably more rounded.
• Any fall in the last year, even one that did not hurt you.
• Any bone broken from a minor fall since you were fifty, if you have not had a bone density scan.
• Aching and stiffness in both shoulders and hips, worst first thing and lasting more than an hour, that came on over days or weeks.

Everything else, including a bad flare-up, can wait for a normal appointment.

15. If you want to read or watch more

Start here

• Tame the Beast. A five minute animation by Professor Lorimer Moseley. tamethebeast.org
• Flippin' Pain. A UK campaign about long lasting pain. flippinpain.co.uk
• NHS activity guidelines for older adults. nhs.uk/live-well/exercise/physical-activity-guidelines-older-adults

On bones

• Royal Osteoporosis Society. The best UK source, including exercise guidance and a free helpline. theros.org.uk
• Strong, Steady and Straight, the UK consensus statement on exercise for osteoporosis. The source of section 10.
• NHS advice on vitamin D. nhs.uk/conditions/vitamins-and-minerals/vitamin-d

Practical help

• The Pain Toolkit, by Pete Moore. paintoolkit.org
• Recovery Strategies, by Greg Lehman. A free illustrated workbook. greglehman.ca/recovery-strategies-pain-guidebook
• Age UK, on staying steady, and strength and balance exercises. ageuk.org.uk

Books

• Explain Pain, by David Butler and Lorimer Moseley.
• The Explain Pain Handbook: Protectometer, by the same authors.

The research behind this guide

• Melzack R, Wall PD. Pain mechanisms: a new theory. Science, 1965. The original pain gate paper.
• Prevalence of thoracic degenerative MRI findings and association with pain and disability: a systematic review. Skeletal Radiology, 2024. The source of the uncertainty in section 7.
• Brinjikji W et al. Imaging features of spinal degeneration in asymptomatic populations. American Journal of Neuroradiology, 2015.
• Brooke-Wavell K et al. Strong, Steady and Straight: UK consensus statement on physical activity and exercise for osteoporosis. British Journal of Sports Medicine, 2022.
• NICE guideline NG259: Osteoporosis, risk assessment.
• National Osteoporosis Guideline Group (NOGG) clinical guideline, 2024. Bring any of this to your next appointment. Especially the parts that did not sit right, or that felt uncomfortably familiar.

This guide is general information. It does not replace the advice I give you in clinic.