Upper Back Pain in Your 30s, 40s and 50s

Upper back pain is the awkward middle child of back problems.

It gets a fraction of the research that necks and low backs get. Most people have never been given a clear explanation for it. And it tends to get described in vague terms: a knot, a burning between the shoulder blades, a band around the ribs, something that catches when you breathe in.

This guide is not saying your pain is in your head. Your pain is completely real. What follows is what we now know about how pain works, in plain words, plus an honest account of where the evidence for this part of the back is thinner than I would like.

One thing before you start. This guide assumes I have examined you. That matters more here than anywhere else in the back, because this is the area where pain from internal organs is most likely to be felt. If nobody has examined you yet, read section 13 first.

Read it in chunks. There is no test at the end.

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.
• Your upper back is built for stability, not movement, and it is attached to twenty four ribs. That is why it behaves differently from your neck or low back.
• The scan evidence here is genuinely poor. Anyone who tells you exactly what your MRI means is going beyond what is known.
• Breathing, stress and sitting still matter here more than almost anywhere else.
• Posture is a much smaller factor than you have been told. Variety is a much bigger one.

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 and rugby players 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 upper 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. More on this in section 6.
• Feeling safe and calm.
• A decent night's sleep.
• Understanding what is going on. Reading this counts.

What opens the gate

• Stress and worry. Your upper back and shoulders are where a very large number of people hold tension, and the tightening is usually unconscious.
• Shallow, held or braced breathing, which is what most of us do under pressure.
• Broken sleep.
• Low mood, and feeling that nobody has listened.
• Reaching round to prod the sore spot to see if it is still there.
• Being told frightening things about your spine.

Here is the key bit. Your brain does not just receive signals at that gate. It sends signals down and changes the settings. That is why an identical working week is fine one month and unbearable the next.

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. The sensors fire more easily. The spinal cord turns the signal up. The brain decides there is danger more quickly.

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.

That is what long lasting upper back pain usually is. And because your body learned it, your body can unlearn it.

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. Those ribs join the spine at the back through two small joints each, wrap round, and mostly meet the breastbone at the front.

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, and they explain most of what confuses people.

It moves less, on purpose. Your upper back is built for stability, not range. That is a design feature, not a fault. No amount of treatment will make it as mobile as your neck, and it should not.

It moves every time you breathe. Around twenty thousand times a day, every rib joint in your upper back moves. That is a lot of repetitions. It is why an irritated rib joint announces itself when you breathe, cough, sneeze or laugh. It is also why it can feel alarmingly like something is wrong with your heart or lungs 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. Someone pointing at the front of their chest is quite often describing a problem at the back.

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. 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 exactly how many pain free people have bulges and degeneration at each age. The answer is: most of them. 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, and I quote them confidently.

For the upper back, those numbers 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 for upper back disc degeneration ranged from under 1 per cent to nearly 90 per cent, depending mostly on how each study defined it. Not one study had looked at whether these findings relate to disability.

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

That uncertainty cuts both ways. It is a reason to be careful, not casual. It is exactly why the examination matters, and why section 13 is worth reading properly.

6. Breathing, stress and the upper back

This section 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 with more effort from the neck and shoulders than from the diaphragm.

Those muscles were not designed to do the bulk of the work of breathing. Using them twenty thousand times a day is exactly the kind of constant low level load this area does not enjoy. At the same time, we brace, hold the shoulders up, and stop the ribcage moving freely.

The result is an area that is loaded non stop, never varied, and at the same time being told by your nervous system to stay alert. That is close to a perfect recipe for upper back pain.

It also explains why so many people notice theirs is worse during hard times and better on holiday, with no change to their desk or their pillow.

What to do about it:

• Two or three times a day, spend sixty seconds breathing slowly, with a longer breath out than in. Let your lower ribs and belly move, rather than the top of your chest. That is enough. This is not a meditation practice you have to be good at.
• Notice the shoulder shrug. Most people who hold tension here have no idea they are doing it. Catching it is most of the work.
• Treat a genuinely stressful stretch as a load, the same as a heavy week of lifting. Expect to need more variety and less endurance during it.

7. Posture, and what actually matters

You have probably been told you are hunched, or rounded, or that your shoulders roll forward. It is the single most common thing people say to me about this part of the body.

The evidence does not support posture as a major cause. Studies have not reliably shown that people who sit or stand in the supposedly bad ways get more upper back pain. Where links exist they are small, and they cannot tell us which came first. A back that hurts tends to adopt a protective shape, so the shape may be the result rather than the cause.

What does matter is staying in any position too long. Any position held long enough gets uncomfortable, and in this area that discomfort is very easily mistaken for damage.

In practice:

• Change position often. Every twenty to thirty minutes is sensible. This matters far more than the exact height of your screen.
• Stop trying to hold yourself upright by effort all day. Sitting rigidly straight is just another fixed position, and usually a more tiring one.
• Aim for variety, not correctness. Standing desks help mainly because they add a second position, not because standing is virtuous.
• Get the ribcage moving daily. Twisting, reaching, overhead movement. Anything that takes the area through its range.

8. What turns your pain up and down

• Sleep. Poor sleep is one of the strongest signs of a bad pain day ahead.
• Stress. More relevant here than in most areas, for the reasons in section 6.
• Mood. Low mood and pain feed each other, both ways.
• What you believe. What you think is happening changes how much it hurts.
• Activity. Too much too soon turns it up. So does too little for too long.
• Staying still. Long drives, long meetings, long stretches at a screen, hours holding a baby, a day of hairdressing or dentistry.
• How you breathe. See section 6.
• General health. Smoking, being unfit and other health conditions all add to the load.

Most of those are things you can influence.

9. Moving is safe, and load is treatment

Your upper back is the best protected part of your spine. It is braced by a full ribcage and surrounded by large, strong muscles. It is not fragile, and it does not go out of place. Guarding it makes long lasting upper back pain worse. Muscles get weaker, the range you use shrinks, and your nervous system gets more protective of whatever you avoid.

Some soreness while you build back up is expected. It does not mean damage. A good rule: pain that rises while you move and settles back to normal within about a day is fine. Pain still up the next day means you did a bit too much, not that you did harm.

What helps most, in my experience and in what evidence there is: get the area strong, and get it moving through its range regularly. Rowing and pulling movements. Overhead work. Carrying things. Twisting.

Strength work for your mid back and shoulders twice a week does more for this area than any amount of stretching. Stretching alone is where most people get stuck.

10. Pacing, and the boom and bust trap

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

Pacing is the way out:

• 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 long spells at a desk or a wheel into chunks. Take breaks before you need them, not after.

It feels annoyingly slow for a few weeks. Over a few months it is the fastest route there is.

11. Flare-ups

Flare-ups are normal, and they do not mean new damage. They are usually a pile-up: a hard week, two bad nights, a long drive, a stressful conversation.

• Keep moving, gently. Do less rather than stopping.
• Drop back to your baseline for a few days, then build again.
• Use whatever settles it: heat, gentle twisting, changing position often, slow breathing, medication as advised.
• If breathing deeply hurts, keep breathing normally anyway. Holding your breath shallow to avoid the pain tends to drag it out. If breathing is genuinely difficult rather than just sore, see section 13.
• Remind yourself that this has settled before and will settle again.
• Get in touch if it is not settling as it normally does, or if anything in section 13 applies.

12. 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. In this area it often makes an immediate difference to how freely you can breathe and twist. That is a real effect and it is worth having.

What it does not do is put ribs or bones back in. Nothing is out.

The clicks and pops you often hear here are gas moving inside a joint. It is the same thing as cracking a knuckle. It is not the sound of anything being moved back. A treatment that makes a satisfying noise is not more effective than one that does not.

The best way to think about a session is as a window. A stretch of time where you can move more freely, and use that freedom to build strength and tolerance. The loading is what changes things in the long run.

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 drive to Leeds? Get through a full working day? Sleep on your side? Take a deep breath without thinking about it? Function usually improves before pain does.

13. When to get urgent help

This section is longer than in my other guides, and that is deliberate.

The upper back is the one part of the spine where pain from internal organs is genuinely common. 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 and people with diabetes.
• 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.
• Sudden breathlessness, sharp pain worse when you breathe in, coughing blood, or a racing heart. Especially after a long flight or drive, recent surgery, or time off your feet, or if you have had a clot before.
• Severe upper back pain straight after a bad fall, crash or blow to the back, 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.
• Upper back pain with fever, shivering, or feeling generally unwell.
• Upper back pain with weight loss you cannot explain, night sweats, or a past history of cancer. The upper back is the most common part of the spine for cancer to spread to, so this combination is always taken seriously.
• 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 straight through to the back that is worse after eating or when 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.

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

14. If you want to read or watch more

Start here

• Tame the Beast. A five minute animation by Professor Lorimer Moseley. The best possible starting point. tamethebeast.org
• Flippin' Pain. A UK campaign about long lasting pain. flippinpain.co.uk
• Retrain Pain. Free, very short illustrated lessons. retrainpain.org
• NHS advice on back pain. nhs.uk/conditions/back-pain

Practical help

• The Pain Toolkit, by Pete Moore. Very good on pacing and boom and bust. paintoolkit.org
• Recovery Strategies, by Greg Lehman. A free illustrated workbook, one idea per page. greglehman.ca/recovery-strategies-pain-guidebook

Books

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

The research behind this guide

• Melzack R, Wall PD. Pain mechanisms: a new theory. Science, 1965. The original pain gate paper.
• Briggs AM et al. Thoracic spine pain in the general population. BMC Musculoskeletal Disorders, 2009.
• 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 5.
• Louw A et al. The effect of pain neuroscience education in chronic musculoskeletal pain. Archives of Physical Medicine and Rehabilitation, 2011.

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.