Spine, Neck & Back

Thoracic Back Pain

Thoracic back pain (pain in the mid and upper back between the shoulder blades) is far less common than lumbar or cervical pain, accounting for only about 2–5% of spinal pain presentations. While most thoracic pain is benign and musculoskeletal in origin, the thoracic spine carries a higher index of suspicion for serious underlying pathology (fracture, neoplasm, infection) than the cervical or lumbar regions. At Maryland Orthopedic Specialists, we evaluate thoracic pain thoroughly to identify serious causes early and provide targeted non-operative management for structural thoracic pain generators.

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What is thoracic back pain?

The thoracic spine consists of twelve vertebrae (T1–T12), each articulating with a pair of ribs at the costovertebral and costotransverse joints. The thoracic cage provides significant structural stability, making disc herniation and instability much less common in this region than in the cervical or lumbar spine.

Costovertebral and costotransverse joints: The articulations between the ribs and thoracic vertebrae are a frequently overlooked source of thoracic pain. These small joints can develop arthropathy and become inflamed, producing well-localized pain that may wrap around the chest wall (thoracic radiculopathy mimicking pleuritic or cardiac pain). Costovertebral joint injections are both diagnostic and therapeutic.

Thoracic facet joints: Like their lumbar and cervical counterparts, thoracic zygapophyseal joints develop osteoarthritis and can generate axial mid-back pain, particularly with extension-loading activities.

Thoracic disc pathology: Thoracic disc herniations are uncommon (less than 1% of all symptomatic disc herniations) but can cause myelopathy when herniation compresses the thoracic spinal cord. MRI is essential when myelopathy features are present.

Structural conditions:

Scheuermann's kyphosis: A developmental condition of adolescent thoracic vertebral endplate irregularity leading to hyperkyphosis (>40° Cobb angle at the thoracic spine); can cause significant thoracic pain in affected adults
Osteoporotic compression fractures: Extremely common in postmenopausal women and older adults with osteoporosis; produce acute thoracic pain and progressive kyphosis; require specific management including vertebroplasty referral evaluation
Neoplastic or infectious disease: The thoracic spine is a common site of metastatic disease and spinal infection. Red flags must be evaluated urgently

Symptoms — do you recognize these?

Mid-back aching or stiffness, often poorly localized
Pain worsened by sustained sitting, trunk rotation, and deep breathing (when costovertebral joints are involved)
Paraspinal tenderness, often unilateral
Pain with rib springing (lateral compression of the rib cage)
In some patients, wrapping chest wall pain that may mimic cardiac or pulmonary pathology
Thoracic pain in a patient with known malignancy
Thoracic pain with unexplained weight loss or fever
Acute thoracic pain after a fall or trauma (especially in an older or osteoporotic patient — compression fracture)
Progressive thoracic kyphosis
Lower extremity weakness, spasticity, or gait disturbance (thoracic cord compression)
Night pain that awakens from sleep

Call us at (301) 515-0900. Same-day appointments available at our Bethesda and Germantown locations. Red flag symptoms require urgent evaluation.

How we diagnose it

Clinical examination includes assessment of thoracic range of motion, palpation for paraspinal tenderness and rib/costovertebral joint tenderness, and a neurological examination screening for thoracic cord compression. Deep palpation over the T6–T10 costovertebral joints commonly reproduces costovertebral joint pain.

Imaging:

Plain thoracic radiographs: First-line imaging; assess vertebral height loss (fracture), alignment, Scheuermann's changes, and obvious malignant lesions
MRI of the thoracic spine: Indicated for red flags, neurological findings, or refractory pain; assesses disc pathology, cord compression, infection, and malignancy
CT scan: Better characterizes vertebral fracture morphology and bony integrity
Bone densitometry (DEXA): Indicated for patients at risk for osteoporotic fracture. Guides fracture prevention and treatment

Treatment options

Most thoracic back pain responds well to physical therapy and activity modification.

Physical Therapy

Thoracic mobility exercises and manual therapy are highly effective at relieving mid-back stiffness and restoring comfortable movement. Postural correction (specifically targeting the forward-rounded shoulders and hyperkyphosis that load the thoracic spine) is central to long-term relief and prevention. Stabilization training reduces mechanical stress on the thoracic facets and costovertebral joints, addressing the root cause of most structural thoracic pain.

Medications

NSAIDs manage inflammation in the facet joints or costovertebral joints and are the first medication choice for thoracic pain. A short muscle relaxant course helps during acute episodes when paraspinal spasm is a significant part of the pain.

Injections

Thoracic facet injections or costovertebral joint injections provide targeted relief for patients with localized joint pain that hasn't responded to therapy alone. These injections are both diagnostic (confirming the specific joint as the pain source) and therapeutic. All injections at MOS are performed under fluoroscopic guidance for accuracy and safety.

Recovery & rehabilitation

Benign musculoskeletal thoracic pain typically responds well to PT, posture modification, and targeted injections within 4–8 weeks. Costovertebral joint pain, in particular, often responds dramatically to a single diagnostic/therapeutic injection. Conditions associated with underlying bone fragility (osteoporosis), structural deformity (Scheuermann's), or systemic disease require a coordinated multidisciplinary approach.

Frequently Asked Questions

Could my thoracic pain be from my heart?

Thoracic back pain (particularly on the left side) should prompt consideration of cardiac and aortic pathology if it is accompanied by chest pressure, shortness of breath, or sweating. MOS will conduct a thorough history to exclude these diagnoses; emergent symptoms require emergency evaluation.

Does thoracic disc herniation require surgery?

The majority of thoracic disc herniations are asymptomatic or mildly symptomatic and are managed conservatively. Significant cord compression causing myelopathy is a surgical indication. MOS coordinates referral when cord involvement is identified on MRI.

What is Scheuermann's kyphosis?

It is a developmental condition causing excessive rounding of the thoracic spine, often beginning in adolescence. Adults with Scheuermann's kyphosis may develop mid-back pain from the mechanical stress of hyperkyphosis. PT and posture-focused management are central to non-operative treatment.

How is thoracic back pain treated?

The majority of thoracic back pain is muscular or postural in origin and responds well to physical therapy emphasizing thoracic mobility, postural correction, and periscapular strengthening. Anti-inflammatory medications and heat or ice can provide short-term symptom relief. When facet joint degeneration is contributing, targeted injections or medial branch blocks may be recommended. For the less common cases involving significant disc herniation or nerve compression in the thoracic spine, surgical decompression can be very effective but is approached carefully given the proximity of the spinal cord. At MOS, our spine specialists evaluate the full picture to find the safest and most effective path for your specific situation.

When should I be concerned that my thoracic back pain is something serious?

Most thoracic back pain is benign and musculoskeletal in origin, but certain features warrant urgent evaluation. These include pain that is constant and not relieved by rest or position, unexplained weight loss, fever, a history of cancer, pain following significant trauma, or any neurological symptoms such as weakness, numbness, or bowel/bladder changes. Pain that radiates around the rib cage in a band-like pattern can suggest nerve involvement from a thoracic disc or, less commonly, conditions such as shingles. If you experience any of these warning signs, contact your MOS provider promptly so that serious causes can be ruled out with appropriate imaging.

Meet the specialists

Christopher S. Raffo, MD

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John J. Christoforetti, MD

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James S. Gardiner, MD

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Peter G. Fitzgibbons, MD

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Medically reviewed by Christopher S. Raffo, MD

Last reviewed May 1, 2026

References

Briggs AM, Smith AJ, Straker LM, Bragge P. "Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults." BMC Musculoskeletal Disorders 2009;10:77. https://doi.org/10.1186/1471-2474-10-77
Scheuermann H. "Kyphosis dorsalis juvenilis." Ugeskr Laeger 1920;82:385–393. (Foundational description)
Manchikanti L, Singh V, Falco FJ, Cash KA, Pampati V. "Effectiveness of thoracic medial branch blocks in managing chronic pain: a preliminary report of a randomized, double-blind controlled trial." Pain Physician 2008;11(4):491–504. PMID: 18690275
Perez-Cruet MJ, Fessler RG, Perin NI. "Complications of minimally invasive spinal surgery." Neurosurgery 2002;51(5 Suppl):S26–S36. https://doi.org/10.1097/00006123-200211002-00005
OrthoInfo / AAOS. "Spinal Stenosis." https://orthoinfo.aaos.org/en/diseases--conditions/spinal-stenosis/