Upper and Middle Back Pain: Causes by Location

When the middle of your back hurts, the cause is most often a strained muscle or a stiff, irritated joint where the ribs meet the spine. Long hours sitting, lifting with a twist and a hard cough are common triggers. This kind of pain usually changes with movement and position, and most episodes ease over a few days to a few weeks. Less often, pain here comes from a bone, a nerve or an organ.

The exact spot narrows the likely causes. This page covers the upper and middle back, from the base of the neck to the bottom of the ribs, area by area. It narrows things down. It does not diagnose. A physical therapist or doctor who examines you can do that.

First: the signs that skip the line

Call your local emergency number now: back pain with chest pressure, breathlessness, sweating or nausea; sudden severe tearing pain between the shoulder blades; or sudden sharp pain on breathing with breathlessness.
Go to the emergency department: new weakness or numbness in both legs, unsteady walking, or loss of bladder or bowel control.
Possible spinal fracture, see a doctor today: sudden mid-back pain after a fall, or after a minor strain, cough or lift in someone over about 50, with osteoporosis, or on long-term steroid medicine. A compression fracture can follow very little force.
Kidney, see a doctor today: pain low in the back just under the ribs on one side, with fever, burning when passing urine, blood in the urine, or waves of severe pain spreading toward the groin.
Other organs, see a doctor today: pain under the right shoulder blade with right upper belly pain after meals (gallbladder), or upper belly pain boring through to the back with vomiting (pancreas or stomach).
See a doctor soon: pain that is constant and worse at night regardless of position, or that comes with unexplained weight loss, fever or a history of cancer.

Between the shoulder blades

An ache or burning across the upper back between the blades, often with tender knots. Desk work, driving, looking down at a phone and carrying a child on one hip tend to bring it on.

Muscle overload (rhomboids, trapezius): tender to press, eases with movement and warmth, builds through the day.
Referred pain from the lower neck: changes with neck movement and can come with a stiff neck or arm tingling.
Upper back joint stiffness: a sharper point next to the spine, worse turning the upper body.

Along the spine

Pain right on the center line, over the bones themselves. Bending forward, arching back and sitting for long periods tend to aggravate it.

Joint irritation: pain eases with movement and changes with position. Common at any age.
Thoracic disc problem: less common than in the neck or lower back. A deep central ache, sometimes with a band of pain around the chest.
Compression fracture (vertebral fracture): sudden, sharp pain at one level after a fall or a small strain, often in people with osteoporosis. Pressing on the bone is very tender, and standing or walking may be worse than lying. Some fractures cause only mild pain or none, noticed later as height loss.

One side, next to the spine

A sharp or catching pain a finger’s width or two to one side of the spine. Twisting, reaching across and lifting while turning often set it off.

Facet joint or rib joint irritation: tender at one point, sharp on twisting and deep breaths. Often eases over one to a few weeks.
Muscle strain (erector spinae): a broader pulling ache along the length of the muscle.
Kidney: lower down, at the bottom of the ribs, a deep ache that does not change with movement, especially with fever or urinary symptoms.

Wrapping around the ribs

Pain that starts at the back and follows a rib around toward the side or front of the chest, like a belt on one side.

Rib joint irritation: worse twisting, coughing and breathing deeply, tender next to the spine.
Irritated nerve between the ribs (intercostal neuralgia): burning, shooting or electric pain along the rib, sometimes with skin sensitivity.
Shingles: burning or tingling in a band on one side, followed within a few days by a blistering rash. See a doctor early, ideally within about three days of the rash appearing.
Rib injury: after a fall or blow, or a hard bout of coughing. Very tender at one point on the rib.

Back pain that follows your movements is usually mechanical. Back pain that keeps its own schedule is worth a doctor’s look.

Pain when breathing

Pain that catches on a deep breath is common with rib joint problems. It can also come from the lungs.

Rib joint or muscle: you can find a tender spot; twisting or reaching also hurts; breathing is otherwise easy.
Inflamed lining of the lung (pleurisy) or pneumonia: sharp pain on breathing in, often with fever, cough or feeling unwell. See a doctor today.
Blood clot in the lung (pulmonary embolism) or collapsed lung (pneumothorax): sudden pain with breathlessness or a fast heartbeat. Call your local emergency number.

Stiff, rounded upper back

A rounded upper back with stiffness, an ache after long sitting and difficulty standing tall or turning to look behind you.

Postural stiffness: the curve straightens when you deliberately sit or stand tall. Common in long-hours desk workers, and usually responds to regular movement and strengthening over several weeks.
Age-related change and osteoporosis: a curve that does not straighten, sometimes with height loss of about 4 cm (1.5 inches) or more, can follow small compression fractures. Ask a doctor about a bone density check.
Scheuermann’s disease: a rigid rounded upper back that develops in the teenage years.
Inflammatory back pain (axial spondyloarthritis): usually starts before about 45, with morning stiffness lasting more than about 30 minutes that improves with exercise and not with rest.

Where else this could be coming from

Neck: the lower neck commonly sends pain between the shoulder blades.
Shoulder: rotator cuff problems can ache over the back of the shoulder blade.
Heart and major blood vessels: pain between the shoulder blades with chest symptoms or sudden tearing pain.
Gallbladder, stomach, pancreas and kidneys: pain linked to meals, digestion or urination rather than movement.

Still not sure

Get assessed by a physical therapist or doctor if your upper or middle back pain is not clearly easing after about one to two weeks, if it does not change with movement or position, if it is worse at night, or straight away for any of the signs at the top of this page.

Note the exact spot, what you were doing when it started, which movements and breaths change it, and any links to meals, urination, fever or weight change.