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Hello El Paso! Welcome to the Stay Healthy El Paso Podcast. My name is Dr. David Middaugh physical therapist and I'm the owner of El Paso Manual Physical Therapy. We are talking today about upper back pain. Just to be specific about where the upper back is, because it can be confusing for some people. I'm going to include the mid back, and upper back as one, because a lot of these problems are in the thoracic spine, which is what we call it in the medical field. Basically, the parts of your spine where ribs are.

That's what I'm going to consider as upper back problem. But this goes all the way up to the base of the neck. It includes the backside of the shoulders as well. Now, some of the common diagnosis, we are going to go into that, and then we'll talk about the treatment options.

I'm just going to give you a little disclaimer right now, a lot of these problems that I'm going to go over, that affect the upper back, aren't always similar. In other words, there are very different body parts that are affected, which makes the treatments very different. We aren’t going to go into too many details on the treatments, just because there is a big giant variety, and it would take a whole episode for each one probably. But it's going to give you an overview of the different types of common causes of back pain, upper back pain and the treatments that are out there for that.

So, let's get into it.

By far, one of the most common problems in the upper back is rib problems. About the ribs, you have 12 pairs of ribs, and the first pair is way up top above your collarbones. I'll show you exactly where it's at. If you take your right hand. If you can't use your right use your left and put it on your neck on the side of your neck, like right into your ear, put your palm on there, and slide it down to where your neck moves into your shoulder. Right above your collarbone, but where your neck ends, and your shoulder starts. That's about the location of the first rib.

A lot of people don't realize that they are that high. And then they go all the way down to just right above your lower back. So, you got tons of ribs, you got 24 ribs, if you think about it. Ribs have the ability to shift, so they can shift up or down, forward or back. When they shift, they tend to get stuck. There are muscles that attach to ribs, and there are of course joints where they meet the spine in the back. Then they wrap around to the front and meet the front part of your sternum, they attach through a bunch of cartilage.

Not all the ribs attach to the front, the last two pairs that’s the 11th and 12th pairs don't actually attach, those are floating ribs. What well if you've got upper back pain, and typically it's off to the side, it's off to one side of the right or the left. Many times, it will radiate, it will shoot from the back off into the side of your body, under your arm might even be in the armpit area. Sometimes it will create some tenderness in the chest. That more often than not, is a real problem.

Depending on how it’s shifted, you have to get the right kind of help to make sure that you shift it back in the right direction. It's critical, because think about it, if your ribs shifted forward, and somebody's trying to put pressure on your back, it's going to further shift the rib forward, because you are pushing it from back to front, it's already shifted from back to front. So, you got to know which direction to go in, how it feels, it's a science definitely, it's its own specialty, in figuring out the position that rib is stuck.

The most common way that ribs get stuck is backwards, where they pop out backwards from the spine. Pushing it in is definitely a common treatment. I can tell you from experience, I've had that happen before. It's not a comfortable experience to have a rib shifted into position. It's one of the few things here in the office that I have to tell people that disclaimer ahead of time and say hey, this time it's going to hurt, but you are going to feel a ton better after it's done. Most techniques don't hurt to get them done on people. One of those, the most common problem that you can have in your upper back is a rib problem. A rib that's shifted or stuck.

You can also have cracked ribs, you can have broken ribs, and that's related to an accident usually, like if you were in a car accident or some severe fall, those are not that common. Here in our office, they can't happen obviously out in normal life. But if you've had a history of a cracked or broken rib, more often than not, after the rib is healed, you might have a shifted rib. That could be causing some back pain. If you have that history of that happening in the in the past.

If you are all the way healed, then you are going to be ready to do some sort of treatment that shoves it back into place. If you have an actively broken rib or it's cracked, you do not want somebody pushing on it right now because you can make it worse.

The next most common thing that happens in upper back pain is shoulder blade problems. The cool things about the shoulder blade is, they are floating bones, they float in a bunch of muscles on your rib cage. Of course, on the outside corner of your shoulder blade is the socket for the ball and socket joint of your shoulder joint. These bones are really cool. There are over 20 muscles that attach and control the shoulder blade. And because there are so many muscles, it's quite easy to develop a muscle imbalance that makes the shoulder blades not operate normally.

If that's there for a long time, it can tension certain muscles too much and create a back problem. Now here in the clinic, we call that scapular dyskinesia, that just means bad movement of the shoulder blade. There are a bunch of different ways that it presents. Sometimes it's related to posture problems. Sometimes it's related to strength. Sometimes it's related to the sleeping positions. Most of the time, it's a combination of all those things.

But shoulder blades can cause problems and it's never the bone. It's always the muscles that attach to the bone. Unless you have had trauma, like I said, with ribs is huge, because it is possible to have a cracked shoulder blade or a fractured shoulder blade, which of course is going to change the way the muscles operate. So, take that into consideration.

If you've been in an accident, you might have back problems, upper back problems related to an old fracture and your shoulder blade. But to fix that, there are tons of options. It just varies. There is usually some sort of exercise, some sort of hands on work needed, to free up the joints of the shoulder blade. It has three main areas where there is, I guess you can call it four joints, where the shoulder blade moves. It attaches to the collarbone, and the collarbone itself will move the ball and socket joint on the outside, and then there's what's called the scapula thoracic joint. It's not a real joint but if there is movement that occurs between the scapula, the shoulder blade and the rib cage, it slides on itself.

Then on the front side, there's a ligament that connects it to the rib cage as well. So the shoulder blade can cause lots of problems.

The other less commonly found, upper back problem that I find in people is nerve problems. If you think about it, our body is covered in nerves, you just don't see it and it's not commonly talked about. But for people that are dealing with having to work at a desk job, having to be in the same position for a long period of time, having to be sedentary because that's what their life requires them to do at this time. Their nerves can get very aggravated in the back.

The way this typically presents is a burning sensation that runs up and down the upper back, an achyness as well. It may get worse if you go pick up something heavy because attentions and nerves more if you look down, in fact, to try this out, you can check yourself if you have got an upper back nerve problem. If you look down and bring your chin to your chest, like try to push your chin against your chest as much as possible. If that begins to set off that bad, achy feeling, that's likely a nerve problem. It could be muscles as well.

There are different ways to differentiate it. But that's a beginning of a common test that we do here in the office to start to figure out if you have a nerve problem, there is more that we have to do for you, but half the time there's a nerve problem. When you look all the way down and you feel pain going down your mid back area that is almost always a real problem. There is muscle imbalances that are associated with that. We have to look at the neck, we have to look at the lower back as well, the shoulder blade positions.

There is a lot involved in fixing nerve problems in the upper back. This pain that radiates down, this burning sensation, this discomfort, it can also be present in the neck. We have to look at the neck joints and muscle imbalances up there as well.

The next two problems that I'm going to cover, that are commonly found in the upper back area are less common, but they do happen, and they are related to each other.

I'm going to talk about thoracic disc problems. In the medical field, they usually talk about cervical disc problems, which is neck problems. In your neck you can herniate those discs, you can bolt those, you can get degeneration in those. Then in the lower back, in the lumbar spine, there are lumbar discs as well that can get injured. But it's rarely ever discussed the discs that are in the thoracic spine, in the middle and upper back part. But you can get problems in those discs as well.

It's hard to detect them on an MRI or X-ray. It's more commonly found by hand, by an expert like myself, like somebody who's pretty good with hands on, feeling the body, feeling the joints, feeling the muscles around there. Once it's found, it's really easy to clear up actually, we have helped people with disc problems in the thoracic spine for years now, and it's actually quite straightforward to clear up. It almost always clears up. I've never seen somebody that was debilitating.

It didn't get better, but it can feel like, and the common words that people use is, it feels like somebody's putting an icepick right into the middle of their mid back, right in the center. And I have to ask, is it off to the right, or off to the left? And they always say Nope, it's right in the middle. Then once I do my testing, and for the discs in the middle back, I'll find the spot and I'll poke a little bit. They'll say, Yep, you found it. That's it. That's the spot that hurts. And I can tell that it's a disc problem based on how stable that section is.

Because whenever there is a disc injury, the vertebrae, the bones in that area aren't moving as good and they get loose. That's how I can feel all those little changes in the spine. Associated with this, with these disc injuries, is something called T4 syndrome. You can Google this it's a thing.

T4 syndrome is a loosening of a disc, they think it's at T45, but in my experience, I think it can be anywhere in the thoracic spine anywhere in the upper back and we are in the mid back. Because there are certain nerves that control a certain part of your nervous system, specifically the sympathetic nervous system, this is higher level stuff. You don't have to go look this up if it's confusing for you.

The sympathetic nervous system controls the fight or flight parts of the nervous system so it can regulate pain. There are all these details that we look at. But what you need to take away is that about t 45. That part of the sympathetic nervous system affects the arms. In people that have this T4 syndrome, they can sometimes get pain, numbness, tingling into their arm. And if it happens to be on the left side, and they also have a neck problem, a lot of times they think that they are having a heart attack, pain in the arm, pain in the neck on the left, especially a female because females tend to not live through heart attacks more so than men. It can freak them out.

We have had patients come in and say, I went to the hospital, I got my heart checked, I had all these checkups with a cardiologist, and they say, I'm fine. There's nothing wrong with my heart, thank God, but my arm still hurts, and I can't sleep at night and my back's killing me and my necks killing me. When we check them out, thankfully they've already cleared out all their heart stuff, so we don't have to send them to the doctor to do that. But then we find that loose disc in their spine and we diagnosed them with T4 syndrome. The good news like with other thoracic disc problems is that it heals just fine as long as you put in the right environment.

Since it is a disc, it can take up to a year to fully scar down and not cause problems constantly. But within the first few months, you can see a dramatic reduction in pain and be able to sleep comfortably, sit comfortably, move your arms and exercise as well.

Some people have trouble exercising because of this. For most people though, when they have been sitting for a while, is when they feel the most. They get that sensation that feels like an icepick into their back. This part of the back, just talking about treatment, because oftentimes, people go to a chiropractor and get their back popped, or they get their relatives to pop their back, they'll just do come up from behind and give them a bear hug and pop their back. That can be quite relieving for people that have stuck joints in their back and it will move some of the ribs that are stuck as well.

But in people that have a thoracic disc problem, you got to be very careful about doing any sort of those techniques. I wouldn't have your spouse do it or your relative do it. You got to make sure that it's done by a professional. I've had a few conversations with chiropractors here and there and I've never heard them know much about T4 syndrome whenever I bring it up. I can't say that I have a good sample of chiropractors that I've asked about it. But the ones that I have, just haven't talked too much about it. I don't think that they are aware of thoracic disc problems.

They have had the experience where clients come in and say, Well, I thought I needed to pop my back because I had that icepick sensation where it felt like stabbing. I went to the chiropractor and they couldn't pop it. They did their thing and it popped a little or didn't even pop at all, but actually left me feeling worse.

I think that that happens because they are overstretching an already loose thoracic disk and unknowingly, they may not know how to check for it and how to handle that kind of situation. They go through their techniques and it might be injury. If you think that you have a thoracic disc problem, if you think that you might have T4 syndrome, I just want to let you know to exercise caution with, letting anybody pop your back.

We do those kinds of techniques here in the office, we do thoracic manipulations. That's where we can create some pops in the back joints if needed. And we do it very judiciously, very carefully. And not everybody gets it, it depends on if you need it or not, and if you are comfortable with it, but for a T4 syndrome or thoracic dis syndrome, we are definitely staying away from those areas that are affected. Because we do not want to contribute to making that worse, we want to make it better.

But in order to make it better, we might need to work on some other spots nearby to make sure that that T4 area, or any of the areas that are affected are safe and getting better.

Now let's talk about some of the treatment options. We already went over thoracic manipulations and adjustments a bit. But let's discuss braces. I've seen some people get really, really into fixing their posture. And I think that's great. You should have improved posture. But some people go so far as to wearing braces that hold their shoulders back and make them sit up a little bit.

There are braces that you can find out there that are special for posture. I've even seen some clients that have a device that they can attach to themselves under their clothes, and it buzzes them a little bit, it vibrates. I haven't seen anybody have the one that shocks you, but there's one out there that actually can shock you a little bit. Where if you lean too far forward, and you start slouching, these devices let you notice it to back up and straighten up your posture.

That's definitely something that can help you out. Posture isn't always the solution, though. And some people overdo it with posture. There are actually cases where I have to tell people, you are sitting up too much, you are overdoing your posture and you actually need to slouch a bit because you are going to hurt your back, and that might be contributing to your upper back problem.

People will also go do certain exercises and stretches and there are so many muscles in the upper back and in the shoulders and neck, that it's hard to tell you exactly what exercises are best for you. The best advice I can give you is that if you are out there doing exercises for your upper back, and they are helping you great. Awesome! Sounds like it's probably going to be a good thing for you to keep going with that.

But if you are doing an exercise and it's making no difference, or it's making you worse, you definitely want to back off from those exercises so that you are not creating a bigger problem for yourself. That's going to take more time and effort and money to fix down the road.

Pain medications are often used, we I often hear people with upper back problems like to take over the counter pain medication. Stuff like Ibuprofen, Naproxen, Tylenol, those types of over the counter medications. Some people will go to the doctor and get prescription strength medications, they'll get steroids type of medications that are anti-inflammatory and pain relieving. They will get some muscle relaxers as well.

I have seen some people get injections into their spine for upper back problems and lower neck problems. Those tend to be pretty effective. But they just have short term benefits. It is still pain medication, but it's just injected into the painful area. It's not creating more joint motion or strengthening the muscles. It's not fixing your posture. There are other factors that need to be considered to make sure that this problem gets better for the long term.

Surgery is rarely done. I haven't really seen anybody get an upper back surgery. I can tell you I've never seen anybody get an upper back surgery. What I tend to see is, people getting shoulder surgeries because they start to have shoulder problems, if an upper back problem has been there long enough.

I've seen people getting neck surgeries for sure. They do neck fusions and discectomy and other things in the neck. That could be contributing from the neck problem as well. Now, something that I haven't mentioned yet that's important, I think, is something called a downward hump.

A downwards hump is the bump that people get on their upper back at the base of their neck. That bump is where the spine is bending forward. And it's stuck there because the joints are stuck, or it might be stuck because the person isn't strong enough to straighten up. But we often see that as a telltale sign that there's going to be some neck problems, there's going to be some upper back problems, and there's likely going to be some nerve and shoulder problems as well.

If you are listening to this podcast right now and you are thinking I might have some of these problems that he's been talking about, and I just put my hand on my neck and my lower neck, upper back and I feel that I've got a little bit of a bump going. Plus, my parents had that bump or one of my parents had the bump, I might be genetically predisposed.

I would urge you to work on fixing that bump as best as you can. Whether it takes some professional help, like you hire somebody like us at El Paso Manual Physical Therapy, or you go and do some stuff on your own. Any way you slice it, having that bump is not a good thing. It's going to set you up for all these problems that I talked about, shoulder blade problems, nerve problems, related problems, the first and second ribs are frequently affected with that bump. The discs above and below that bump can often get affected as well.

Even though the bump might not be painful, most of the time it is very tender, and painful. Plus, it's unsightly. I often see women that have it, they don't like to wear their hair up because the bump is exposed. They wear their hair down to hide it and they try to work on their posture but just can't quite seem to get it. There are many different reasons why the bump is there and there are many different ways to fix it, you have to find the best way to fix it.

But I would make it a pursuit to make that bump go away for your health. I'm sure you'll love the aesthetics benefit of it anyway, where the bump is no longer there. But have to fix it for your health.

If that bump has been there long enough, if you are older and you've had it for decades, what can happen is the joints in that area can become really stuck. We call it our thrust or fused and it won't get better. It won't really straighten out. And you see some people that are stuck in that position. They need a lot of pillows to get comfortable and their back. They are hunched over, and they have to look up at you and they get shorter.

There are all kinds of side effects to that. So, you don't want to live with that. You want to make sure you take care of it while you are younger. Here in the clinic, we check if there is any potential for the mobility to improve in those joints. We check the muscles that support the spine in that area. We look at the bones above and below there, to see if they effect in any way the muscles that run down from the back into the shoulders. And if we find that bump in somebody who's got a shoulder problem or another upper back problem, you bet we make a big deal out of it because they need to fix it.

For that bump I've never seen a surgery for it. I've seen people get it injected. I see people taking pain medications for it and people trying to work on their posture to get a better but sometimes there are specific treatments that need to happen.

Oftentimes here in the clinic, we help people fix problems like these upper back problems, the bump, the T4 syndrome, thoracic disc problems, nerve issues, problems with their shoulder blades and the rib issues. We help them address those problems without relying on pain medication, injections and surgeries. Usually an option for a lot of these things. We help them because there's no other option and they tend to get better where all these issues improve tremendously, as long as they are not too far gone.

People can generally get better sleep at night. Remove the unsightly bump, to get rid of the achyness and burning, they are having running down their back. That sharp, deep pain. They can come out with a disc issue or a shifted rib that just doesn't let you breathe right, and the pain radiates from the back to the front. That is very correctable.

I hope that this podcast was helpful in increasing your knowledge in upper back problems. I hope that you feel much better prepared in making a decision about how to treat your back problem. Know where to go, what to do, how to approach it, how to think about it even. Because some people may or may not be that bad, you may not need to do anything about it right now. But if it's been going on for a while, then you need to start thinking about how you are going to fix this for the long term.

If you are interested in hiring us to help you with this problem, it's really easy. The best place to start is calling us at 915-503-1314. And if you know of anybody else that probably needs to hear this podcast, please share it with them. Let them know about the tips that we have in here and to listen to it. Have the best day ever. Bye.

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