Less common than low back or neck pain, and less common in menEmerging evidence
In a Danish study of 34,902 adults, 13% had upper or middle back pain in the past year, against 43% for the low back and 32% for the neck. At 40, about 10% of men had it against 20% of women, and men more often had short spells of a few days. It didn't climb with age. Across 33 population studies the figures vary widely (3.5% to 34.8% a year), because studies define it differently.
In working adults it goes with heavy workloads, ergonomic problems at work, dull tasks, long hours driving and mental pressure. These are links, not proven causes, and nothing suggests men's backs are weaker or stronger.
Sources 1, 2, 3
Posture is less to blame than people thinkMixed evidence
In 686 young Australians, how a young man sat at 17 didn't predict neck pain at 22. In office trials, adjusting the workstation or giving people sit-stand desks didn't reduce arm or upper-body pain; in 756 UK council workers, sit-stand desks cut sitting by about an hour a day, but upper-body aches fell in every group alike. Most of this evidence is about the neck, and much of it is from women.
NHS inform puts it plainly: "Although your posture doesn't need to be perfect, try and move often so you don't stay in the same position for too long."
Sources 4, 5, 6, 7
Lifting, the gym, the ribs and the neckEmerging evidence
Men made up 82.3% of the weight-training injuries seen in US emergency departments, and men's injuries were more often in the upper trunk (26.8% against 18.4% in women), mostly strains and sprains. Lifting sports are still low-risk: weightlifting and powerlifting cause about 1 to 4 injuries per 1,000 hours of training, low next to contact sports.
A rib joint beside the spine causes "a deep, dull ache, and pressure sensation" over the joint, in a small study of 8 volunteers. The NHS describes a chest wall strain as starting after an injury or exercise, worse when you breathe in and better when you rest the muscle. Rowers can get stress injuries of the ribs. A trapped nerve in the neck can be felt at the shoulder blade, sometimes before the arm.
Sources 8, 9, 10, 11, 12, 13
Ankylosing spondylitis: stiffness that eases with exerciseStrong evidence
Ankylosing spondylitis (AS) is the form of axial spondyloarthritis that shows on X-rays, and about 70% of people with it are men. The form that doesn't show on X-rays is about as common in women as in men, so the National Institute for Health and Care Excellence (NICE) says axial spondyloarthritis "affects a similar number of women as men". The NHS says AS "usually first starts to develop between 18 and 40", and diagnosis takes about 6 to 8 years on average, longer in women.
The pain "gets better with exercise, but does not improve or gets worse with rest", is worse in the morning and at night, and can cause pain where the ribs join the breastbone, making a deep breath hard. Experts' criteria add a slow start before 40 and pain at night; the Berlin criteria add morning stiffness of more than 30 minutes, waking in the second half of the night and pain switching between the buttocks. In 708 people with recent inflammatory back pain, 44.6% had chest wall pain.
NICE's referral rule for suspected axial spondyloarthritis is written for low back pain that started before 45 and has lasted more than 3 months; there is no separate rule for the upper back. Upper back stiffness with these features still needs a GP.
Sources 14, 15, 16, 17, 18, 19, 20
Scheuermann's disease in boys and young menMixed evidence
In about 35,000 Danish twins, Scheuermann's was diagnosed in 3.6% of men and 2.1% of women, close to 2 to 1. On the X-rays of 2,753 Dutch adults it was only slightly, not significantly, more common in men (4.5% against 3.6%), so boys may be noticed more often. It is a sharp, stiff curve that stays when standing tall; the NHS says exercises help pain and stiffness "But they will not improve the curve".
Sources 21, 22, 23
Men break their spines tooStrong evidence
Across 19 European countries, squashed vertebrae showed on the X-rays of 12% of both men and women aged 50 to 79. New spinal fractures happened at about half the women's rate (5.7 against 10.7 per 1,000 a year). About 1 in 5 men over 50 will break a bone because of osteoporosis, the Royal Osteoporosis Society says, and a third of the UK's 549,000 fragility fractures a year are in men. Most spinal fractures are never diagnosed.
Risks in men include long-term steroid tablets, heavy drinking, smoking and low testosterone, including "some prostate cancer drug treatments". A spinal fracture can cause sudden pain after a minor fall, lift, cough or sneeze, height loss or a new curve. These fractures are "stable" and "do not cause paralysis". People with ankylosing spondylitis are more prone to fractures, and NICE asks them to get checked after any fall.
Sources 24, 25, 26, 27, 28, 29, 15
The heart, felt in the upper backStrong evidence
Upper back pain with chest pain or pressure, breathlessness, sweating or feeling sick needs 999. The NHS angina page lists pain that "spreads to your left or right arm, or your neck, jaw, shoulder, stomach or back" among its 999 signs, and says angina is more likely in "a man aged 45 or over". The British Heart Foundation (BHF) names the upper back too.
Chest pain is still the commonest heart attack symptom in men (79% across 27 studies), but in one US registry 30.7% of men had none. Pain between the shoulder blades is reported more by women: women had about twice the odds of it in two analyses. Pain that changes when you move or press on the back, with none of the heart signs, points to the back.
Sources 30, 31, 32, 33, 34, 35
The aorta and the lungs: rare, but 999Strong evidence
A tear in the body's main artery (aortic dissection) is rare: about 6 per 100,000 people a year in Oxfordshire, average age 72, and about 1.5 to 2 times more common in men. Uncontrolled high blood pressure is the main risk that can be treated. There is no NHS page for it; the NHS describes it on its costochondritis page as "sudden chest or back pain that can feel like something being torn inside".
A collapsed lung (pneumothorax) is about 2.3 times more common in men in England, most often at 15 to 34, in people who smoke and in tall, thin people, the charity Asthma + Lung UK says. It causes "a sudden, sharp stabbing pain in your chest or shoulder" that is worse breathing in, with breathlessness. Fewer than 1 in 2,000 people go to hospital with one each year.
Sources 36, 37, 38, 39, 40, 41, 42
Other causes, and how rare they areStrong evidence
Gallstone pain is just under the right ribs or in the middle of the tummy, lasts more than 30 minutes and "may spread from here to your side or shoulder blade", NHS inform says. Shingles starts with tingling or pain in one patch on one side, with a rash a few days later; it becomes more common after 50.
Cancer is a rare cause of upper back pain. New back pain with a past cancer, especially if it is constant, getting worse, worse at night or with tenderness over the spine, needs an urgent check, NICE says, and it asks for blood tests for myeloma in people 60 and over with persistent bone pain. Bony bridges along the spine (diffuse idiopathic skeletal hyperostosis, DISH) are more common in older men and with type 2 diabetes, and can stiffen the upper back.
Sources 43, 44, 45, 46, 47, 48, 49, 50, 51, 52
When a scan or test helpsStrong evidence
"For most back pain problems, you'll not normally need an X-ray or MRI scan", NHS inform says, though the NHS asks you to see a GP for pain "coming from the top of your back (between your shoulders)". Disc and joint changes on a magnetic resonance imaging (MRI) scan of the upper back range from almost no one to most people depending on how they're defined, and only 2 studies have tested whether they track pain.
Tests answer specific questions. A suspected spinal fracture needs a spine X-ray or a spine check at a bone density (DXA) scan; NICE suggests this for men 70 and over, and for younger men with unexplained back or rib pain or height loss of more than 4 cm. Suspected axial spondyloarthritis needs blood tests (normal results don't rule it out), then an X-ray and MRI. Heart pain needs an electrocardiogram (ECG) and blood tests; a torn aorta needs a scan in hospital, and a normal ECG doesn't rule it out.
Sources 7, 53, 54, 55, 26, 56, 15, 57, 32, 38
How it usually goesEmerging evidence
Back pain "often improves on its own within a few weeks", the NHS says, and NHS inform suggests talking to a healthcare professional if it hasn't improved within 6 weeks. In a trial of 143 adults with long-standing upper back pain, every group improved over 12 months, whatever the treatment. Ankylosing spondylitis is long-term, but treatment helps the symptoms and helps "delay its progression". No one can promise a timescale.
Sources 53, 58, 59, 60
