The mix of causes changes more than how often it hurtsEmerging evidence
In 34,902 Danish adults aged 20 to 71, upper back pain was the least common spinal pain (4% had it for 30 days or more in a year), women reported it more at every age, and it wasn't more common in the oldest groups, though their pain lasted longer. In 1,037 people aged 68 to 100 in the US Framingham Study, back symptoms didn't become more common with age, and those in the mid or upper back were commoner in women. Studies of upper back pain beyond 70 are few, so most of what follows comes from studies of the whole back or of particular causes.
What does change is the list. Desk and gym strains matter less; spinal fractures from thin bones, a rounding back, shingles, polymyalgia rheumatica and the heart matter more. Most upper back pain still comes from the muscles, small joints and rib joints. In 119 women after the menopause (average age 61), half had upper back pain in the past month, and better endurance in the back muscles went with lower odds of it (odds ratio 0.46), a link rather than proof of cause.
Sources 1, 2, 3
Spinal fractures from thin bones: common from 50Strong evidence
A spinal fracture (a vertebral or compression fracture) is when a weakened bone in the spine squashes. In 15,570 people aged 50 to 79 in 19 European countries, 12% of women and 12% of men had a squashed vertebra on an X-ray, more often with age and more steeply in women; new ones happened at about 10.7 per 1,000 women and 5.7 per 1,000 men a year. In a US town, 83% of diagnosed spinal fractures followed moderate or no injury, and of 107 people seen in a Swedish emergency unit with a new one (average age about 75), 65.4% had fallen from standing height or had a minor injury and 34.6% remembered no event at all. The NHS says a cough or sneeze can sometimes break a rib or partly collapse one of the bones of the spine.
The upper back is a common place for them: wedge-shaped fractures cluster in the middle of the upper back and around the waist, in women and men alike (13,562 Europeans). The UK osteoporosis guideline asks GPs to think of a spinal fracture in women past the menopause and men 50 and over with sudden back pain, "especially thoracic pain" (pain in the upper or middle back). Of 669 people over 55 who saw a GP in the Netherlands with back pain, 5% were diagnosed with a spinal fracture within a year, more often at 75 or over, after an injury, with known osteoporosis, with severe pain or with upper or middle back pain. The National Institute for Health and Care Excellence (NICE) lists back pain or rib pain spreading round the chest with no clear cause, height loss of more than 4 cm and an exaggerated curve among the signs of a spinal fracture, and long-term steroid tablets as a reason to check too.
Sources 4, 5, 6, 7, 8, 9, 10, 11, 12
Often missed, and not always painfulStrong evidence
In a large trial of older women, only about 1 in 4 new spinal fractures seen on X-rays had been diagnosed (22.6% of 446; 14.3% of milder ones and 28.4% of more severe ones). In an international study of 2,451 women, local X-ray reports missed 34% of spinal fractures, and the UK osteoporosis guideline says "The majority of vertebral fractures do not currently come to medical attention". The Royal Osteoporosis Society adds that "Sometimes, spinal fractures don't cause the pain you'd expect from a broken bone", and the pain can be mistaken for arthritis.
They still matter. In 7,223 women aged 65 and over, a new spinal fracture raised the odds of more back pain (odds ratio 2.4), back disability (2.6) and a day or more of bed rest (6.7), even when it never came to medical attention. In 2,992 women aged 65 to 70, mild deformities weren't linked with back pain, but severe ones were (1.9 times the risk of moderate to severe back pain), so a scan finding isn't always the source of pain either.
Sources 13, 14, 10, 15, 16, 17
A rounded upper back is common, and it isn't the same as a fracture or as painEmerging evidence
A rounded upper back (hyperkyphosis) affects roughly 20% to 40% of older men and women. In women the curve rises from an average of 43 degrees at 55 to 60 to 52 degrees at 76 to 80, usually by less than 1 degree a year, and a very rounded back goes with lower bone density, fractures and poorer balance and walking. The NHS says some older people develop a stooped posture "when the bones in the spine have broken".
But a curve isn't a fracture in itself: in the most curved quarter of 1,407 Californians aged 50 to 96, only about 36% had fractures in the upper back, and disc wear, not fractures, was the commonest finding. The authors still advise a check for fractures. Nor is it the same as pain: the 10% of 610 women aged 65 to 91 with the most curved backs "had no greater back pain, disability caused by back problems, or poorer health". So a new or growing curve, or height loss, is a reason to see a GP, and pain shouldn't be written off as the curve or as age.
Sources 18, 19, 20, 8, 21
Arthritis and bony bridges on a scan: common, and not a cause on their ownEmerging evidence
On computed tomography (CT) scans of 1,195 adults in the Framingham Study, moderate to severe arthritis in the small facet joints of the upper back showed in 80% to 81% of people aged 60 to 69 and 83% to 85% of those aged 70 to 89, much the same in women and men. A review of magnetic resonance imaging (MRI) studies of the upper back could draw no firm conclusions about whether such findings explain pain (only 2 studies tested upper back pain), and in the 119 women after the menopause, upper back arthritis on X-ray wasn't independently linked with upper back pain.
Bony bridges down the side of the spine (diffuse idiopathic skeletal hyperostosis, DISH) are mostly in the upper back: 22.0% of men and 4.8% of women had them in a Japanese population study, and 42% of US men aged 65 and over, rising to 56% from 80. Those men reported less back pain in the past year, not more (59% against 71%). A report of "degeneration" or "DISH" is common and isn't a cause of pain on its own.
Sources 22, 23, 3, 24, 25
Shingles: pain can come before the rashStrong evidence
The NHS says the first signs of shingles can be "a tingling or painful feeling in an area of skin" and a headache or feeling generally unwell. "A rash will usually appear a few days later. In rare cases shingles can cause pain without a rash." The rash is on one side of the body only, usually the chest and tummy. About 3 in 10 people get shingles in their lifetime, the risk rising sharply after 50, to about 8 to 12 cases per 1,000 people a year at 80 (130 studies).
Long-lasting nerve pain after shingles (post-herpetic neuralgia) is "more common in older people" and can last "from a few months to over a year", the NHS says. The shingles vaccine reduces the chance of both. On the NHS it is offered to all adults turning 65, to everyone aged 70 to 79, and to people aged 18 and over with a severely weakened immune system (the UK Health Security Agency).
Sources 26, 27, 28, 29, 30
Polymyalgia rheumatica: both shoulders and hips, not the upper back itselfStrong evidence
Polymyalgia rheumatica causes pain and stiffness in the muscles around the shoulders, neck and hips, with morning stiffness that lasts longer than 45 minutes, and sometimes tiredness and weight loss. The NHS says most people diagnosed are over 65 and it is very rare under 50; NHS inform says most are over 70, and that both sides of the body are usually affected. Neither page, nor Arthritis UK's, lists the upper back itself: the clue is both shoulders and the hips.
It is more common in women than men. In UK general practice records, about 96 people in every 100,000 over 40 were diagnosed each year; in one US county (Olmsted County, Minnesota), the lifetime risk was 2.4% for women and 1.7% for men. Up to 1 in 5 people with it develop temporal arteritis (giant cell arteritis), whose signs are in the urgent warning signs.
Sources 31, 32, 33, 34, 35
The heart, the aorta and the lungs: rare, but 999Strong evidence
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. In a US registry of 1,143,513 heart attacks, 35.4% of people had no chest pain at first (42.0% of women and 30.7% of men), and older people more often had a heart attack without chest pain; the gap between women and men narrowed with age. Across 27 studies, women had about twice the odds of pain between the shoulder blades (odds ratio 2.15). So upper back pain with chest discomfort, breathlessness, sweating or feeling sick is a 999 call, at any age.
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, starting about 10 years later in women than in men, with similar rates in women and men from 75. Uncontrolled high blood pressure is the main risk that can be treated. There is no NHS page for it; its costochondritis page describes "sudden chest or back pain that can feel like something being torn inside". A blood clot in the lungs brings sudden breathlessness with chest or upper back pain.
The NHS lung cancer page lists chest or shoulder pain, a cough that won't go away, breathlessness and weight loss, and its 999 box includes pain in your chest or upper back. NICE offers an urgent chest X-ray from 40 with 2 or more unexplained symptoms, or 1 if you have ever smoked; chest pain is on its list, back pain isn't. A tumour at the very top of the lung (a superior sulcus or Pancoast tumour, about 5% of non-small cell lung cancers) most often causes shoulder pain (60% across 31 studies) and arm or nerve symptoms, and is sometimes first mistaken for a muscle or joint problem.
Sources 36, 37, 38, 39, 40, 41, 42, 43
Cancer, myeloma, infection and the gallbladder: rare, with their own cluesStrong evidence
Of 669 people over 55 who saw a GP with back pain, 6% were diagnosed with a serious cause within a year, mostly spinal fractures (5%). With a past or current cancer, NICE asks for specialist advice within 24 hours for back pain that is severe and unrelenting, getting worse, worse at night, worse when you strain, or with tenderness over the spine; its list is written for back pain in general and doesn't single out the upper back. NICE also asks GPs to offer blood tests for myeloma, a cancer of the bone marrow, at 60 and over with persistent bone pain, particularly back pain, or an unexplained fracture.
An infection in the spine is rare: 2.2 rising to 5.8 cases per 100,000 people a year in one Danish county, highest over 70. Pain that spreads from the tummy to the back, with being sick, can be a gallstone problem and is a 999 call, the NHS says.
Sources 11, 44, 42, 45, 46
When a scan or test mattersStrong evidence
Ordinary upper back pain usually needs no scan; NICE, writing about low back pain, says don't routinely offer imaging. A suspected spinal fracture needs a spine X-ray or a spine check during a bone density (DXA) scan: NICE suggests the spine check for men 70 and over and women 60 and over having a bone density scan, and for younger people with unexplained back or rib pain, height loss of more than 4 cm, a rounded back or long-term steroid tablets. Once that check has found a fracture, NICE says further spinal imaging isn't routine unless the result is uncertain or another cause, such as cancer, is suspected; imaging also confirms the level before any cement procedure.
There is no single test for polymyalgia rheumatica, but NHS inform says you should have blood tests for signs of inflammation before starting steroids, and NICE asks for myeloma tests at 60 and over with persistent bone pain and a chest X-ray for lung symptoms. Heart and aorta symptoms are tested in hospital. After a spinal fracture from thin bones, NICE recommends offering a bone density scan to guide treatment, and the Royal Osteoporosis Society says a doctor may prescribe an osteoporosis medicine "without further tests".
Sources 47, 12, 48, 32, 42, 49, 15
How it usually goesMixed evidence
NHS inform says new back problems should begin to settle within 6 weeks, written for adults of any age. A spinal fracture takes 6 to 12 weeks to heal, the Royal Osteoporosis Society says, and you can usually expect it to heal within about 3 months, though for some people the pain doesn't go away completely. In 107 people seen in a Swedish emergency unit with a new, painful spinal fracture, pain had improved only 10% to 15% by 3 months and changed little after that, up to a year. The two pictures differ, so the honest answer is that the bone usually heals within about 3 months, many people improve as it does, and some have pain for longer.
The shingles rash can take up to 4 weeks to heal, and the skin can stay painful for weeks after. Polymyalgia rheumatica usually needs steroid treatment for 12 months to 2 years. A rounded back changes slowly. No one can promise a timescale.
Sources 50, 51, 7, 26, 31, 21
