Common, and reported more often by womenStrong evidence
A review of 33 population studies found that 3.5% to 34.8% of people have pain in the upper or middle (thoracic) back over a year, more often women and girls; the figures vary because studies define it differently. In one Danish twin study of 34,902 adults, 13% had it in the past year, and at 40 about twice as many women as men had it (about 20% against 10%, read from the study's graph). It didn't climb steadily with age.
Upper back symptoms affected 28% of 1,185 office workers over a year, more often women. Why women report more isn't known, and nothing suggests their backs are weaker; in Danish girls, puberty went with low back pain but not mid back pain.
Sources 1, 2, 3, 4, 5
Posture isn't the main causeMixed evidence
A review of 54 studies found no strong evidence linking the curves of the spine with spinal pain, though most of the studies were weak. In 119 women after the menopause, a rounded upper back and photographed head, shoulder and upper back posture were not linked with upper back pain, while weaker back-muscle endurance was. In the only long-term study, young women who sat upright at 17 had more neck pain at 22 than those who slumped.
Forward head posture was only slightly commoner in adults with neck pain, in studies that can't show which came first, and for low back pain, a review of reviews found no agreement that posture causes it. NHS inform says "your posture doesn't need to be perfect, try and move often"; the NHS neck page, which is past its review date, still lists bad posture as a common cause.
Sources 6, 7, 8, 9, 10, 11, 12, 13
The neck, the ribs and desk workEmerging evidence
NHS inform says "neck problems can sometimes cause pain in your shoulders, arms and upper back". In studies of trapped nerves in the neck, shoulder-blade pain was described in 72% and can come weeks before arm pain. The joints where the ribs meet the spine cause a deep, dull ache over the joint, in a small study of volunteers.
In office workers, new neck pain was predicted by a keyboard close to the body, little variety in tasks and feeling tense; being a woman and having had neck pain before were the strongest predictors. This is neck evidence, borrowed for the upper back.
Sources 14, 15, 16, 17, 18
Breasts and bras: the evidence is thinMixed evidence
In two small studies of older Australian women, larger breasts went with more upper back pain (in 44 women; and in 119, until height and back-muscle endurance were counted). In 30 young women and in 400 Nigerian mothers, breast size wasn't linked with it, and in 339 hospital staff, cup size didn't track neck and shoulder pain across sizes. No study shows that breast size causes back pain.
Most women in these studies wore a bra that didn't fit, usually too small: 80% to 93% in the small studies, 85% of 104 Australian women, and all 102 women referred for breast reduction at one UK clinic. Trying on several bras or using a tape measure didn't fix it, and the traditional tape method tended to get the band too big and the cup too small.
Sources 8, 7, 19, 20, 21, 22, 23, 24
After the menopause, bones matterStrong evidence
About 1 in 2 women have a fracture from thin bones in their lifetime, the UK osteoporosis guideline says, and most spinal fractures are never diagnosed: only 22.6% were in one large trial of older women, and X-ray reports missed 34% in another. Between 18% and 26% of older European women have spinal fractures on X-ray.
Thin bones don't hurt until a bone breaks, but a spinal fracture can cause sudden back pain, muscle spasms, height loss or a curved spine. These fractures are "stable" and "do not cause paralysis", the Royal Osteoporosis Society says, and they heal in 6 to 12 weeks. In the 119 women after the menopause, a spinal fracture was commoner in those with upper back pain.
Sources 25, 26, 27, 28, 29, 30, 7
The heart, felt in the upper backStrong evidence
The British Heart Foundation lists pain that spreads to "either arm, your neck, jaw, upper back or stomach" among heart attack symptoms, and says women sometimes have these less well-known symptoms rather than chest pain. The NHS angina page also lists pain spreading to the back among its 999 signs; the NHS heart attack page names the arms, neck and jaw.
Across 27 studies of more than a million people, women having a heart attack had about twice the odds of pain between the shoulder blades, and more often felt sick or breathless, but chest pain was still the commonest symptom (74% of women, 79% of men). In a US registry, 42.0% of women and 30.7% of men had no chest pain, the gap largest in younger women. A rare tear in a heart artery (SCAD) mostly affects women aged 45 to 53, sometimes in or soon after pregnancy. Most upper back pain is still the back.
Sources 31, 32, 33, 34, 35, 36
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 can spread to the side or shoulder blade; NHS inform says it is sometimes set off by fatty food and can wake you. Gallstones are more likely in women and over 40. Shingles starts with a tingling or painful patch on one side, with a rash a few days later. A tear in the body's main artery feels like "something being torn inside" and is rare (about 6 per 100,000 a year, a little more often in men, average age 72).
Breast cancer that spreads to bone is uncommon (in 35,912 Danish women, 0.5% at diagnosis and 3.6% over the next 3.4 years); new back pain with a history of cancer needs an urgent check. Fibromyalgia is more common in women. A curved spine (scoliosis) in teenagers is commoner in girls, especially larger curves, while Scheuermann's is diagnosed more often in men.
Sources 37, 38, 39, 40, 41, 42, 43, 44, 45, 46
Pregnancy and feeding a babyEmerging evidence
In an online survey of 395 breastfeeding mothers in Poland, 36% had upper back pain at least weekly, and mothers with back pain fed for longer at a time; that is one survey. The NHS says get comfortable before a feed, with cushions and your shoulders relaxed. In pregnancy, back pain in the second or third trimester needs a call to your GP or midwife, the NHS says, as it can occasionally be early labour.
Sources 47, 48, 49
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)".
Tests answer specific questions: a spine X-ray or spine image at a bone density appointment for a suspected fracture (with sudden back pain and risk factors for thin bones, height loss of 4 cm or more, a new curve or long-term steroids); a bone density (DXA) scan after a spinal fracture from thin bones; an electrocardiogram (ECG) and blood tests for suspected heart pain; and an ultrasound and blood test for gallstones.
Sources 12, 50, 25, 51, 52, 35, 37
How it usually goesEmerging evidence
Back pain "often improves on its own within a few weeks", the NHS says, and neck problems should begin to settle within 8 weeks (NHS inform). In children and teenagers, mid back pain came back or carried on in 13% to 45% over 1 to 4 years; no study has tracked recovery in adults. In a trial in adults with long-standing upper back pain, all groups improved over 12 months. A spinal fracture heals in 6 to 12 weeks. No one can promise a timescale.
Sources 50, 53, 14, 30, 54
