Understanding Mid-Back Pain from Muscles, Joints, and Discs
The thoracic spine is the middle part of your back, where the ribs attach. It is more stable than the neck or low back, so pain here is less common, but it can be just as limiting. Most mid-back pain comes from muscles and the small joints between the vertebrae (facet joints) and the ribs (costovertebral joints), often linked to posture. Because mid-back pain can occasionally signal a problem elsewhere in the body, a careful evaluation comes first.
Causes
Muscle strain and myofascial pain, often from prolonged sitting, desk work, or poor posture.
Facet joint and costovertebral joint arthritis.
Thoracic disc bulges or herniations (less common than in the neck or low back).
Compression fractures from osteoporosis.
Scoliosis or kyphosis (excess curvature).
Shingles or nerve irritation along a rib.
Symptoms
Aching or tightness between the shoulder blades or in the mid-back.
Sharp pain with twisting, deep breathing, or certain positions.
Pain that wraps around the chest along a rib.
Muscle knots and tenderness.
Seek immediate medical care if: Mid-back pain comes with chest pain, shortness of breath, fever, unexplained weight loss, a history of cancer, recent significant trauma, leg weakness or numbness, or loss of bladder or bowel control.
Imaging Studies to Consider
X-rays show alignment, curvature, arthritis, and fractures.
MRI of the thoracic spine shows discs, nerves, and the spinal cord.
CT scan provides bone detail.
Other tests (such as heart or lung studies) may be needed when pain could come from outside the spine.
Physical Therapy, Home Exercise & Other Conservative Techniques
Physical Therapy
Thoracic mobility and extension exercises.
Scapular and postural strengthening.
Manual therapy.
Home Exercise Program
Foam roller extensions and open-book stretches.
Rows and shoulder blade squeezes.
Hourly posture breaks.
Other Studied Techniques
Ergonomic workstation setup.
Heat therapy.
Interventional Treatment Options
Trigger point injections: For tender muscle knots.
Thoracic medial branch blocks: Numbing injections near the nerves of the facet joints to confirm whether they are the pain source.
Thoracic radiofrequency ablation: Heat applied to those nerves for longer-lasting relief after successful blocks.
Costovertebral joint injection: For pain where the rib meets the spine.
Thoracic epidural steroid injection: For pain from an irritated nerve root.
Platelet-rich plasma (PRP): For myofascial pain, ultrasound-guided PRP into trigger points has shown encouraging results in early studies.
Neuromodulation: Spinal Cord & Peripheral Nerve Stimulation
Spinal cord stimulation (SCS): May be considered for chronic thoracic or chest wall pain that persists despite other treatment.
Peripheral nerve stimulation (PNS): For localized pain along a specific nerve.
Evidence Base: Guidelines & Levels of Evidence
Thoracic medial branch blocks and radiofrequency ablation: Level III · ASIPP facet joint intervention guidelines (Manchikanti et al., Pain Physician 2020)
Thoracic epidural steroid injection: Level II–III · ASIPP guidelines
Platelet-rich plasma (myofascial): Level II-2 · Grade C · 2025–26 literature review (outside ASPN 2024 scope)
Exercise and manual therapy: Level II · Clinical trials in mid-back and neck pain
Evidence levels and guideline citations above are summarized for general clinical reference based on the literature and major society guidelines available at the time of writing. Guidelines are periodically updated; please verify current recommendations before relying on this summary for clinical decision-making.
Pain Psychology Techniques
Cognitive behavioral therapy (CBT) for pain.
Relaxation training and diaphragmatic breathing.
Mindfulness-based stress reduction.
Biofeedback for muscle tension.
Graded activity pacing.
Non-Opioid Medication Options
Anti-inflammatory and analgesic options
NSAIDs like ibuprofen or naproxen.
Acetaminophen.
Muscle relaxants (short-term)
Cyclobenzaprine or tizanidine for muscle spasm.
Topical treatments
Lidocaine patches or topical diclofenac gel.
Related Procedures
Related Conditions
Talk With Us About Your Options
Call 650-507-4113 or send us a message to schedule a consultation at our Daly City, Los Altos, or Stockton office. We will review what may be causing your pain and walk through the risks, benefits, and alternatives of each option with you.
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This information is provided for general patient education and does not replace individualized medical advice. Please discuss your specific symptoms, diagnosis, and treatment options with your pain management physician.
