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Upper-back pain (cervicothoracic junction)

Before anything else — 6 symptoms that need urgent care
  • •Pain that wakes you from sleep
  • •Progressive arm or hand symptoms — possible cervical radiculopathy or myelopathy
  • •Hand clumsiness or gait imbalance (myelopathic signs)
  • •Fever with neck or upper-back pain
  • •History of cancer
  • •Trauma
Full red-flag guide

Likely conditions

Common causes based on epidemiology alone — a physical exam and sometimes imaging are needed to identify which one applies to you.

Non-specific thoracic pain

Common in desk-based workers

Condition detail

Cervical spondylosis (can refer to upper back)

Common on imaging with age; many findings are asymptomatic

Condition detail

Cervicogenic headache

A recognized subset of chronic headaches; referred pain from the cervical or cervicothoracic spine

Condition detail

Who to see first

Physical Medicine & Rehabilitation (PM&R)

Physicians who specialize in non-surgical treatment of musculoskeletal and nerve-related conditions. Often called "physiatrists."

When to see them: First stop for most persistent back or neck pain without red flags. Non-surgical. Often faster to book than a spine surgeon.

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Treatment sequence

Published guidelines (NASS, AAOS, ACP, NICE) recommend a conservative-first sequence unless red flags are present. Each step below lists the evidence strength and the primary source.

  1. 1
    Week 1–2Moderate evidence

    Postural review and self-care

    Ergonomic assessment for desk-based work — monitor at eye level, elbows supported, feet flat. Brief activity modification. Heat/cold and OTC NSAIDs for pain. Most acute episodes improve within 2–4 weeks.

    Source

  2. 2
    Week 2–6Moderate evidence

    Physical therapy

    PT targeting deep neck flexor strengthening, scapular stabilization (lower trapezius, serratus anterior), and thoracic extension mobility. Manual therapy at the cervicothoracic junction for localized facet dysfunction. Trigger-point work for myofascial components.

    Source

  3. 3
    Week 6–12Moderate evidence

    PM&R or pain management consult

    If pain persists without structural lesion, consider diagnostic medial branch blocks for suspected cervicothoracic facet-mediated pain, or trigger-point injection for confirmed myofascial sources. If referred pain from the cervical spine is suspected, MRI of the cervical spine is warranted.

    Source

  4. 4
    As indicatedExpert consensus

    Surgical consultation (uncommon)

    Surgery is not typical for axial cervicothoracic pain alone. Referral is warranted if imaging reveals a structural cause of referred pain — cervical disc herniation with radiculopathy, cervical spondylotic myelopathy, or cervicothoracic instability.

Common causes

  • •Postural and myofascial strain (trapezius, rhomboids)
  • •Cervicothoracic junction (C7–T4) facet joint dysfunction
  • •Referred pain from a cervical disc or nerve root (can present as interscapular pain before arm symptoms appear)
  • •Scapulothoracic dysfunction (shoulder-blade mechanics)

Your next steps

  • 1Screen yourself for red flags. If any apply, go to an emergency department before continuing with this Guide.
  • 2Start the first stage of the treatment ladder. Most new pain episodes improve significantly in the first 2–6 weeks with self-care and PT.
  • 3If symptoms persist, book with the specialist above. Bring: when it started, what makes it better or worse, medications tried, any imaging you have, and the questions from our surgery decision framework.
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