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Mid-back pain (thoracic)

Before anything else — 5 symptoms that need urgent care
  • •New severe mid-back pain after minor trauma in anyone over 50 (possible fracture)
  • •Pain in a dermatomal band wrapping around the chest (possible thoracic nerve root irritation or myelopathy)
  • •Fever with thoracic pain
  • •History of cancer or recent unexplained weight loss
  • •Progressive leg weakness (rare but serious — thoracic myelopathy is surgical)
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

Less common than lumbar or cervical pain

Condition detail

Thoracic disc herniation

Uncommon relative to lumbar or cervical herniation, but can cause myelopathy

Condition detail

Osteoporotic vertebral fracture

More common with age and bone loss

Condition detail

Who to see first

Primary Care Physician

Your general physician — family medicine, internal medicine, or DO.

When to see them: First visit for most non-emergent new pain — they can coordinate PT and determine whether specialist referral is needed.

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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

    Self-care, posture review, and movement

    Maintain activity. Short activity modification if symptoms flare. Heat/cold and OTC NSAIDs if no contraindications. If desk-based work, assess monitor height and chair support — sustained thoracic flexion is a common contributor.

    Source

  2. 2
    Week 2–6Moderate evidence

    Physical therapy

    PT focused on thoracic extension mobility, scapular stabilization, and rib-cage mechanics. Manual therapy for costovertebral or costotransverse joint dysfunction where localized. Breathing-pattern retraining if pain worsens with deep inspiration.

    Source

  3. 3
    Week 6–12Moderate evidence

    PM&R or pain management consult

    For persistent thoracic pain without structural lesion, consider diagnostic thoracic medial branch blocks for suspected facet-mediated pain. MRI is appropriate at this stage if it has not already been obtained and symptoms are not improving.

    Source

  4. 4
    As indicatedExpert consensus

    Surgical consultation (rare)

    Surgical referral is warranted for confirmed thoracic disc herniation with myelopathy, for unstable fracture, or for tumor. For non-specific thoracic pain, surgery is not a first-line option.

Common causes

  • •Thoracic muscle strain or postural fatigue
  • •Costotransverse or costovertebral joint dysfunction (rib-to-spine joints)
  • •Thoracic disc degeneration (rarely herniated)
  • •Thoracic facet joint arthropathy
  • •Osteoporotic vertebral compression fracture (in older adults or with prolonged corticosteroid use)

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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