The causes and treatment of mid-back and upper back pain
byDr. Lev Kalika

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Your middle back spans from the top of your shoulder blades to your bottommost ribs. Even though middle back pain is not as potentially harmful as low back pain (LBP) or neck pain, it can be equally disabling.

Middle back pain is fairly common, especially today, when use of computers and hand-held devices has made us more sedentary and more prone to poor posture. Middle back pain is synonymous with interscapular pain, although pain in the mid-back may manifest itself anywhere along the spine and ribcage. Until recently, doctors and scientists paid little attention to this region, concentrating more on the cervical and lumbar spine. However, interest in the mid-back has increased in recent years, and new research indicates that the integrity of the thoracic spine and ribcage is vital to proper neck and low back function.


The middle back is part of the functional unit called the trunk, consisting of 12 thoracic vertebrae and ribs that connect the spine to the sternum and abdomen. The shoulder blades connect the trunk to the arms and shoulders. The core muscles in this area connect the trunk to the pelvis from both inside and outside. Functionally, the legs are connected to the trunk via the psoas muscle. The functional unit connecting the lower body to the trunk is called the abdominal canister. The coordinated activity of the diaphragm with the back and abdominal muscles creates spinal and pelvic stability by means of intraabdominal pressure. Another important role of the of the trunk is the integration of breathing with spinal stability. The visceral organs are suspended and anchored within the trunk (spine and ribcage) and are interconnected with the trunk muscles though the fascial network.


Many people associate the core with the abdomen, however its genuine location is in the muscles that connect the trunk to the lower extremities via the pelvis. The core is a functional unit of the body which has multiple functions:

1. Spinal stability
2. Lumbopelvic/hip stability
3. Control of basic rotation
4. Functionally connects the upper body to lower extremities


The trunk, made up of the ribcage and thoracic spine, forms an anatomical, functional and physiological crossroads for the entire body, and connects the lower and upper body. The natural, reciprocal movement of walking could not be achieved without these intricate trunk connections. The body’s rotation occurs mainly in the trunk, as does the integration of breathing. The body’s core muscles are also part of the trunk.



Symptoms of middle back pain may vary in location and intensity depending upon which structures are generating pain.

Middle back pain can be divided into five categories:











The most common type of middle back pain is myofascial, followed by vertebrogenic pain (involving the spinal joints) and vertebro-costal pain (involving the rib joints).
Middle back pain can also arise from neurogenic or neural origins that may involve a thoracic herniated disc, although this is very rare. Viscerosomatic pain can sometimes arises from visceral (internal) organs.

Intercostal neuralgia
(irritated nerves in the area between ribs)


Slipped rib syndrome


There is also viscerosomatic pain that arises from visceral (internal organs) organs. However, what is more common is viscerosomatic pain in the mid-back.

Risk factors

  • Inefficient workspace ergonomics
  • Poor posture
  • Paradoxical breathing
  • Trauma
  • Disorders of the neck and low back
  • Organ disease or dysfunction



Because middle back pain arises at the anatomical and functional crossroads of the human body, treatment requires a whole-body integrative approach. At NYDNR, we are proud of our high success rate of quickly resolving pain and restoring function. We use a combination of DNS (Dynamic Neuromuscular Stimulation), ISM (Integrated Systems Model), myofacial release techniques, chiropractic, acupuncture, and ESWT (Extracorporeal Shock Wave Therapy).

Because the trunk (thorax) plays a critical role in the healthy function of the entire musculoskeletal system, it is important, once pain has been banished, that therapists focus on restoring strength, flexibility and motor control to this area.

We are proud to be at the forefront of holistic rehabilitation for middle back disorders.


Meet C.A.R.E.N, our computer assisted rehabilitation environment. C.A.R.E.N takes patient diagnosis and treatment to a whole new level by challenging motor neurons to adapt. First developed by the US military to help wounded warriors recover from amputations and other extremity traumas, C.A.R.E.N is now available to the public.

Because human gait patterns can be impaired by trauma, disease, or age-related natural decline, gait analysis helps physical therapists identify impaired gait patterns. C.A.R.E.N then provides a virtual reality environment for purposes of rehab. Rather than walking on a treadmill against the backdrop of the sights, sounds and smells of a clinical environment, C.A.R.E.N patients are engaged and motivated as they steer a boat across a tranquil lake, drive a car down a city street, or take a nature hike along a rocky path. C.A.R.E.N provides patients with a positive virtual reality rehab experience that translates to dramatically improved gait, balance and coordination.


From research we know that people with Low back pain (lbp) belong to different categories (or groups) and therefore should be treated with individual approach.

C.A.R.E.N can successfully facilitate treatment of people with LBP which belong to following categories:

  1. 1. insufficient dynamic core activation
  2. 2. excessive core activation
  3. 3. Low back pain which results from gait (walking) impairment due to asymmetrical weight bearing such as with adaptation to healing by unweighting the injured extremity as well as many other types of weight bearing asymmetry
  4. 4. Loss of balance
  5. 5. Gravitational / postural disorders where there is an uneven distribution of trunk versus pelvis and feet as well as loss of control of the center of mass (COM) ober base of support (BOS) Lumbar fatigue: (rephrase for explanation) or may be leave it but isnt it to long?

Protection against spinal injury requires proper anticipation of events, appropriate sensation of body position, and reasonable muscular responses. Lumbar fatigue is known to delay lumbar muscle responses to sudden loads. Patients with chronic low back trouble had significantly poorer ability than control subjects on the average to sense a change in lumbar position, which was noticed before and after the fatiguing procedure. This feature was found in patients and control subjects, but patients with low back trouble had poorer ability to sense a change in lumbar position than control subjects even when they were not fatigued.


At NYDNR we use diagnostic ultrasonography to visualize tendons, ligaments, bursas, muscles and plantar fascia of the foot. We also use sophisticated video gait analysis technology to visualize and measure: forces acting on the foot, shock absorption, foot and whole lower kinetic chain mechanics.


Redcord Neurac therapy

Redcord Neurac Therapy:
Suspension Training Meets Physical Therapy for Rehab, Fitness and Performance
Your body is a masterpiece of form and function, designed to move in fluid and coordinated patterns governed by your nervous system. But oftentimes, overuse, underuse or abuse of your muscular system can result in pain, injury, uncoordinated movement and poor performance. Thankfully, through proper training and rehabilitation, your miraculous body is able to heal and recoup its natural functional capacity.



In this instance, an athlete was originally diagnosed with minor quadriceps muscle strain and was treated for four weeks, with unsatisfactory results. When he came to our clinic, the muscle was not healing, and the patients’ muscle tissue had already begun to atrophy.

Upon examination using MSUS, we discovered that he had a full muscle thickness tear that had been overlooked by his previous provider. To mitigate damage and promote healing, surgery should have been performed immediately after the injury occurred. Because of misdiagnosis and inappropriate treatment, the patient now has permanent damage that cannot be corrected.

The most important advantage of Ultrasound over MRI imaging is its ability to zero in on the symptomatic region and obtain imaging, with active participation and feedback from the patient. Using dynamic MSUS, we can see what happens when patients contract their muscles, something that cannot be done with MRI. From a diagnostic perspective, this interaction is invaluable.

Dynamic ultrasonography examination demonstrating
the full thickness tear and already occurring muscle atrophy
due to misdiagnosis and not referring the patient
to proper diagnostic workup

Demonstration of how very small muscle defect is made and revealed
to be a complete tear with muscle contraction
under diagnostic sonography (not possible with MRI)


Complete tear of rectus femoris
with large hematoma (blood)


Separation of muscle ends due to tear elicited
on dynamic sonography examination

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