What are the causes and treatment options for upper back pain between the scapula?

Upper Back Pain Between the Scapula

Initial Assessment and Red Flags

For acute upper back pain between the scapula without red flags, imaging is not warranted initially—conservative management should be pursued first. 1

Critical Red Flags Requiring Immediate Imaging

• Myelopathy symptoms: urinary retention, fecal incontinence, saddle anesthesia, or motor deficits at multiple levels require urgent MRI 2
• Malignancy risk factors: history of cancer (increases probability from 0.7% to 9%), unexplained weight loss, age >50 years, or failure to improve after 1 month 1, 2
• Infection indicators: fever, recent infection, intravenous drug use, or immunocompromised status 2
• Fracture risk: age >65 years, known osteoporosis, chronic steroid use, or significant trauma 1
• Prior thoracic spine fusion warrants early imaging 1

When to Consider Imaging Without Red Flags

• After 4-6 weeks of conservative treatment with little or no improvement 1
• MRI is preferred over CT for thoracic spine evaluation 1
• Plain radiographs should not be repeated more frequently than every 2 years unless specifically indicated 1

Common Causes of Interscapular Pain

Musculoskeletal Etiologies

Dorsal scapular nerve (DSN) neuropathy is an underrecognized cause of mid-scapular and upper back pain that presents with:

• Pain between the scapulae, often extending to the costovertebral region 3
• Possible scapular winging or atrophy 3
• Mechanism typically involves postural strain or overhead work/sport activities 3
• May present with dysesthesia in the affected area 3

Scapulothoracic disorders include:

• Scapulothoracic bursitis from trauma or overuse, causing inflammation and pain 4
• Snapping scapula syndrome with grinding, popping, or thumping sensations during scapular motion 4
• These conditions are often associated with glenohumeral dysfunction, muscle atrophy, or postural abnormalities 4

Systemic Conditions to Consider

Non-spine causes that can mimic thoracic spine pain include:

• Intrathoracic pathology 1
• Renal conditions 1
• Vascular etiologies 1
• Gastrointestinal disorders 1

Inflammatory arthropathies such as ankylosing spondylitis should be considered if inflammatory back pain features are present (see separate guidelines for axial spondyloarthritis) 1

Treatment Approach

First-Line Conservative Management

Remain active and avoid prolonged bed rest—this is more effective than rest for spine pain 1

NSAIDs are the first-line pharmacologic treatment for thoracic spine pain with inflammatory features:

• Continuous NSAID use is preferred for persistently active, symptomatic disease 1
• Consider cardiovascular, gastrointestinal, and renal risks when prescribing 1

Self-care measures include:

• Heat application via heating pads for short-term relief 1
• Evidence-based educational materials about the favorable prognosis of spine pain 1
• Postural correction and activity modification 3, 5

Second-Line Options for Persistent Pain

Physical therapy and rehabilitation targeting:

• Scapular strengthening exercises 4
• Postural reeducation 4
• Core strength and endurance training 4

For myofascial pain with suspected nerve involvement:

• Ultrasound-guided trigger point injections targeting trapezius, rhomboids, levator scapulae, and nerve hydrodissection have shown efficacy 5
• This approach is particularly effective for pain associated with anterior head carriage and upper crossed syndrome 5

Interventions to Avoid

Strong recommendations against the following for chronic spine pain (≥3 months):

• Joint radiofrequency ablation with or without steroid injections 1
• Epidural injections of local anesthetic, steroids, or their combination 1
• Intramuscular injections of local anesthetic with or without steroids 1

Corticosteroid considerations:

• Local corticosteroid injections directed at the site of musculoskeletal inflammation may be considered 1
• Systemic glucocorticoids for axial disease are not supported by evidence 1

Analgesics for Refractory Pain

Paracetamol and opioid medications should only be considered for residual pain after other treatments have failed, are contraindicated, or poorly tolerated 1

Surgical Considerations

Surgery is reserved for specific structural problems:

• Scapular angle resection for persistent snapping scapula syndrome unresponsive to conservative care 6, 4
• Partial scapulectomy or arthroscopic bursectomy for refractory scapulothoracic bursitis 4
• Most reports demonstrate good to excellent outcomes in appropriately selected patients 4

Clinical Pitfalls to Avoid

• Do not routinely image acute thoracic back pain without red flags—this provides no clinical benefit and incurs unnecessary expense and radiation exposure 1
• Do not delay imaging when red flags are present—immediate MRI is indicated rather than waiting 4-6 weeks 2
• Do not overlook dorsal scapular nerve neuropathy as a differential diagnosis for persistent interscapular pain, especially in patients with postural strain or overhead activities 3
• Do not pursue interventional procedures (epidural injections, radiofrequency ablation) for chronic spine pain, as strong evidence recommends against these interventions 1