What could be the cause of recurrent mid‑thoracic back pain for two years with associated upper right and left quadrant abdominal pain, breast pain, and normal imaging including multiple magnetic resonance cholangiopancreatography (MRCP) studies?

Chronic Thoracic Back Pain with Multifocal Pain and Normal Imaging: Likely Musculoskeletal or Functional Pain Syndrome

Given two years of recurrent mid-thoracic back pain with upper quadrant abdominal and breast pain, plus multiple normal MRCPs and imaging studies, this presentation most likely represents chronic thoracic back pain without red flags—a condition where further advanced imaging is not indicated and conservative management should be prioritized. 1

Clinical Context and Imaging Appropriateness

According to the 2024 ACR Appropriateness Criteria for thoracic back pain, in adults with subacute or chronic thoracic back pain without myelopathy, radiculopathy, or red flags, imaging is typically not indicated 1. Your case fits this profile precisely:

• Duration: Two years (chronic, >12 weeks) 1
• No neurologic deficits: No mention of myelopathy or radiculopathy
• Extensive negative imaging: Multiple MRCPs and other studies are normal
• Diffuse pain pattern: Multiple sites without clear anatomic correlation

The guidelines explicitly state there is no relevant literature supporting the use of MRI thoracic spine (with or without contrast), CT, bone scans, or other advanced imaging in chronic thoracic back pain without red flags or neurologic deficits 1.

What This Pain Pattern Suggests

Musculoskeletal Origin Most Likely

The combination of mid-thoracic back pain with upper quadrant abdominal pain and breast pain, in the absence of imaging abnormalities, strongly suggests:

1. Thoracic spine-related referred pain: The lower thoracic and thoracolumbar segments (T6-T12) innervate the upper gastrointestinal tract and upper abdominal wall. Research demonstrates that 72% of patients with functional upper abdominal pain have concurrent back pain, with 75% showing physical examination abnormalities in the lower thoracic/thoracolumbar spine 2. This viscerosomatic connection can create referred pain patterns mimicking intra-abdominal pathology.

2. Costochondral or intercostal involvement: Breast pain without masses often originates from chest wall structures, particularly when associated with thoracic spine dysfunction.

3. Myofascial pain syndrome: Chronic, multifocal pain without structural abnormalities frequently represents myofascial trigger points in the thoracic paraspinal muscles, intercostals, and chest wall.

Critical Differential Considerations (Already Excluded by Your Workup)

While rare structural causes can present with chronic thoracic pain and abdominal symptoms, your extensive imaging has effectively ruled out:

• Thoracic spinal cord tumors: Can cause chronic abdominal pain for years 3, 4, but would be visible on MRI
• Thoracic radiculopathy from structural lesions: Foraminal stenosis, disc herniations, or tumors 5 would show on imaging
• Thoracic demyelinating lesions: Can rarely cause isolated abdominal pain 6, but MRI would detect these
• Biliary/pancreatic pathology: Multiple MRCPs have excluded this

Red Flags That Would Change Management

You should reconsider imaging only if new symptoms develop 1:

• Myelopathy signs: Gait disturbance, spasticity, hyperreflexia, positive Babinski, bladder dysfunction
• Progressive neurologic deficits: Numbness, weakness, sensory level
• Constitutional symptoms: Fever, night sweats, unexplained weight loss (suggesting infection or malignancy)
• Significant trauma: Even minor trauma in older patients or those with osteoporosis risk
• Age >65 years with new-onset pain: Higher risk for compression fractures 1

Recommended Management Approach

Since imaging is not indicated and structural pathology has been excluded:

1. Physical therapy focused on thoracic spine mobilization and postural correction
2. Myofascial release techniques targeting thoracic paraspinal muscles and chest wall
3. Trial of NSAIDs or acetaminophen for pain control
4. Consider neuropathic pain medications (gabapentin, duloxetine) if pain has neuropathic features
5. Evaluate for functional pain syndrome if symptoms persist despite conservative measures
6. Psychological evaluation for chronic pain management strategies, as functional abdominal pain is strongly associated with thoracic spine dysfunction 2

Common Pitfall to Avoid

Do not pursue additional imaging studies (repeat MRI, CT, PET scans) in the absence of new red flags or neurologic changes. This leads to unnecessary radiation exposure, cost, and potential false-positive findings that trigger invasive procedures without improving outcomes 1. The extensive negative workup you've already completed is sufficient to exclude serious structural pathology.

The multifocal nature of your pain (back, bilateral upper quadrants, breasts) without anatomic correlation on imaging strongly supports a functional or musculoskeletal pain syndrome rather than a single structural lesion requiring surgical intervention.