One of the more common complaints I hear from people when they come to see me is of a chronic pain, one right between or just below the shoulder blades in the upper back. It’s usually dull, but can sometimes be sharp, and is usually at it’s worst later in the day. While it is most often found in writers, students, and people who spend long periods behind either the wheel or the keyboard, it has also shown up in dancers, athletes, and hobbyists of all kinds. What is this pain, how does it come to be, and what can be done about it? These are the questions that will be addressed in this addition to the Caveman Medicine Blog.
Upper Back Pain – What is it?
The reason why upper back pain is so persistent and so hard to completely eliminate on one’s own is because it involves muscles, fascia, and repetition. As the muscles become tight and stiff (the how’s of which will be explained in the next section), the lack of movement causes pressure to build in those muscles and the tissues around them. This pressure causes nearby structures to be impinged and otherwise negatively effected which the body then translates as pain and discomfort. As the tension continues to affect the area, the body will start to stiffen the connective tissue as well, in an effort to aid the body in maintaining the adopted posture. This further increases the tension and pressure in the area leading to more pain while simultaneously making it harder to find relief. This pattern of ever-increasing tension and pain often continues until eventually some other structure in the area gives, leading to a sharper, more acute pain that is often what finally causes the person to seek treatment.
Some common examples of this type of injury include torn labrums, rotator cuff injuries, rib head subluxations (which can often be triggered by something as innocuous as a sneeze), or even vertebral disc issues. While these conditions can all be treated on their own, independent of treating the tight muscles, failure to address the muscles as part of the treatment and recovery process increases the odds the injury or condition will return.
How Does It Happen?
The most important thing to remember about the body when dealing with this type of situation is that it exists in a constant state of balance. Our muscles are like cables attached to pulleys and for every muscle that pulls something one way, there is another muscle that performs the opposite action. Even when we are perfectly still, there is a constant application of force by these muscle pairings that hold us in whatever position we may find ourself in. If one muscle in a pair is considerably tighter and/or stronger than it’s opposing muscle, then this will usually result in one of several outcomes, depending on lifestyle, general health, and time involved.
The most common result is low level muscle strain in the weaker muscle, not enough to keep the muscle from functioning, but enough to limit it as well as cause chronic pain and discomfort. This is a direct cause for the second result, which is an increased rigidity in the connective tissue. When this occurs, it is a sign that the strain has become constant enough that the body is trying to correct for it by using the connective tissue as a splint in an effort to take some of the pressure off. By stiffening this tissue, the muscle does have some of the strain reduced, but at the cost of range of motion and it can no longer fully relax. This increases the pressure in the area over time and leads to increased discomfort in the long term as well as allowing for the formation of adhesions (which are more permanent connections between the muscles and connective tissue and require much more work to reverse).
As this tension continues to affect the body, over time the constant pulling of the tense muscles on the joints themselves will start to have a negative effect on joint stability and integrity. In many cases, a joint can become loose enough to allow for minor, incomplete dislocations (such as in a ‘rib out’ where the head of a rib dislocates from between two vertebrae). While these often aren’t serious, they can be very painful when they occur and often require outside intervention to reverse. The greater problem is when the constant force in an area like the shoulder weakens the connective tissue in that joint to the point where serious damage can occur, damage which often requires surgery to repair and which can permanently weaken the joint.
The most counter-intuitive aspect of this type of situation is how it is often the result not of some sports-related accident, car crash, or other large moment in one’s life, but instead it is something that builds slowly over time, usually exacerbated by daily habits, including one’s workout. As I said above, the body maintains posture through the balance of muscles pulling against each other. What many people don’t know or realize is that any time we hold one position for an extended period of time, the muscles involved in holding us in that position gain strength. Picture someone working at a computer. His or her arms are extended in front of his or her body and the palms are facing the keyboard. In this position, the primary muscles groups that are being engaged are those of the chest and the flexors and internal rotators of the shoulders. Over time, especially as these muscles become tired from holding in this position, other muscles will become recruited, like those in the tops of the shoulders, to make this posture easier to maintain. As those muscles wear out, the connective tissue will start to stiffen, also making the posture easier to maintain.
Unfortunately, as these muscles become stronger and this posture becomes more pronounced and easier to hold, the muscles that pull a person out of this position are simultaneously being put under more and more stress while also becoming weaker. This leads to increased strains and stiffness, which causes increased discomfort. If a sudden or rapid movement is forced on these areas of the body, the injuries that occur are much more likely to appear in the back of the shoulders than the front, since those muscles are under increased strain. While the shoulder itself is the most common location for this type of injury, the rhomboids (the muscles between the shoulder blades) can often be affected as well, leading to that very familiar tension in the upper back that can sometimes be a cause of issues like headaches and a stiff neck in addition to localized discomfort.
Another factor which can aggravate this condition is one that you may not suspect: exercise. The reason for this is, as mentioned above, the muscles in the front of the shoulders are often far stronger than the ones in the back. But when people work out, they often spend far more time building up the chest, shoulder, and arm muscles that are already strong while neglecting the weaker ones. Push-ups, bench press, bicep curls – these exercises can all aggravate an existing muscle strength disparity, especially if they are not performed properly or are done at far higher intensity than exercises that work the opposing muscles.
What To Do About It
Fortunately, there are a lot of things that can be done to treat this condition. Acupuncture, massage, and cupping can all be very helpful in relieving the discomfort associated with this type of muscles tension and for reversing any connective tissue adaptations that may have occurred. For long term relief, however, the only reliable method of treatment is through stretching and exercise. In the section below, I’ve included several stretches which can relax the muscles in the chest, shoulders, and upper back as well as exercises to build up the muscles in the back and posterior shoulders. The biggest things to realize are that it’s better to do less than more, as long as you are doing something every day, and to keep in mind that the goal is to build up the muscles of the back and shoulders while relaxing the chest. This is especially important to keep in mind when doing the push-ups (which can work the entirety of the upper torso when done correctly, which unfortunately, few of us are taught to do).
The Doorway Pec Stretch
This is one of the easiest and most effective stretches for the chest. Find a doorway and place your toes so that they are level with the doorframe. Now rest the forearms against the door frame. Your elbows should be bent to about 90° and should be about level with your nipples (or 5th rib space). Now let gravity do the work as you fall forward, being supported mostly by your arms. If done correctly, you should feel a gentle stretch across the chest and front of the shoulders and your shoulder blades should be drawn together in the back. Do this stretch for about 30 seconds at a time and whenever you feel it is necessary.
Levator Scauplae Stretch
This one can be intense so be careful with it. The first thing you will want to do is find something that weighs between five and ten pounds. It can be a weight, a water jug, or even the edge of a counter. The key is that whatever you choose, it’s heavy or immobile enough so that you can tell if your shoulder muscles engage. So first, take your chosen object in your left hand. The shoulder should be as low and relaxed as possible. Next, tilt your head to the right. This may be enough for you to feel a stretch. If it isn’t, then take your right arm and extend it straight out to your side. Bend the elbow and place your palm on your ear. DO NOT PULL! Instead, let gravity provide the force as the combined weight of your head and arm increase the stretch on the left side of your neck. If you feel your left shoulder start to rise, take a breath and try to relax it back down. After ten seconds, gradually come out of the stretch. Switch arms and repeat the stretch for the other side of the neck.
The first few times you do this stretch, you might feel some discomfort in your neck. This is due to the connective tissue being stretched as well as the muscles. The pain should fade relatively quickly. Be aware there is a chance to overstretch with this movement so proceed very, very slowly. If the pain on the stretched side feels especially hot, there might have been a tangle in the connective tissue that tore (this is not a bad thing, just uncomfortable). If that is the case, running an ice cube over the area can help reduce discomfort.
Standing Lateralis Stretch
Stand with your feet about hips with apart and raise your hands over your head until your arms are mostly straight. Take the right wrist in your left hand and do a side bend slowly over to the left with your right hip jutting to the right. If done correctly, you should feel a stretch through the ribs and muscles in the right side. Reverse the directions to stretch the left side. Hold each side for about 5 to 10 seconds, switching once and repeat once or twice a day.
Stand with your feet hips distance apart (this one can also be done in the seated position once you have it down). Now raise your hands directly above your shoulders with the palms facing forward. Once the arms are fully extended, pull the arms down so that your elbows are bent and are alongside the body. You should feel the shoulder blades coming together as the arms come down. As you bring the arms down, come down slowly like you are moving through molasses. If you feel unsure about this stretch, perform it with your back against a wall so that your arms are in contact with the wall throughout the movement. Repeat as often as you feel you need to.
This is one of the best exercises for balancing out the strength differences between the front and back of the shoulders. If you have access to a gym, you can use the standard upright row machine, with a few caveats. First, make sure you are using a weight that you can move comfortably. If you are grunting and straining, it’s too much. These muscles tend to be weak, so especially when starting out, too little weight is preferable to too much. Second, don’t hyper extend the chest. When lowering the weight, stop the movement when the arms are completely extended. If your chest moves forward, you’ve gone too far.
If you don’t have access to a gym, or if your gym doesn’t have the right equipment, there is still a variation you can do. You can use free weights, resistance bands, or even water bottles or cans of food for this. Start by standing with your feet shoulder distance apart with the weights about a foot in front of your feet. Now bend through the hips (not the waist) until your upper body is perpendicular to the floor. Reach down and take the weights. Then, with your palms facing each other and your hands under your shoulders, bring your hands towards your shoulders. Your arms and shoulder blades should be the only parts moving during this exercise. Try to use a weight that allows for 15-20 repetitions and multiple sets. Finally, when you are finished, but before you straighten up, release the weights to avoid straining the low back.
This is another exercise that will help build up the muscles of the upper back and shoulders, which in turn will balance out the muscles of the chest and help maintain proper posture. There are several variations that can be done depending on one’s preferences, limitations, and equipment available. The most important factors to keep in mind are that the back should be straight (but not rigid) between the hips and the neck, doing more reps with less weight is better than doing fewer reps with a higher weight (this exercise can be done with no weight at all if necessary and still be effective), and if at any time the breathing becomes rapid or labored, then it’s time to take a break.
As mentioned above, there are several positions this exercise can be done in. The most common position is standing with the knees slightly bent, the waist bent to 90°, and the upper body parallel to the floor. The arms should be hanging perpendicular to the floor, hanging straight down from the shoulders, with the hands directly below the shoulder joint. Another common variation is to lay on one’s stomach on a weight bench, which will often limit the range of motion, but allow for much less stress to be placed on the low back. A third variation is to lay on one’s stomach on the floor with the arms stretched out at a 90° from the body with the hands parallel to the shoulders on the horizontal plain.
There are some basic elements in performing this exercise that remain the same regardless of which position is chosen. The primary focus of this exercise should be shortening the muscles in the back of the shoulders and between the shoulder blades. If starting from a standing position or lying on a bench, the hands should hang directly below the shoulders with the the palms facing each other and the thumbs parallel to each other and pointed forward. If no weight is being used, then gently curl the hands into fists while performing the following movement. Bring the shoulder blades together as you move the arms from a perpendicular position to the floor to a parallel one. As you do this, the arms should remain slightly bent at the elbows and remain at a 90° to the body at all times. Also, as the arms move up away from the floor and the shoulders come together, there will be tendency for the shoulders to come up towards the ears. This can be stopped by pushing the chest out as the arms come up. Once the hands are slightly higher than the body, slowly release them back to the starting position. A good pace to keep is to perform the first motion on the inhale and bring the arms back down on the exhale with a slight pause at both the top and the bottom.
If lying flat on the floor, this is performed as a micromovement. By contracting the muscles between the shoulder blades and in the backs of the shoulders, the arms will lift slightly off the ground until they are higher than the shoulders. As long as the muscles are engaging, the benefits from this exercise will be there, in spite of the smaller range of motion when performed this way.
Push-ups can be an incredible exercise for working both the core muscles as well as those of the chest and upper back, but they can just as easily create muscle imbalances if done incorrectly. The biggest problem most people face when performing this exercise is that they have a tendency to focus on moving the body up and down and in doing so, lose focus on maintaining the proper form needed to get the most positive benefits from the exercise.
To properly execute this exercise, lay face-down on the floor with the hands directly below the shoulders. Engage the muscles of the core by drawing the belly button in towards the spine while simultaneously drawing the muscles from the sides of the abdomen towards the center. This will help keep the back straight and prevent excessive lumbar curve. The preferred execution of this exercise is balance on the toes, but if the muscles of the upper body aren’t developed enough to do this, balancing on the knees is also acceptable.
So, whether using the toes or the knees, straighten the arms while keeping the elbows tight against the sides of the body. There will be a temptation to allow the elbows to move perpendicular to the torso, especially as fatigue sets in, but by allowing this to happen, the shoulders will start to rise, and neck and shoulder issues can develop as a result. Continue to straighten the arms until they are almost completely straight, but do not lock the elbows. Pause here as this is the point to start doing push ups.
Allow the arms to slowly bend, again making sure they are tight against the torso, while gently lowering the chest towards the floor. Go down as far as feels comfortable with the goal of touching the tip of the nose to the floor. As the body descends, the shoulder blades should move towards each other. Pause at the bottom before straightening the arms and returning to the starting position.
There are several things to keep in mind while performing this exercise. The back should remain as straight as possible. If the belly starts to sag during the course of the movements, this is a sign that fatigue is setting in. Breathing is also important, so inhale during the descent and exhale upon rising back to the starting position. As mentioned, the elbows should stay tight against the body throughout the movement. If any of this becomes difficult to maintain during the course of the movement, it is better to stop than to continue to do the exercise incorrectly. 25-50 repetitions 3 to 4 times a week should be enough to develop and maintain good upper body strength, but only as long as they can be done correctly. Keep in mind that even working towards this point will aid in developing the muscles so it’s a goal, not a starting point.
So hopefully you now have a somewhat better idea of both the causes and some solutions to the issue of chronic upper back pain. For more information and exercises, I’d recommend also checking out my guide to the shoulder. For those of you with the resources available, working with a physical therapist or personal trainer can also be extremely helpful, but since that isn’t always an option, my goal with this was to give people some tips for dealing with it using the resources they do have. I hope it helps, and as always, if you have any questions, feel free to email me at cavemanmedicine @gmail.com.