Physical Therapy for Upper Back Pain: From Injury to Overuse

Upper back pain, which can include thoracic spine pain, often takes a backseat to more prevalent cervical and lumbar complaints in physical therapy settings. However, it represents a significant, though less common, challenge for physical therapists (PTs) and patients alike.

Consider one study of more than 9,000 participants where 8% of respondents indicated that upper back pain specifically was a primary source of chronic pain. Comparatively, 54% of respondents in the same study noted low back pain as their primary source of chronic pain. Given that upper back pain may not be a daily occurrence in every physical therapy practice, it’s important to have accessible guidance when patients do present with this issue.

This guide aims to fill that guidance gap, serving as a key resource for PTs like you on the proper assessment considerations, evidence-based treatment strategies, and coding requirements necessary to confidently and effectively manage patients presenting with upper back pain.

Understanding Upper Back Pain

The thoracic spine, or upper spine, is a critical region comprising 12 vertebrae directly connected to the rib cage. This inherent stability, while limiting motion compared to the cervical and lumbar spine, serves vital purposes: protecting internal organs like the heart and lungs, and facilitating respiration.

Given its unique biomechanics, upper back pain often stems from musculoskeletal issues such as muscle strains, ligament sprains, spinal injuries, or dysfunction in the facet or rib joints. Poor posture, like excessive kyphosis, is another frequent contributor. Less common, but still important, considerations include injuries and conditions like disc herniations, compression fractures (particularly in older adults), and scoliosis.

Physical Therapy for Upper Back Pain: Assessment

A thorough assessment is paramount for effective physical therapy intervention for upper back pain as it informs accurate diagnosis and targeted treatment. A comprehensive assessment encompasses both a detailed subjective history and a systematic objective examination.

Notably, always remember to screen for red flags—symptoms like unexplained weight loss, unrelenting night pain, or progressive neurological deficits—which necessitate immediate medical referral to rule out serious underlying conditions. Though persistent back pain without clear red flags may still indicate a more serious issue.

Subjective Examination

The subjective history provides important insights into the patient’s pain experience and functional limitations.

• Pain characteristics: Ask about the exact location, quality (e.g., sharp, dull, aching), and intensity (using a pain scale) of the pain, what exacerbates or alleviates the pain, and how it fluctuates throughout a 24-hour period.
• Mechanism of injury: Determine the onset of symptoms, whether acute (e.g., specific trauma, sudden movement) or insidious (gradual onset without a clear trigger), and if repetitive movements are involved.
• Aggravating activities: Identify specific postures or movements that worsen symptoms, such as prolonged sitting or standing, deep breathing, coughing, sneezing, or arm movements above shoulder height.
• Functional limitations: Understand how the upper back pain impacts the patient’s daily life, including their ability to perform work duties, activities of daily living (ADLs), and recreational pursuits. This helps in setting patient-centered goals.
• Medical history review: Gather information on prior injuries, relevant surgeries, comorbidities (e.g., inflammatory conditions, osteoporosis), and current medications, and critically, conduct a thorough red flag screening, as noted above. Questions should aim to rule out serious systemic or neurological pathology (e.g., unexplained weight loss, fever, bowel/bladder changes, progressive weakness).

Objective Examination

An objective examination assesses the physical impairments contributing to upper back pain.

• Observation and postural assessment: Observe the patient’s static posture (e.g., head position, shoulder alignment, thoracic kyphosis, scapular symmetry) and dynamic posture during functional movements. Note any altered breathing patterns.
• Palpation: Systematically palpate for tender points, muscle spasm, and tissue texture abnormalities along the thoracic spine, ribs, sternum, and surrounding musculature (e.g., paraspinals, rhomboids, trapezius).
• Range of motion (ROM): Assess active and passive ROM of the thoracic spine in all planes (flexion, extension, rotation, lateral flexion). Also, evaluate relevant cervical and lumbar ROM, considering their interconnectedness.
• Neurological screen: Perform a neurological screen including dermatomal sensation, myotomal strength, and deep tendon reflexes if there are any signs or symptoms suggesting nerve root involvement or myelopathy (e.g., radiating pain, numbness, weakness).
• Special tests: Utilize specific tests to confirm suspicions, such as rib springing for costovertebral dysfunction, the thoracic slump test for neural tension, or upper limb tension tests if symptoms radiate into the arm. If testing remotely, be sure to follow telehealth best practices such as adopting proper “webside manner” and mitigating fall risks in the patient’s general vicinity.
• Strength assessment: Evaluate the strength of key muscles, including deep neck flexors, scapular stabilizers (e.g., serratus anterior, lower trapezius), and core musculature, as their weakness can contribute to thoracic dysfunction.
• Joint mobility assessment: Perform specific joint play assessments, including posterior-to-anterior intervertebral mobilizations and passive physiological intervertebral movements of the thoracic spine. Assess rib mobility as well.

Evidence-Based Treatment Interventions for Upper Back Pain

Effective physical therapy for upper back pain integrates a multimodal approach that combines manual therapy, therapeutic exercise, judicious use of modalities, and comprehensive patient education.

Manual Therapy

Manual therapy techniques aim to restore joint mobility, reduce muscle tension, and alleviate pain.

• Mobilizations and manipulations: Grade I-IV mobilizations and high-velocity low-amplitude thrust manipulations can be applied to the thoracic spine, ribs (costovertebral and costotransverse joints), and cervicothoracic junction. Indications often include joint hypomobility, segmental stiffness, and localized pain. Contraindications include recent fracture, osteoporosis, malignancy, unhealed surgical sites, and signs of neurological compromise (e.g., myelopathy).
• Soft tissue mobilization: Techniques like myofascial release, trigger point pressure release, and instrument-assisted soft tissue mobilization target dysfunctional paraspinal, scapular, and intercostal muscles. These interventions aim to decrease muscle spasm, improve tissue extensibility, and reduce local tenderness. Dry needling, if within a therapist’s scope of practice, can also be effective for myofascial trigger points.

Therapeutic Exercise

Active therapeutic exercise is essential for long-term pain management and functional restoration.

• Mobility exercises: Focus on restoring full, pain-free movement. Examples include thoracic extension over a foam roller, cat-cow stretches, and “thread the needle” rotations to improve spinal and rib mobility.
• Strengthening exercises: Address muscle imbalances and improve stability. Key areas include scapular stabilization (such as rows), deep neck flexor strengthening, and core muscle engagement (e.g., planks, bird-dog).
• Postural correction: Provide specific education and exercises to promote optimal sitting and standing posture. This includes ergonomic advice for work and daily activities to minimize sustained stress on the thoracic spine.
• Breathing exercises: Diaphragmatic breathing retraining can significantly improve rib cage mobility, reduce reliance on accessory breathing muscles, and alleviate pain associated with restricted respiration.

Modalities

Modalities can serve as adjuncts to facilitate other interventions, primarily for pain relief and tissue preparation.

• Heat/cold therapy: Application of heat (via moist hot packs) can promote muscle relaxation and increase circulation, while cold therapy (via ice packs) can reduce acute pain and inflammation.
• Electrical stimulation: Transcutaneous electrical nerve stimulation (TENS) can be used for pain modulation by interfering with pain signals.
• Ultrasound therapy: Therapeutic ultrasound can be applied for deep tissue heating, particularly in chronic conditions, or for non-thermal effects to promote tissue healing. Its use should always be evidence based and judiciously applied.

Patient Education

Empowering patients through education is fundamental for self-management and sustained recovery.

• Pain neuroscience education: Explain the complex nature of pain, emphasizing that pain does not always directly correlate with tissue damage, especially in chronic conditions. This helps to reduce fear-avoidance behaviors and promote active participation.
• Self-management strategies: Teach patients practical strategies for managing their symptoms, including activity modification, stress reduction techniques, and proper body mechanics during daily tasks.
• Importance of consistency: Stress the long-term benefits of consistent adherence to home exercise programs, postural awareness, and ergonomic principles to prevent recurrence and promote lasting functional improvement.

Documentation and Coding Essentials for Upper Back Pain

Precise documentation and accurate coding are fundamental for physical therapists treating upper back pain, ensuring compliance, justifying medical necessity, and optimizing reimbursement.

Understanding Upper Back Pain Diagnoses

Selecting the most specific and appropriate ICD-10-CM codes is critical.

• ICD-10-CM codes: For general thoracic pain, M54.6 (pain in thoracic spine) is a common and billable code. However, whenever possible, strive for greater specificity. For example, use:
  • S29.012A (strain of muscle and tendon of back wall of thorax, initial encounter) for acute muscle strains
  • M40 (Kyphosis) or M41 (Scoliosis) for postural deformities
  • M51.14 (intervertebral disc disorders with radiculopathy, thoracic region) if nerve root involvement is present
  • R29.3 (abnormal or imperfect posture) for postural syndromes
• Sequelae of conditions: Differentiate between acute and chronic pain. While M54.6 can apply to both, consider using G89.21 (chronic pain due to trauma) in conjunction with M54.6 or other relevant codes when managing chronic thoracic pain requiring specific chronic pain management strategies.

CPT Codes for Physical Therapy Interventions

Accurate CPT coding reflects the skilled services you provide.

• Evaluation and re-evaluation codes: Select 97161 (low complexity), 97162 (moderate complexity), or 97163 (high complexity) for initial evaluations based on history, examination, and clinical decision-making complexity. Use 97164 for re-evaluations.
• Therapeutic exercise (97110): Document specific exercises, repetitions, sets, and progression, demonstrating the skilled instruction needed.
• Manual therapy (97140): Detail the specific techniques (e.g., mobilization, manipulation, soft tissue release), body regions treated, and the clinical rationale for their application. This code is timed (per 15 minutes).
• Therapeutic activities (97530): Use for dynamic, functional activities directly related to improving patient function (such as reaching, lifting, or bending) specific to upper back pain. This is also a timed code.
• Neuromuscular re-education (97112): Appropriate for addressing movement patterns, balance, coordination, or postural control issues related to upper back pain. This is another timed code.
• Modalities:*
  • Hot/cold packs (97010): Unattended modality, typically not billable alone.
  • Electrical stimulation, unattended (97014) or electrical stimulation, manual (97032): Depending on therapist presence.
  • Ultrasound (97035): Timed, for therapeutic ultrasound application.

*Modalities should always support a skilled intervention and demonstrate medical necessity.

Documentation Best Practices

Robust documentation is your primary defense for services rendered and should always include:

• Medical necessity. Every intervention must be clearly linked to the patient’s diagnosed impairments and functional goals. Justify why skilled physical therapy is required over unskilled care.
• Goal setting. You can establish SMART goals—these are specific, measurable, achievable, relevant, and time-bound—that outline expected functional improvements. For example: “Patient will independently perform overhead reaching for 10 minutes without pain (from current two minutes with pain) within four weeks to improve ability to dress.” These should also be specific to the patient, keeping in mind what they specifically want to get out of their physical therapy.
• Progress notes. Consistently provide objective measurements of progress (e.g., increased ROM, improved strength scores, functional task completion) and clearly justify any modifications to the plan of care to demonstrate ongoing skilled intervention.
• Communication with referral sources. Maintain clear and concise communication through initial reports, progress notes, and discharge summaries to ensure coordinated care and justify continued therapy.

Physical Therapy for Upper Back Pain: Better Outcomes

Treating upper back pain, while it presents unique assessment and intervention challenges, offers profoundly rewarding outcomes for physical therapists and patients. By embracing the above principles and guidance, you can confidently manage upper back cases in your physical therapy patients and optimize their recovery. Keep in mind that as research continues to deepen our understanding of upper back injuries and thoracic spine dysfunction, the effectiveness of physical therapy interventions for upper back pain will only continue to evolve and strengthen.