Upper Right Back Pain: Causes, Symptoms, Treatment, Diagnosis

Back pain is a common complaint and is often caused by the diseases of skin, paravertebral muscles, facet joint and spinal nerves. bones. Back is divided into upper and lower back. Upper back is also known as thorax or rib cage and lower back is recognized as lumbar segment. Upper back spreads from first to twelfth thoracic vertebra in the midline and entire rib cage over the back or chest. Lower back spreads from first lumbar vertebra to coccyx. The upper right back pain can originate from skin, subcutaneous tissue, muscles, ribs, facet joint, spinal cord, spinal nerve and lungs. The most often upper right back pain is expressed as a sharp and stabbing pain. Occasionally pain is dull and generalized pain.

Upper right back pain originates from following anatomical tissues-

1. Skin and subcutaneous tissue,
2. Paravertebral and intercostal muscles on right side,
3. Ribs and facet joint on right side,
4. Thoracic spinal and intercostal nerve,
5. Pleura and lungs on right side and
6. Pain originates from lungs, liver, pancreas and right kidney

Most of the right upper back pain originates in skin, subcutaneous tissue, muscle, ribs, nerve and lung. The type and intensity of pain experienced in the upper right back varies from person to person and depends on the underlying cause. Upper right back pain can be of acute type that lasts less than 6 months or chronic pain that lasts more than 6 months.

1. Trauma
2. Muscular pain
3. Rib pain
4. Facet joint pain
5. Nerve pain
6. Lung Diseases
7. Gastrointestinal Diseases

1. Upper Right Back Pain Caused Due to Trauma

   1. Skin injury
   2. Subcutaneous tissue injury
   3. Paravertebral muscle injury
   4. Rib injury
   5. Traumatic injury of Scapula
   6. Thoracic spinal nerve injury and
   7. Lung injury.

   Upper back injuries resulting in mild to severe upper back pain are caused by automobile accident, work injuries, domestic fall and sport injuries. The trauma causes injuries of skin, subcutaneous tissue, paravertebral muscle, ribs, nerves and lung.

1. Skin Injury- Skin injuries over the upper right back causes mild to severe pain. Most skin injuries are caused during automobile or work accident. The common skin injuries observed are skin laceration, cut and bruises
2. Subcutaneous Tissue Injury- Subcutaneous tissue injury causes laceration and cut. The trauma in most cases causes bleeding and infection. Subcutaneous bleeding results in hematoma and infection may become cellulitis.
3. Paravertebral Muscle Injury- Vertebral column and ribs are protected by several muscles. Muscle trauma causes muscle spasm, laceration and tear. Such injury of right upper back causes moderate to severe pain.
4. Rib Injury- Rib injury is observed following domestic fall or sport injury. The rib trauma causes contusion, laceration or fracture. Such injuries on right upper back causes moderate or severe pain that is spread over right upper back.
5. Traumatic Injury of Scapula- Scapula covers 1/3rd of upper back on each side. Trauma causes bruises or fracture of scapula. The pain following injury of right scapula is always felt over right upper back.
6. Thoracic Spinal Nerve Injury²– The nerve injury is observed when accident causes penetrating wound that lacerate or cut the thoracic intercostal nerve.
7. Lung Injury- Lungs are covered by parietal and visceral pleura. Injury of pleura and lung causes pneumothorax, laceration of lung and bleeding. Such injury when occurs on right side causes right upper back pain. Most patients also complaint of difficulties in breathing.

2. Diseases of Skin and Subcutaneous Tissue²: Cause of Upper Right Back Pain

   1. Boil or furuncle
   2. Cellulitis
   3. Stings
   4. Impetigo
   1. Boil or Furuncle- Infection of sweat gland over right upper back causes infected swelling filled with pus. The boil is extremely painful and pain is felt over upper right back. Boil spreads in surrounding tissue and causes multiple furuncle or boil.
   2. Cellulitis- The infection of subcutaneous tissue often spreads into surrounding tissue including skin and muscles. Such infection frequently causes abscess in subcutaneous tissue.³ Such condition is known as cellulitis. Cellulitis of subcutaneous tissue over back of upper right side of chest causes severe pain. Cellulitis spreads wide in subcutaneous tissue if ignored and not treated with antibiotics.
   3. Stings- Wasp or honey bee sting over the upper back on right side causes swelling of the skin as well as subcutaneous tissue. The inflammation caused by such sting causes severe pain.
   4. Impetigo- Impetigo is a contagious painful condition. The disease causes pain and itching. The impetigo rapidly spreads over adjacent skin of upper back on right side when lesion forms a crust and secretions spreads to adjacent skin.

3. Muscular Pain: Cause of Upper Right Back Pain

   1. Muscle spasm
   2. Myofascial pain syndrome
   3. Fibromyalgia

   The upper back is covered by paravertebral thoracic muscles and intercostal muscles. The disease that causes muscular pain are muscle spasm, fibromyalgia, myofascial disease and trauma. The non-traumatic muscle injury is caused by repeated twisting and turning of back as well as maintaining abnormal posture of upper back. In few cases muscle spasm is trigger by lifting heavy object and overstretching.

1. Muscle Spasm- Fatigue or overuse muscles often undergoes severe contraction that results in muscle spasm. Abnormal posture or overuse of right upper back muscles causes muscle spasm and severe upper back pain.
2. Myofascial Pain Syndrome⁴– Myofascial pain syndrome is a degenerative muscle disease. The condition affects simultaneously several back muscles. Rarely one may suffer with isolated right upper back muscle disease that causes severe pain over right upper back.
3. Fibromyalgia- Fibromyalgia is caused by abnormal function of actin and myosin. Fibromyalgia causes wide spread pain and may also cause a pain in right side upper back.

4. Upper Right Back Pain Caused Due to Diseases of Rib and Facet Joint :

   1. Osteomyelitis
   2. Osteoarthritis
   3. Rheumatoid arthritis

   Rib pain in upper right back is caused by musculoskeletal diseases like osteoarthritis, and rheumatoid arthritis.

   1. Osteomyelitis- Osteomyelitis is an infection of bone. Osteomyelitis of vertebra, transverse process and spinous process causes severe pain.5 Osteomyelitis of rib and facet joint is rare condition. The severe pain is observed following inflammatory changes of ribs and facet joint over the right upper back. Such condition then causes severe pain that is spread over right upper back.
   2. Osteoarthritis- Osteoarthritis is a degenerative bone disease. Osteoarthritis mostly affecting facet joint and causes severe pain spread over right upper back. Osteoarthritis also causes inflammatory degenerative changes of joint where ribs are attached to vertebra. Occasionally osteoarthritis causes rib pain. Such pain may be observed on right upper back.
   3. Rheumatoid Arthritis- Rheumatoid arthritis is an autoimmune disease that mostly affects joint and cartilages. The rheumatoid arthritis rarely affects facet joint. Rheumatoid arthritis may cause inflammatory changes of joint that links ribs to vertebra. The condition is very painful and such pain rarely observed on right upper back.

5. Upper Right Back Pain Caused Due to Intercostal Nerve Diseases:

   1. Intercostal neuralgia
   2. Radicular pain
   3. Post herpetic neuralgia
   4. Post thoracotomy pain

   Disorders of the spine, intervertebral disc protrusion and damage to the disc causes irritation or pinch of spinal nerve that can cause upper right back pain. Compressed or pinched nerve is also caused by spinal stenosis, foraminal stenosis and pressure from vertebral tumor mas. Such disease when occurs on right upper back causes pain on right upper back. Spinal nerve continues as intercostal nerve.

   Intercostal Neuralgia- Intercostal neuralgia is a condition that indicates pain is spread along intercostal nerve. Thoracic spinal nerve comes out of vertebral column passes under the ribs. The nerve lies between intercostal muscle and is known as intercostal nerve.

   The causes of intercostal neuralgia are as follows-

   • Post-Herpetic Neuralgia or Post Shingle Neuralgia
   • Post Traumatic Neuralgia
   • Post Thoracotomy Neuralgia- Trapped intercostal nerve in scar tissue following thoracic surgery causes upper thoracic pain.

   Radicular Thoracic Pain- Radicular thoracic pain is caused by pinched or irritation of thoracic spinal nerve. The pinch or irritation is caused within spinal canal or intervertebral foramina.

   The causes of pinched or irritation of thoracic spinal nerve-

   • Thoracic intervertebral disc bulge or herniation
   • Thoracic intervertebral foraminal stenosis
   • Thoracic spina stenosis
   • Epidural hematoma, abscess or cancer

6. Lung Diseases That Can Cause Upper Right Back Pain

   1. Pleuritis
   2. Pneumonia
   3. Pleural Effusion
   4. Lung Cancer

   Respiratory conditions or lung infections on right side can cause chest pain and upper right back pain. Lung infection or cancer associated with cough, difficulty in breathing and sometimes fever.

1. Pleuritis- Pleura is a thin membrane covers lungs and the chest wall. The pleura that covers lung is known as visceral pleura and one covers chest wall is known as parietal pleura. Infection or inflammation of pleura is known as pleuritis. Pleuritis of right sided pleura causes symptoms of right upper back pain.
2. Pneumonia⁶– Lung infection is known as pneumonia. Right lung pneumonia causes right side chest pain, cough and fever.
3. Pleural Effusion- Pleural effusion is collection of fluid between parietal and visceral pleura. Such condition is observed when individual is suffering with inflammation of pleura or heart failure. Right sided pleural effusion causes right upper back pain and short of breath.
4. Lung Cancer- Right lung cancer causes pain over right upper back.

7. Gastrointestinal Diseases That Can Cause Upper Right Back Pain

   1. Liver disease
   2. Cancer of pancreas
   3. Gall stone and
   4. Gall bladder infection
   5. Right kidney stone

   Diseases of liver, pancreas and gall bladder causes refer pain that is often felt over upper right back.

1. Liver Disease- Liver disease like hepatitis and cancer of liver causes pain over right upper back.
2. Cancer of Pancreas- Cancer of head of pancreas causes pain over lower thoracic segment and is felt over lower chest wall or upper back.
3. Gall Stone- The among abdominal organ gall stone is the most common abdominal disease that causes referred pain to right upper back or back of lower thorax. Gall stone causes inflammation of bile duct and gall bladder known as cholecystitis, which is acute inflammation of the gall bladder.
4. Gall Bladder Infection (Cholecystitis)- Cholecystitis causes severe pain under right ribs and may extend to the right upper back and right shoulder blades. It is often accompanied with nausea, vomiting, yellowish discoloration of skin and loss of appetite. Other conditions affecting the liver, gallbladder and abdominal organs can cause upper right back pain.
5. Right Kidney Stone- Conditions related to urinary system like right kidney stone causes colicky pain on right upper back.

The above mentioned diseases cause upper right back pain. The types of additional symptoms associated with upper back pain depends on organ and type of disease that causes upper back pain.

Following symptoms are observed with upper right back pain-

1. Fever- Fever is caused by pneumonia, pleuritis, kidney infection and hepatitis.
2. Anemia- Low hemoglobin in blood is caused by cancer disease of right lung, pancreas and right kidney.
3. Dyspnea or Short of Breath- Pleural effusion, pneumonia and pleuritis causes dyspnea or short of breath.
4. Loss of Appetite- Caused by liver disease, cancer of pancreas and cancer of right lung
5. Loss of Weight- Loss of weight is observed in individual suffering with cancer of right lung, liver and pancreas.
6. Paravertebral Muscle Spasm and Pain- Paravertebral muscle spasm is caused by fatigue muscles, myofascial disease, fibromyalgia and muscle over use.
7. Radiculopathy- Pinch or irritation of thoracic spinal nerve causes symptoms like tingling, numbness and paravertebral as well as intercostal muscle weakness. The condition associated with these symptoms is known as radiculopathy.
8. Paravertebral Muscle Atrophy- The right thoracic spinal nerve damage or degeneration causes muscle atrophy.
9. Boil and Skin Rashes- Skin and subcutaneous tissue abnormalities are caused by infection of sweat gland and subcutaneous tissue. Such infection causes boil and cellulitis. The skin looks red and feels warm. Occasionally purulent discharge known as pus comes out of skin lesions.
10. Jaundice- Liver diseases like hepatitis and cancer causes right upper back pain as well as jaundice.
11. Burning Urine- Kidney stone and kidney infection causes right upper back pain as well as burning urine.

Diagnosis is made with history taking and physical examination. Recent history of fall, accidents or injuries suggest cause of pain is tissue injuries. Examination reveals the anatomical location of tissue injury.

1. White Blood Cell Count (WBC)- White blood cell count is increased when cause of pain is infection. Increased level of WBC is observed when individual suffering with upper back pain on right side is also suffering with right side pneumonia, hepatitis, cholecystitis and right side pyelonephritis (kidney infection).
2. Erythrocyte Sedimentation Rate (ESR)- Increased rate of ESR is found when individual is suffering with chronic infection and anemia. Anemia is caused by cancer of liver, lung and kidney.
3. Radiological Studies- Radiological studies include detailed reading of images of X-Ray, Computerized tomography (CT scan) and Magnetic Resonance Imaging (MRI) images. X-rays, bones scans and MRI are performed to find bone, muscle, ligament and soft tissue fracture, tear, diseases and cancer growth.
4. Ultrasonography- Ultrasound study of lungs, kidney, pancreas and liver helps to diagnose abnormal conditions of these organs that causes pain. Nerve Conduction Studies- Nerve conduction study shows abnormalities of spinal and intercostal nerve. If the pain is caused by abnormal spinal or intercostal nerve condition then nerve conduction study helps to diagnose disease that causes pain.
5. Electromyography (EMG) study- EMG study helps to diagnose abnormal muscle fiber function and thus helps to diagnose disease that is causing right upper back pain.

1. Conservative Treatment- Conservative therapy for upper right back pain includes several options and is often known as RICE formula. RICE stands for Rest, Ice application over injured or painful area, Compression to stop bleeding and Elevation of the body that is hurting.

2. Medications for Upper Right Back Pain-

   1. NSAIDs- Non-steroidal anti-inflammatory medications are prescribed for inflammation and pain.
   2. Tylenol- Tylenol is prescribed for mild to moderate upper right back pain.
   3. Opioids- Opioids are prescribed for severe pain. Opioid prescriptions are restricted for 2 to 3 weeks. Long term opioid therapy in few cases causes dependence and addiction to opioids. Opioids prescribed are hydrocodone, oxycodone and morphine.
   4. Muscle Relaxants- Muscle spasm, myofascial pain syndrome and fibromyalgia causing upper right back pain are treated with muscle relaxants. Muscle relaxants prescribed are flexeril, soma and baclofen.
   5. Adjuvant Pain Medications- Antidepressants like Elavil and Cymbalta are prescribed for neuropathic pain that is caused by cancer, fibromyalgia and kidney stone. Similarly, anticonvulsant medications like Neurontin and Lyrica are also prescribed for neuropathic pain.
   6. Antibiotics- Antibiotics are prescribed for pneumonia, cholecystis and pyelonephritis.
   7. Chemotherapy- Cancer of pancreas, liver, lung and kidney are treated with chemotherapy.

3. Interventional Pain Treatment- Chronic right side upper back pain caused by diseases of spinal and intercostal nerve are treated by cortisone injection in epidural or intercostal space. Facet joint pain is treated with facet joint block or facet nerve ablation. Cancer pain is treated with nerve block.

4. Physical therapy- Upper right back pain caused by muscle and nerve diseases are treated with physical therapy.

5. Surgery- Surgery is performed to remove gall stone, kidney stone and gall bladder. Surgery is also performed to remove cancer of pancreas, liver and lung.

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