Keywords: DEEP UPPER BACK PAIN, Upper Limb Tension Test, Cervical facet syndrome, tingling in arms and hands
The villain of the peace disturbing your nights and causing a deep constant ache is often irritated nerve supply to the rhomboid muscles (pure C5) or the levator scapular muscle (C5, but also C3 and C4).
They are innervated by the Dorsal Scapula nerve that comes from the mid neck, specifically the C5 nerve root.
Deep upper back pain is difficult to manage for a number of reasons.
Neuro anatomy is a difficult subject so just scroll down if you're really not interested in the following paragraph. Sorry, always a tidbit to stretch jah! Notice how this nerve complex lies in the groove just behind the collarbone.
Notice the two terms "root" and "ramus" below.
There are two "roots", one is sensory, the dorsal root, bringing information in from the fingers tips for example. Pain, touch, position sense, mechano receptors and so on.
The other "root" is motor, the ventral root, taking information from the "grey matter" in the spinal cord to the muscles, for example. If you want to raise your arm, the stimulus to the muscle is relayed along the ventral root.
It's these "roots" that are affected by a slipped disc, or degenerative change, or subluxations in the spine. Cervical facet syndrome ....
Thumb and forefinger tingling? Then the dorsal nerve "root" of the C6 nerve root is being irritated. Can't do a press up? Then it's probably the motor "root" of C7 that is pinched because the triceps muscle is weak. Trivial details for you, vital stuff for your chiropractor.
Then the two roots join (ignore that bump on the dorsal root) to form a "spinal nerve." (Ignore the white and gray ramuses or rami too).
Then the spinal nerve divides into two "rami". Singular "ramus." It's the ventral ramus of C5 that goes on to form (in part, continuing to form the Median and Ulnar, and other, nerves that supply the arm) the Dorsal Scapular nerve. The nerve that innervates our two muscles, the Rhomboids and the Levator Scapular.
THE INTER SCALENE TRIANGLE
("inter" = between - between two scalene muscles)
The inter scalene triangle is bordered by the anterior and middle scalene muscles (in red), and the first rib below (grey).
From there, the Dorsal Scapular nerve enters the Inter Scalene Triangle and, instead of passing through it, penetrates through the belly of the Medial (middle) Scalene muscle, one of the boundaries of the triangle.
After penetrating the Medial Scalene muscle, the Dorsal Scapular nerve descends, piercing the Levator Scapular muscle (sending off branches to innervate the muscle) and proceeding to innervate the Rhomboid muscles.
Anywhere along this path, the nerve root, as it passes in the inter scalene triangle, through the Medial Scalene muscle, piercing the Levator Scapular muscle, there is the potential for the nerve to be irritated: deep upper back pain.
Let's admit they aren't common, but they must be included. The only patient to appear at my Chiropractic Coalface with deep upper back pain caused by lung cancer was my father. It had already been diagnosed and surprisingly his last days were greatly helped by gentle chiropractic treatment of his deep upper back pain. The cause, not subluxations, but referred pain from the cancerous tissue in his lung. Smokers beware!
Secondary cancers, particularly from a primary breast cancer, to the ribs are always a concern in Chiropractic clinics, even years after breast cancer patients have been declared "clear".
Others? I'm sure there are plenty, but lets be realistic: when you hear hoofbeats, don't think zebras! Pancreatic cancer causes deep upper back pain, heart attack causes neck and jaw, back and arm pain. An aortic aneurism... this is an interesting web page: Pathophysiology of Atherosclerosis ...
Right, now to the heart of this page. Firstly, I'll list the thoughts that come to my head:
In short, there are a lot of possible causes of deep upper back pain.
C5 nerve root lesion
The C5 nerve root, affected for example by a slipped disc in neck supplies sensory innervation to the skin on the side of the upper arm extending down the lower arm towards, but not including the thumb; and muscular innervation to numerous muscles, but usually the biceps and the biceps reflex would be tested.
The deltoid is another muscle often tested for C5, but truth is that there has often been a low grade irritation of the nerve (axillary nerve, C5/C6) leading resulting in painful shoulder pathology such as rotator cuff syndrome ... resulting in pain inhibition during testing.
Because both the biceps and deltoid (and all the other muscles of C5, bar rhomboids) are supplied by C5 AND C6, true neurogenic weakness is not common.
A key sign is the so-called Shoulder Abduction Relief sign in which relief is obtained by placing the hand on the head. It takes the stretch off the nerve root.
Conversely, the Upper Limb Tension Test (a test you can do at home) places increasing stress on the nerve root producing tightness, pain and tingling in the arm.
C6, C7 and C8 nerve root lesions
These roots are not likely to cause upper back pain, but rather pain and tingling in arms and hands, and especially the lower arm and fingers.
T1, T2, T3, T4 nerve root lesions
T1 nerve root is a primary candidate of suspicion when dealing with deep upper back pain, the pain usually extending in this instance down the inner arm, and sometimes to the chest.
Again the SAR and ULTT tests will be positive.
Specific muscle weakness in the hand will be sought by your chiropractor. In particular, "opposition" of the thumb and pinkie, and the muscles that you would use to squeeze your fingers together (PAD muscles) and apart (DAB muscles).
Deep upper back pain, AND tingling down the inner arm, AND weakness in the hand? T1 nerve root lesion.
Cervical compression and Spurling's tests
Both the C5 and T1 lesions, if severe, will produce radiating pain when turning the head to the side of pain and then looking up. If extra downward pressure is exerted by your chiropractor, then it's called Spurling's test.
In short, does turning to the same side produce deep upper back pain and/ or tingling and pain in the arm?
Another series of tests that your chiropractor would do are the Cervical Compression tests ... this is a fun page, don't miss it!
THORACIC OUTLET SYNDROME
I won't write much here as there is extensive coverage of the Thoracic Outlet Syndrome at this Chiropractic Help website. The key sign is that elevation of the arm, instead of relieving the symptoms, makes them worse. Both the artery and the bundle of nerves called the "brachial plexus" are irritated primarily by a subluxated first rib.
It is diagnosed using a difficult test known as Adson's test
I receive many questions at Chiropractic Help. It might be help for a spinal condition, but it could also be about a failed Carpal Tunnel operation, or some such thing.
I will do that by answering your questions personally, but it will be converted to a Web Page so others can benefit from your questions. Omit your name if you like...
However, do understand that, in the main, I'm going to be directing you (should it be pertinent) to a Chiropractor in your neck of the woods. I'll respond to all reasonable inquiries, but please be specific, and give some details: which fingers, what increases the pain, and relieves it, injuries, do xrays show anything, does placing your arm on your head relieve or increase tingling in the arm... without these sort of details, I'm unable to give a sensible answer.
Please also don't write from your blackberry or iphone. Many many people will be reading what you write, and I don't want gobbledygook at chiropractic help. It lowers the tone of the whole site, and Google is now downgrading sites with poor grammar and spelling. I just won't answer.
There is no charge for this service, however if you find my answer useful, you might like to consider purchasing my latest book, Stones in my Clog. Gems, both funny and healthful, from the life and work of a Chiropractor. It's only $2.99. Stones in my Clog ...
Pose Me A Question! Pretty please, in decent grammar and spelling.
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Interesting challenges of the day
1. Mr D has very severe midback back. He bent and twisted, feeding his son, and then laughed. Every breath is a nightmare. A sprung rib is every chiropractor's delight. He or she has golden hands. 30 percent better after one treatment.
2. Mrs C has a long history of severe, disabling migraine headaches since having her wisdom teeth removed. She clenches her teeth at night. After six treatments she has no migraines but some jaw joint discomfort remains; a bite plate is in the offing.
3. Mrs U has the trophy for the worst back this year. After major surgery with plates and screws two years later she still had paresis in the lower leg and severe disabling back pain. She's doing far better than expected, in no little part due to a lift in her shoe for a very short leg.
4. Mr V is 86 years old and hurt his back helping his wife into the car. Just one treatment of the sacroiliac joint and he's eighty percent better. It's not always like that.
5. Mr W lay on his back knocking down a pillar. Turning his head causes severe vertigo. He needs the Epley exercises, not pills, research shows. Update, he's fine.
6. I myself had an acute exacerbation of a femoral nerve lesion last year. One immediate treatment by my colleague has fixed the pain in the lower back, but there's some residual numbness in the lower leg; no soaring tomorrow alas.
7. This lady is a 86 year old woman with a 63 scoliosis. Chronic lower back has been her lot in life but she's well pleased with chiropractic and comes for chiropractic help once a month; some conditions you can never cure.
8. She is an 78 year old woman, is doing remarkably well with a bad sciatica. But over 200 pounds she is not losing weight; in fact, gaining despite my suggestions. She's high risk for a stroke. I have referred her to a dietician to crack the whip.
9. A 61 year old man with upper cervical pain yesterday; it's not severe but also not getting better of its own accord. He's afraid it may turn very acute as when I treated him three years ago. Since then it's been fine.
10. A 64 year old woman has had scheuermanns disease; it's left her with a spinal kyphosis and chronic middorsal pain. She responds well to chiropractic treatment provides she come every six weeks or so for maintenance treatment.
11. Mrs C has been having severe headaches, and taking a lot of analgesics. It's a non complicated upper cervical facet syndrome, and she's doing well.
12. Mrs D, a middle aged woman with hip pain of one year duration, despite other treatment. Xrays reveal an impingement syndrome and early hip arthritis. There's much to be done.
13. Mrs B has had one of the nastiest of conditions; vertigo caused by a disturbance in the inner ear. Falling repeatedly and vomiting she consulted her doctor but medication didn't help. After two sessions of the Epley manoeuvres she was 50 percent better. After two weeks 75 percent improved. No longer vomiting all falling. She's not enjoying the Brandt Daroff home exercises.
And so the day goes; chiropractors shouldn't be treating the elderly most medical sites state but that's so much bunkum.
Have a problem that's not getting better? Looking for a different slant on your pain? Want to pose a question?
Greetings, Dr B.
You helped me quite some time back with a soothing and professional response which turned out to be exactly correct. I now consult a local chiropractor. You write a superb newsletter, too.
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You visited this chiropractic help site no doubt because you have a problem that is not resolving and want to know more about what chiropractors do.
The quickest and most interesting way is to read one of my ebooks of anecdotes. Described by a reader as gems, both funny and healthful, from the life and work of a chiropractor, you'll love them. Priced right at $2.99, though Kindle fiddles the price without telling me.