Pain between the shoulder blades is often treated as a muscle problem by default. But a specific joint may be causing it. The costotransverse joints, where the ribs meet the mid-back bones, are a commonly missed source.1 This pain gets less attention than low back or neck pain. A diagnostic block (a numbing shot that tests one spot) proves the source instead of guessing.
A commonly overlooked generator
The costotransverse joints are small fluid-filled joints. They sit where the ribs meet the side bumps of the mid-back bones. Researchers describe them as possibly common but overlooked pain sources in the thoracic spine (the mid back).1
They matter for two reasons. They sit exactly where people point when they describe pain between the shoulder blades. And nothing about the pain clearly says joint instead of muscle.
What a worked-up case looks like
A published case report describes a 35-year-old woman. It is a single case, not a trial. Her mid back was stiff, with a severe pressure feeling and dull pain on both sides from T7 to T10. The pain sat between the inner edges of her shoulder blades.1
Physical therapy, pain medications and a thoracic epidural steroid injection all failed. A CT scan of the thoracic spine then showed joint damage limited to the costotransverse joints at T8 and T9 on both sides.1
The sequence is the lesson
An intra-articular steroid injection (a shot into the joint) gave strong short-term relief. Next came a diagnostic block, which gave over 80% pain relief. That confirmed the target before anything longer-lasting was tried. Then came thermal radiofrequency ablation of the nerves to the costotransverse joints at T8 and T9. This uses heat to quiet the nerve. The patient had three months of relief. She moved better and needed less pain medication.1
Treat that as an example of method, not proof of how well the procedure works in general. One patient cannot prove it works. What it does show is the logic. Find a likely structure. Confirm it with a block. Then treat what was confirmed. The same steps are described in facet joint pain and medial branch blocks.
The authors say more anatomy studies are needed to map all the nerves that supply the costotransverse joints.1 This area is still being worked out.
Thoracic pain is not only an older person’s problem
A cross-sectional study looked at 1,628 Brazilian high school students aged 14 to 18. Thoracic spine pain affected 51.5% of them (95% CI 49.1–53.9).2 These were teens, not adults, so the figure does not carry over to adults. But it shows the problem starts early.
In that cohort, thoracic pain was associated with several things. These were being female, using a computer more than three hours a day, and using a cell phone while half lying down. Using a cell phone more than three hours a day and having mental health problems were also on the list. Regular physical activity was protective.2
Where evaluation goes
Several structures can cause mid-back pain. So the useful question is which one, proven instead of guessed. Options here include facet joint injection, facet joint radiofrequency ablation, trigger point injections when muscle pain spreads into the area, and digital X-ray and image-guided procedures for the testing steps.
If a vertebral compression fracture is possible, kyphoplasty and vertebroplasty are the pages to read. New thoracic pain with weight loss, fever, a history of cancer, or neurological changes needs a prompt exam. Do not treat it as simple wear-and-tear pain.
Frequently asked questions
Why is mid-back pain harder to diagnose than low back pain?
Because thoracic back pain has many possible causes and treatments, and no single one dominates. That is why finding the exact source matters. See the range of pain treatments.
What is a costotransverse joint?
A small fluid-filled joint where a rib meets the side bump of a mid-back bone. These joints are described as possibly common but overlooked pain sources in the thoracic spine. See facet joint injection for the related joint-focused approach.
Does radiofrequency ablation work for thoracic pain?
The published record here is a single case report. It describes three months of relief after a diagnostic block confirmed the target. One case cannot prove it works in general. The authors call for more anatomy study. See facet joint radiofrequency ablation.
Is my posture or phone use to blame?
In teens, thoracic pain has been associated with long computer and cell phone use. That includes using a phone while half lying down. Physical activity was protective. Those findings come from a study of 14 to 18 year olds. Do not assume they apply unchanged to adults. See lifestyle medicine.
When should mid-back pain be seen urgently?
New thoracic pain with unexplained weight loss, fever, a history of cancer, or any neurological change needs a prompt exam, not a wait-and-see approach. See same-day and emergency visits.
To have mid-back pain evaluated, request an appointment, call (314) 481-5000, or text (314) 886-5902.
Sources
- Patel J, Eaves AM, Deschler E, Bowlin C, Galang E. Radiofrequency Ablation of the Costotransverse Joint in a Case of Chronic Thoracic Back Pain. Cureus. 2024;16(7):e63958. doi:10.7759/cureus.63958. Retrieved via PubMed. DOI
- de Vitta A, Campos LD, Bento T, Felippe LA, Maciel NM, Perrucini P. Thoracic Spine Pain and Factors Associated in High School Students. Pain Management Nursing. 2021;23(4):517–523. doi:10.1016/j.pmn.2021.11.005. Retrieved via PubMed. DOI
Dr. Gurpreet Singh Padda, MD, MBA, MHP
