Upper Back (Lung?) Pain

November 12, 2005 4:13 PM

For the past four and a half years I have had pain in my upper back, between and just below my shoulder blades. It feels to me like its lung pain. It is worse when its cold, and at night (I think because it's cold at night). My doctor doesn't know what it is. Any ideas?

You are not a doctor, I know. But my doctor is stumped and if I could take some ideas that might be helpful. So, in greater detail:

History
I'm a 29yo female. Relatively healthy. However, almost 5 years ago, I had non-hodgkin's lymphoma in my eyes (not in my lymph nodes) treated with radiation. Towards the end of the course of radiation, I got pneumonia, presumably because my system was weakened. I am cancer free and the chances of my cancer coming back are pretty close to 0. Supposedly the kind I had doesn't come back.

This back pain started at the same time as the pneumonia. Since, as I said, it feels like its my lungs, I told my doctor about it, calling it "lung pain" at the time. He said it was normaly for my lungs to hurt after pneumonia and that it could take a long time to pass (this was 3 or 4 months after the pneumonia.

After about three years, I figured, well I know he said it could take a long time to pass, but it's been long enough, and I brought it up again. This time we went into more detail and I showed him where the pain was. He looked a little perplexed and said "That's not where your lungs are." Oops...I never said I was an anatomist. He did a full exam as well as x-rays and can't find anything wrong. He says maybe it's muscular. It doesn't feel muscular to me.

The Pain
It's in my upper back, between and immediately below (though still sort of centre-ish) my two shoulder blades. So divide your back into 5 horizontal sections...it's in the middle 3.

It feels like it's "inside" not on the surface. It doesn't feel like muscle pain, at least not the sort of muscle pain you get from exertion or fatigue, which is the only kind I know. It feels "hollow". I don't know how else to describe it other than hollow. It is not a sharp pain, it's fairly constant when it's there. It's not *bad* pain, meaning I'm not incapacitated by it by any stretch and only occasionally does it interfere with my sleep.

It is worse when it's cold. Meaning it's worse when my back is cold or not snugly covered (undershirt). If my back itself is kept warm, it doesn't matter if I'm in a cold place (e.g. warm parka keeps the pain at a low-level even if I'm outside and breating freezing air in the dead of winter).

I realize that last point contradicts my lung hypothesis. Yes, I still feel like it's my lungs. The doctor said my lungs would hurt in the front, not the back. That seems strange to me...I'm not that deep, my lungs are presumably pretty close to the surface from either direction. And besides, this doesn't feel like the surface. Further, it just "feels" like it's a lung thing. Lastly, it did start with the pneumonia.

It does not seem to be related to any physical exertion. it gets worse in the winter as you might expect, but AC in the summer when I'm wearing those little spaghetti-strapped tops, also doesn't do me an favours.

As I said, the pain is not terrible. It's not like I need painkillers or like I can't do things. But the long duration and constancy of the pain worries me, and I would like to know what it is so I don't have to worry about it anymore.

posted by duck to health & fitness (16 comments total)

Has he checked your gall bladder?

Seriously there is such a thing as referred pain. I had that with mine.
posted by konolia at 4:41 PM on November 12, 2005

Heartburn, maybe? I had heartburn for several years without realizing what it was--the pain I felt wasn't what I'd expect backed-up stomach acid to feel like, and it was vaguely hollow and in approximately the same location as you describe.

Heartburn doesn't seem that likely to me, but because it's so easy to rule out (see if a half teaspoon of baking soda in water makes the pain go away), it's worth mentioning.
posted by needs more cowbell at 4:54 PM on November 12, 2005

Has he checked your gall bladder?
Seriously there is such a thing as referred pain. I had that with mine.

Referred gall bladder pain is typically the right shoulder, not the middle of the back.

Get a second opinion. I think your lymphoma + radiation therapy complicates your case.

Probably would want to do an imaging study, but somewhat wary because you've already had a lot of radiation.

I'd get an anatomy textbook (or look at Gray's online) so you can really pinpoint where the pain is on you, compared to where the muscles run, etc.
posted by gramcracker at 5:07 PM on November 12, 2005

So far, the story is somewhat unusual. I appreciate the detailed history, can I ask:

1) Has the pain basically been there all the time since the pneumonia?

2) Do you ever wake up in the middle of the night with it?

3) Is it ever excruciating?

4) Is it worse with breathing or coughing?

5) Is it evenly distributed throughout your back (vertical planes), more in the middle where your spine is, more on the sides of the spine, or on one particular side?

6) Is the pain affected by movement at either shoulder?

7) Any history of trauma or radiation there?

8) Are you otherwise healthy now? No other major illnesses, recurrent infections, reflux disease, sinusitis? No other symptoms (fevers, chronic cough, leg pain or tingling, anything..)?
posted by drpynchon at 5:07 PM on November 12, 2005

I had an ulcer that caused a sensation like back pain, around about where you seem to be describing it. It definitely felt like it was 'inside' my back.
posted by The Monkey at 5:10 PM on November 12, 2005

If it's not actually *inside* your lung and is in fact a referral pain, a registered massage therapist might be able to pinpoint and perhaps work the problem out.
posted by PurplePorpoise at 5:34 PM on November 12, 2005

The fact that it appears temperature dependent really leads me to believe it is in you spine, not lungs. Since it is not sharp, it could be a minor disc problem with the hollow pain coming from your muscles in the area tightening up to protect the problem disc. Does massage help, is there tightness there? Sometimes it takes an experienced hand to detect the tightness. However, I am not a doctor, chiropractor, or a physical therapist, so what do I know?
posted by caddis at 5:43 PM on November 12, 2005

From your description it sounds like it could be scapular bursitis or another type of shoulder problem. It is very easy for a orthopedist to test you for that.
posted by McGuillicuddy at 5:46 PM on November 12, 2005

Has he checked your gall bladder?

I don't think so (more below). And my mom had her gall bladder out, so I suppose that's a possibility if it's partially an inherited problem. Konalia, can you explain in what ways your pain was similar to mine?

1) Has the pain basically been there all the time since the pneumonia?

Do you mean is it all day every day since then? No. I'm conscious of it at least 3 days a week, let's say. Now that it's getting cold, its every day. It's a mild enough pain much of the time that I can ignore/forget about it even when it is there, sometimes.

2) Do you ever wake up in the middle of the night with it?

I don't think it's ever woken me. It's not severe enough for that. However if I do wake up in the middle of the night (for other reasons) it's there sometimes. When it's at its worst it can make it difficult to fall asleep. I put an undershirt on and have a space heater and that helps.

3) Is it ever excruciating?

Never.

4) Is it worse with breathing or coughing?

I had a cold recently and yes, it was worse at the moment of coughing. When it's at a low-level I definitely don't notice any breathing effects. Right now this minute it's moderate, on the inner bottom curve of my left shoulder blad and taking a deep breath seems to make worse.

5) Is it evenly distributed throughout your back (vertical planes), more in the middle where your spine is, more on the sides of the spine, or on one particular side?

More on the sides, but not way over to the side. Along the insides of the shoulder blades, I would say. It happens on both sides.

6) Is the pain affected by movement at either shoulder?

No.

7) Any history of trauma or radiation there?

No trauma. Radiation to that area only for diagnostic purposes. A chest x-ray when I had the pneumonia, an x-ray to try to identify the source of pain, a CT scan, and an aborted CT scan (more below). That's all I can remember that would involve radiation.

8) Are you otherwise healthy now? No other major illnesses, recurrent infections, reflux disease, sinusitis? No other symptoms (fevers, chronic cough, leg pain or tingling, anything..)?

Yes.

However...now that people are bringing up digestive issues. There is something else, which I didn't consider relevant earlier....Two or three years ago I got a stomach ache one day and it was recurrent daily for weeks. Every time I ate my stomach would start hurting about 20 minutes later. So I went to the doctor, of course. In trying to find the source of the problem, they did an "Upper GI" (? a series of x-rays after making me drink some dye of some sort), an endoscopy, in which they took biopsies of my stomach, and a CT scan which was aborted because when they turned on the machine they realized I still had dye in my system from the x-rays and they couldn't do it. These tests all found nothing, and eventually the pain stopped. I did consider and suggest the possibilty of stress-related causes (though I wasn't especially stressed at the time, my stress does tend to manifest itself digestivelly), but the doctors didn't seem to think that was it.

Based on it's wierdness and it's seeming randomness (related to little but the cold and related to the cold in a wierd way), I've considered the possibility that this pain is psychosomatic. I obviously can't rule it out, but fwiw, the pain doesn't seem to be related to my stress levels. For example, it's there when I'm on vacation.

Also, I'm not sure it was clear before, but the cold really is about keeping my back covered as much as about keeping it warm. I mean warm is definitely necessary, but not sufficient to alleviate the pain. So if I wore three sweatshirts on top of one another, that wouldn't help. There really needs to be an undershirt involved. It has to be snug against the back. Similarly, it's not enough to be covered at night, I have to tuck the comforter around myself so it's snug against my back, not just forming a tent over me. (I suppose that's the part where it sounds to start psychosomatic, since there's no reason that should matter).

I have not tried massage or a physiotherapist.
posted by duck at 7:52 PM on November 12, 2005

From the way you describe it, it's most likely not the lungs or the lining of the lungs that is the problem. The only thing that confuses the picture is the timing in relation to the episode of pneumonia. It's possible for example, that a bad pneumonia might have caused inflammation and scaring either somewhere in the pleural space or lung itself and that this pain might refer to the back, but some of the things you describe go against this as a possibility.

As some have noted, it's also not an uncommon location for referred pain, but again, there are things in your description that would suggest otherwise. Things like gall stones, diaphragmatic/hiatal hernias, and aortic aneurysms or dissections may refer to the back (aortic disease being most concerning but least likely given the chronic nature of the pain).

More likely are musculoskeletal stuff like myofascial pain, lower cervical spondylosis, spasms, or trigger points.

Of course, it's impossible to get a complete picture of things over the net, but I'd say that it might be worthwhile to consider getting further imaging (possibly MRI of the c- and t-spine, a hi-res chest CT, and evaluation of the gallbladder) if you haven't yet, and to see a specialist regarding the pain. There's a good chance imaging won't yield a diagnosis but it might rule out more concerning causes, and at least buy you some peace of mind.
posted by drpynchon at 8:54 PM on November 12, 2005

I will definitely bring up the possibility of referred pain and my gall bladder at my next physical. I'm not terribly worried about the possibility of aneurysm, since besides the low baseline probability, I've always had and continue to have low blood pressure, which I gather wouldn't be the case if I had an aneurysm.

I'll also try an antacid the next time it's particularly bad, and see if that does anything.

What kind of specialist would be appropriate given that the source of the pain is so up in the air?
posted by duck at 9:24 PM on November 12, 2005

Also, it seems like referred pain would make sense since it's not always in the exact same place -- sometimes the right, sometimes the left etc. etc. Is that correct?
posted by duck at 9:31 PM on November 12, 2005

You're largely right in your assumption about aortic disease.. it's very unlikely, although if you had something like Marfan's syndrome or an underlying connective tissue disorder, that would change things.

I'd say that once a physician has confidently ruled out things like gallstones, diaphragmatic hernia, and ulcer disease/GERD, I'd go to a pain specialist (which is usually an anesthesiologist who has focused on pain syndromes). Such a person generally sees a lot of patients with pain that is hard to diagnose and treat, and would probably have the most experience with something like this. She may ultimately treat you herself or suggest things like physical therapy.

I don't know about Toronto (I'm sure it's fine), but if you're in Cambridge, there's definitely no shortage of overly specialized medical experts who focus on pain.
posted by drpynchon at 8:48 AM on November 13, 2005

I'm not an MD, but my wife, who has a weakened immune system because of medication she takes for rheumatoid arthritis, had pneumonia this summer, and 4 months later, she still has pleurisy, which is an inflammation of the pleura, the lining of the lungs.
posted by lukemeister at 7:42 PM on November 13, 2005

Have you gained or lost weight, or had a change is your muscular distribution? Changed chairs, beds?
I found that when I lose even 5 lbs. (out of about 115) that my posture changes enough to produce some spine/muscle pain. I also tend to stiffen up and contract my core muscles when cold, which makes it worse.
Getting the chronically tense areas warm seems to let them relax.
Exercises to strengthen the core muscles have helped them to be more forgiving of fluctuating geometry.
posted by tcy at 8:29 PM on November 13, 2005

I would like to mention that my mother, who has been diagnosed with BOOP, periodically gets a chill at approximately that part of her back. Diagnosing BOOP appears to be somewhat difficult; it took about a year of doctor visits and guessing for them to identify it.
posted by frecklefaerie at 1:47 PM on November 22, 2005