The forgotten pain of pregnancy — when the mid-back complains

Every pregnant woman hears about low back pain in pregnancy. But there is an equally common and much less discussed pain: pain in the thoracic region — the "middle of the back" — that quietly sets in during the second trimester and intensifies until delivery. While gestational low back pain receives all the attention from obstetricians and manuals, thoracic pain is frequently ignored, minimized as "normal in pregnancy", or vaguely attributed to posture.

The reality is that gestational thoracic pain has well-defined biomechanical causes and effective treatment with medical acupuncture. The increase in breast weight, compensatory lumbar hyperlordosis, and the resulting thoracic hyperkyphosis overload the thoracic spine erectors and rhomboids, which develop painful trigger points between the shoulder blades and along the mid-spine. Acupuncture during pregnancy is safe when performed by a trained physician, with appropriate positioning and careful point selection. If pain radiates to the leg, see also sciatic pain in pregnancy. For pain concentrated between the shoulder blades, read about interscapular burning.

Why the thoracic spine suffers só much in pregnancy

  1. Increased breast weight and shift in center of gravity

    The increase in breast size during pregnancy (frequently 500 g to 1 kg per breast in the third trimester) shifts the center of gravity forward. The thoracic spine responds by increasing its kyphosis — the forward curvature — to try to maintain balance. The thoracic erector muscles work constantly against this increased kyphosis.

  2. Compensatory lumbar hyperlordosis

    The weight of the gravid uterus accentuates lumbar lordosis, which in turn increases thoracic kyphosis through biomechanical compensation. This postural cascade overloads the entire posterior muscle chain of the thoracic spine, from the rhomboids to the paravertebral erectors.

  3. Relaxin and ligamentous laxity

    The hormone relaxin, produced in large quantities from the first trimester, loosens the ligaments of the spine. Without the usual ligamentous stability, the thoracic paravertebral muscles take on the role of active stabilizers — a function they were not designed for chronically. The overload results in trigger points in the erectors and rhomboids.

  4. Trigger points in the rhomboids and middle trapezius

    The rhomboids (major and minor) and the middle trapezius, overloaded by increased kyphosis, develop trigger points that generate referred pain between the shoulder blades — the most common complaint of pregnant women with thoracic pain. The pain may be burning, tightness, or "weight" in the back.

Epidemiology of gestational thoracic pain

40–50%
OF PREGNANT WOMEN
experience pain in the thoracic region during the second and third trimesters — although most do not spontaneously report it to the obstetrician, considering it "part of pregnancy"
2nd–3rd
TRIMESTERS
is the period of greatest incidence — coinciding with the significant increase in breast and abdominal weight, and with the peak of circulating relaxin
4–6
SESSIONS
of medical acupuncture are typically sufficient for significant relief of gestational thoracic pain, with frequent improvement starting from the second session
Significant
REDUCTION IN PAIN
reported in clinical studies of acupuncture for gestational low back and pelvic pain — favorable safety profile in most series, although mild adverse events (discomfort, local bleeding, vagal reaction) are described

Recognizing gestational thoracic pain

Critérios clínicos
07 itens

Typical pattern of mid-back pain during pregnancy

  1. 01

    Pain between the shoulder blades that worsens over the course of the day, especially when sitting

  2. 02

    Sensation of burning or weight in the mid-thoracic spine (T4–T8)

  3. 03

    Pain that intensifies starting in the second trimester

  4. 04

    Worsening when breastfeeding or holding the first child

  5. 05

    Difficulty finding a comfortable position to sleep

  6. 06

    Morning stiffness in the mid-spine that improves with movement

  7. 07

    Pain that radiates around the ribs in a band-like pattern

Myths about back pain in pregnancy

Myth vs. Fact

MYTH

Back pain is inevitable in pregnancy — there is nothing to do

FACT

Although the biomechanical changes of pregnancy predispose to pain, it is neither inevitable nor untreatable. Interventions such as medical acupuncture, specific stabilization exercises, and adequate ergonomics significantly reduce pain intensity. The fact that it is "common" does not mean it must simply be endured for months.

MYTH

Acupuncture in pregnancy can provoke contractions and miscarriage

FACT

Acupuncture performed by a physician trained in pregnant patients, with appropriate point selection and correct positioning, is safe in all trimesters. Systematic reviews have not found an increased risk of spontaneous abortion or preterm labor associated with acupuncture. The points used in the thoracic spine are not among those traditionally contraindicated in pregnancy.

MYTH

It is better not to treat anything during pregnancy to avoid affecting the baby

FACT

Untreated chronic pain during pregnancy is not harmless — it is associated with maternal stress, sleep disturbances, increased cortisol, and a negative impact on quality of life. Medical acupuncture is precisely one of the safest therapeutic options in pregnancy because it does not involve medications that cross the placental barrier. It is treatment, not risk.

The pregnant woman who could no longer sleep

Treatment protocol

Assessment and safe positioning
1st visit

Postural assessment with attention to thoracic kyphosis and lumbar lordosis. Palpation of the thoracic erectors, rhomboids, and middle trapezius to identify trigger points. Definition of positioning for treatment: left lateral decubitus (preferred) or seated with support. Exclusion of warning signs that require obstetric evaluation.

Dry needling of the thoracic erectors
Sessions 1–3

Needling of the thoracic paravertebral erectors (T4–T8) bilaterally, with needles inserted 1–2 cm deep, perpendicular to the skin. Treatment of trigger points in the rhomboids (major and minor). Low-frequency electroacupuncture (2 Hz) for analgesia. Immediate ergonomic guidance: lumbar support when seated, appropriate pillow height.

Trapezius and cervicothoracic chain
Sessions 3–5

Inclusion of the middle and upper trapezius if they contribute to the pain. Treatment of trigger points at the cervicothoracic junction (C7–T2), frequently involved. Gentle thoracic mobilization and pectoral stretching exercises — compatible with the gestational stage.

Maintenance until delivery and postpartum
Sessions 6–10

Biweekly maintenance sessions until delivery. Guidance on breastfeeding posture (a phase in which thoracic pain may recur due to sustained posture). After delivery, reassessment of the need for additional sessions, considering progressive hormonal and postural normalization.

Clinical pearl: positioning is therapeutic

Scientific evidence

Frequently asked questions

FREQUENTLY ASKED QUESTIONS · 04

Frequently Asked Questions

Acupuncture can be performed in all trimesters of pregnancy when administered by a physician experienced with pregnant patients. Many patients begin treatment in the second trimester, when thoracic pain starts to manifest. In the first trimester, acupuncture is equally safe at the points used for the thoracic spine, but most cases of thoracic pain arise from the 20th week onward.

No. From the second trimester, the prone position (face down) is not recommended. Treatment is performed in lateral decubitus — preferably left — or seated with support. These positions allow appropriate access to the thoracic spine and are comfortable for the pregnant patient. Treatment efficacy is not compromised by the position.

Gestational thoracic pain tends to improve significantly after delivery, with normalization of posture and hormones. However, breastfeeding can perpetuate pain between the shoulder blades due to the sustained posture of holding the baby. Postpartum maintenance sessions and postural guidance for breastfeeding prevent chronification.

Nonsteroidal anti-inflammatory drugs (NSAIDs such as ibuprofen and naproxen) are contraindicated in pregnancy, especially in the third trimester, due to fetal risks. Acetaminophen is considered safer but has limited efficacy for musculoskeletal pain. Medical acupuncture is one of the few effective and safe analgesic options during pregnancy, without medication exposure for the fetus.