A Long-Term “Upper Back Pain” Patient Later Found to Have Significant Coronary Artery Disease
Upper Back Pain Is Not Always a Back Problem
When patients develop upper back pain, many people immediately assume:
muscle tension;
fascia irritation;
postural strain;
shoulder blade problems;
or chronic muscular tightness.
Even many acupuncturists and manual therapists naturally think about:
rhomboid muscle strain;
scapular dysfunction;
myofascial pain;
or dorsal scapular nerve irritation.
But some dangerous conditions can initially present exactly like an ordinary musculoskeletal complaint.
This case is one I encountered about seven or eight years ago, and it left a very deep impression on me.
1. The Patient’s Initial Presentation
The patient was a man in his fifties.
He came to see me because of:
long-term left upper back pain.
He described the pain as:
aching;
heavy;
tight;
and easily aggravated by fatigue.
The symptoms had already been present for several years.
Most of the time, he simply felt:
persistent upper back discomfort;
fatigue around the shoulder blade area;
and intermittent soreness.
However, when he:
walked quickly;
became physically tired;
or exerted himself more than usual;
the pain became significantly worse.
After resting, the symptoms would ease again.
At first glance, the condition looked very much like:
chronic upper back muscular strain.
2. The Detail That Immediately Raised My Suspicion
During history taking, the patient mentioned one particular event.
He told me that once, while rushing through an airport to catch a flight, he had to walk very quickly over a long distance.
Suddenly, his left upper back pain became extremely severe.
The pain became so intense that he had to:
stop walking;
sit down;
rest for several minutes;
before he could continue.
This detail was extremely important.
Because mature clinical thinking is often not about:
“Where is the pain?”
but rather:
“When does the pain occur?”
This patient’s symptoms clearly showed:
exertion-related aggravation.
At that moment, I began to consider:
Could this actually be exertional angina?
3. Why This Did Not Feel Like an Ordinary Musculoskeletal Problem
I performed further examination.
However, I could not find:
significant local tenderness;
typical fascial trigger points;
clear nerve irritation signs;
or findings consistent with a simple muscular strain.
The clinical pattern simply did not fit an ordinary upper back problem.
In addition, the patient was already in his fifties.
Combined with:
pain triggered by fast walking;
pain relieved by rest;
the pattern became highly suspicious for:
cardiac ischemia.
Although the patient did not complain of:
typical chest pain;
chest tightness;
or crushing chest pressure;
many cardiac conditions do not initially present with classic chest symptoms.
Cardiac referred pain may appear as:
left shoulder pain;
upper back pain;
scapular pain;
or posterior thoracic discomfort.
This is why these cases are easily misdiagnosed.
4. What an Acupuncturist Can Realistically Do
Of course, we are not cardiologists.
I did not directly tell the patient:
“You have coronary artery disease.”
Instead, I strongly advised him to:
see his GP;
undergo further investigation;
and consider specialist cardiac assessment.
The patient followed the recommendation.
He later underwent:
stress testing;
cardiac investigations;
and coronary artery assessment.
During exertional testing, his symptoms were reproduced again.
Further investigation revealed:
significant coronary artery narrowing.
The patient subsequently underwent:
coronary stent treatment.
Years later, whenever I see him, he still says:
“Dr Huang, you may have saved my life.”
Because if the condition had continued to be treated only as a musculoskeletal problem, it might eventually have progressed to:
myocardial infarction;
acute coronary syndrome;
or even sudden cardiac death.
5. The Real Clinical Value of This Case
The most important lesson from this case is not:
“discovering coronary artery disease.”
The real lesson is:
not all upper back pain is musculoskeletal.
Especially when symptoms are:
triggered by exertion;
worsened by physical activity;
and relieved by rest;
clinicians must become more alert.
Many dangerous diseases initially disguise themselves as ordinary pain conditions.
Atypical angina is one of the most common examples.
Because many patients never experience:
classic chest pain.
Instead, they present with:
upper back pain;
scapular pain;
left shoulder discomfort;
or posterior thoracic tightness.
6. History Taking May Be More Important Than Treatment
This case also reminded me that:
careful history taking is sometimes more important than the treatment itself.
If I had simply thought:
“upper back pain can be treated with acupuncture,”
this patient might have continued receiving symptomatic treatment while the underlying disease progressed.
What changed the entire direction of thinking was not simply:
“back pain.”
It was:
“pain triggered by exertion and relieved by rest.”
Sometimes one sentence from the patient changes the entire clinical picture.
This is why acupuncturists should carefully ask about:
aggravating factors;
relieving factors;
activity relationship;
exercise relationship;
and progression patterns.
These details are often clinically critical.
7. Acupuncturists May Not Need Final Diagnostic Authority — But Must Have Clinical Awareness
This case is not meant to suggest that every acupuncturist must diagnose coronary artery disease.
That is unrealistic.
But at minimum, we should develop the ability to recognize:
“This does not behave like an ordinary musculoskeletal condition.”
That level of clinical awareness is already extremely valuable.
Sometimes:
a reminder;
a referral suggestion;
or simply advising further investigation;
can completely change a patient’s outcome.
8. Dr Huang’s Clinical Reflection
A mature acupuncturist is not someone who:
“treats everything.”
A mature clinician is someone who knows:
when a condition no longer behaves like an ordinary pain disorder.
Sometimes what truly helps the patient is not:
how many needles were used.
But rather:
recognizing danger while the disease is still disguising itself as ordinary pain.
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