Cervical thoracic pain is a common chief complaint that presents to outpatient musculoskeletal clinics. The differential diagnosis is vast, including trauma, arthritic, muscle dysfunction/myofacial pain, central pain syndromes, infectious, radicular, and neuropathic pain syndromes and a multitude of spinal pathologies. This is a case of isolated thoracic paraspinal myopathy presenting as exertional cervicothoracic pain in an otherwise healthy older adult.

A 67-year-old male hiker presented with a two-year history of burning and aching pain in the left parascapular region, precipitated by prolonged uphill hiking. Neurologic and musculoskeletal physical exam showed rounded shoulders and a macular rash over the painful area, otherwise unremarkable. Routine laboratory studies and cervical MRI were normal. Thoracic spine MRI revealed marked bilateral paraspinal muscle atrophy confined to the thoracic region, with normal appearing cervical and thoracic musculature. Electromyography was consistent with a myopathic process.

The patient’s pain was attributed to postural fatigue due to reduced thoracic paraspinal support. His symptoms were managed with physical therapy focusing on building core musculature and postural stabilization, which provided partial relief. Pharmacologic treatment with gabapentin was ineffective. Physio-taping helped the patient with postural support as well as activity modification with shorter hikes.

This is a rare case of isolated thoracic paraspinal myopathy, a condition that should be considered as a diagnosis of exclusion for axial pain syndromes. MRI and EMG findings are essential for diagnosis and appropriate conservative management. The localization of atrophy to the thoracic paraspinals suggests a distinct myopathic process that warrants further investigation into its pathophysiology and long-term outcomes.

Emily Akamine is a third-year medical student at Western University of Health Sciences COMP- Northwest. Originally from Honolulu, Hawai‘i, she earned a BS in Public Health from the University of Washington and has a background in public health and environmental advocacy. At WesternU, she is involved in headache research, including carotid artery dissections through the parotid gland and development of an OMT-based headache treatment protocol. She plans to pursue a career in Physical Medicine and Rehabilitation. In her free time, she enjoys cooking, running, surfing, and hiking.