Back Pain in Kids and Teens

There are several unique aspects to consider when back pain occurs in a child or teenager. In rare cases, back pain may be a sign of a serious underlying condition that requires prompt medical attention.¹Bernstein RM, Cozen H. Evaluation of back pain in children and adolescents. AFP. 2007;76(11):1669-1676. Available from https://www.aafp.org/afp/2007/1201/p1669.html

Back pain in children and adolescents may increase with age and typically affects girls more than boys.²Calvo-Muñoz I, Gómez-Conesa A, Sánchez-Meca J. Prevalence of low back pain in children and adolescents: a meta-analysis. BMC Pediatrics. 2013;13(1):14. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3571904/

This article provides comprehensive information about back pain in children and teens, including the probable causes, diagnostic considerations, and available treatment options, to help parents and caregivers understand and support kids with this symptom.

Common Risk Factors for Back Pain in Kids and Teens

The most common risk factors for back pain in children and teens include:

• Sports participation
• Obesity
• A sedentary lifestyle
• A family history of lower back pain
• Smoking
• Psychological stress

For example, children and teens with a positive family history of lower back pain are almost twice as likely to experience back pain in childhood or adolescence versus their counterparts with no relevant family history. Evidence suggests that those with lower back pain in childhood are at higher risk of developing lower back pain in adulthood.³Kordi R, Rostami M. Low back pain in children and adolescents: an algorithmic clinical approach. Iran J Pediatr. 2011;21(3):259-270. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3446176/

School-age children who complain of back pain typically also have high levels of psychosocial difficulties, such as emotional distress and problems with behavior and/or everyday functions.¹Bernstein RM, Cozen H. Evaluation of back pain in children and adolescents. AFP. 2007;76(11):1669-1676. Available from https://www.aafp.org/afp/2007/1201/p1669.html

Typical Characteristics of Back Pain in Children and Adolescents

Depending on the underlying cause, pain may be restricted to a localized area of the back or may include the entire upper and/or lower back region. The common, benign causes of back pain in kids and teens generally have the following characteristics²Calvo-Muñoz I, Gómez-Conesa A, Sánchez-Meca J. Prevalence of low back pain in children and adolescents: a meta-analysis. BMC Pediatrics. 2013;13(1):14. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3571904/:

• In the initial stages, back pain in childhood and adolescence typically occurs with low intensity, and the pain commonly lasts for less than a week.
• There is usually a high rate of recurrence of back pain within this specific age group.
• When the pain recurs, it typically resurges with greater intensity.

There may be limitations in carrying out daily activities, missed school days, and the reduction of or hesitancy in performing physical activity.²Calvo-Muñoz I, Gómez-Conesa A, Sánchez-Meca J. Prevalence of low back pain in children and adolescents: a meta-analysis. BMC Pediatrics. 2013;13(1):14. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3571904/

Types of Back Pain in Kids and Teens

Based on the underlying cause, a few types of back pain experienced by children may include¹Bernstein RM, Cozen H. Evaluation of back pain in children and adolescents. AFP. 2007;76(11):1669-1676. Available from https://www.aafp.org/afp/2007/1201/p1669.html:

• Acute pain. A sharp, stabbing, and/or shooting pain may occur in event of an injury, trauma, fracture of the vertebra or vertebral growth plate, or herniated disc.
• Chronic pain. A constant ache, pain that comes and goes, or posture-related pain may occur due to inflammatory spondyloarthropathies, psychological issues, or developmental problems, such as Scheuermann's disease.
• Pain that worsens with spinal movement. Flexion (forward bending) increases pressure on the front part of the spinal bones, aggravating pain from conditions such as a herniated disc, discitis, osteomyelitis, or vertebral body tumor.

  Extension (backward bending) of the spine increases the strain on the posterior part of the spinal bones, including the facet joints, pars interarticularis, and pedicles. A lesion or injury, such as an osteoid osteoma, osteoblastoma, or spondylolysis, in this area can cause pain while bending backward.

• Night-time pain. Frequent pain that occurs at night and awakens the child is typically associated with tumors or infections, such as osteomyelitis, discitis, osteoid osteoma, osteoblastoma, eosinophilic granuloma, aneurysmal bone cyst, leukemia, Ewing's sarcoma, or spinal cord tumors.

Night-time back pain in children and teens warrants immediate medical attention.

Backpacks and Back Pain

There is some evidence to suggest that heavy backpacks may cause back pain in children.

• Habitually carrying heavy backpacks over one shoulder may cause the muscles in the area to strain in order to compensate for the uneven weight, resulting in localized or one-sided pain in the shoulder and upper back.⁴Rateau MR. Use of backpacks in children and adolescents: a potential contributor of back pain. Orthopaedic Nursing. 2004;23(2):101-105. Doi: 10.1097/00006416-200403000-00004
• Heavy backpacks may strain the neck muscles, contributing to or worsening existing back pain, shoulder pain, and arm pain.⁴Rateau MR. Use of backpacks in children and adolescents: a potential contributor of back pain. Orthopaedic Nursing. 2004;23(2):101-105. Doi: 10.1097/00006416-200403000-00004
• Improperly loading a backpack and stooping forward while walking can distribute weight unevenly within the bag, causing strain on the back muscles.⁴Rateau MR. Use of backpacks in children and adolescents: a potential contributor of back pain. Orthopaedic Nursing. 2004;23(2):101-105. Doi: 10.1097/00006416-200403000-00004

The American Academy of Pediatrics’ most recent non-evidence-based guidelines recommend that the optimal weight of a child’s backpack may be restricted to 10% to 20% of the child's body weight.¹Bernstein RM, Cozen H. Evaluation of back pain in children and adolescents. AFP. 2007;76(11):1669-1676. Available from https://www.aafp.org/afp/2007/1201/p1669.html Certainly if a child or teen complains about back pain after carrying their backpack, it is reasonable to try reducing the weight of the backpack, use a rolling pack, or explore other remedies.

Back Pain in Children and Adolescents Must Be Evaluated at the Earliest

Any complaint by a child or teenager about acute back pain or chronic back pain is taken seriously by pediatricians and is usually followed up with a detailed consultation that will include a review of the child’s medical history, an in-depth physical exam, and a psychological evaluation, if warranted.⁵Ryder C, Harrison K, Johnson K. Back pain in children and adolescents. Paediatrics and Child Health. 2015;25(12):549-554.

If the medical history and physical examination suggest an underlying condition, a series of tests may be conducted. These tests typically include blood tests and radiographic imaging studies, with a possible referral to a specialist for further examination and diagnostic tests.¹Bernstein RM, Cozen H. Evaluation of back pain in children and adolescents. AFP. 2007;76(11):1669-1676. Available from https://www.aafp.org/afp/2007/1201/p1669.html

When Back Pain in Kids and Teens May Be Serious

Back pain, specifically severe pain in the lower back region in children under 10 years of age and particularly in those younger than 4 years, should be considered a red flag for serious underlying pathologies, which may include³Kordi R, Rostami M. Low back pain in children and adolescents: an algorithmic clinical approach. Iran J Pediatr. 2011;21(3):259-270. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3446176/:

• Vertebral fracture
• Spinal tumors
• Infectious diseases
• Cauda equina syndrome

Spinal tumors and fractures may be associated with additional symptoms, such as fatigue, stiffness in the spine upon waking in the morning, weight loss, loss of appetite, fever, and/or local tenderness on the spine. Night pain, pain that awakens the child from sleep, and pain at rest may be specific to tumors.

Back pain associated with cauda equina syndrome may cause progressive neurological sciatica-like symptoms and bowel and/or bladder incontinence.

See When Sciatica Pain Is a Medical Emergency

Mild to moderate back pain in kids and teens may occur due to a sudden, direct hit to the back or as a result of a fall (such as while playing on a playground or participating in sports), and usually resolves within a few days with self-care and/or over-the-counter medications. Persistent, progressive, and/or severe back pain may indicate a serious medical condition and it is advisable to get medical help right away.

See When Back Pain May Be a Medical Emergency