Back Pain in High School Athletes Should Be Taken Seriously

June 11, 2019

Back pain is a common complaint in adults, with research indicating that up to 80 percent of adults will develop back pain in their lifetime. The incidence of low back pain in adolescents is much lower; however, pain in this age group should be taken seriously. Delays in diagnosis and treatment can lead to lifelong complications. Even if a young athlete is well-conditioned, injuries will occur, and training errors may be a factor in their development.

During adolescence, the muscles and ligaments cannot keep pace with the bone growth and their bone density does not reach its peak until the early 20s. Therefore, high school athletes are more susceptible to bone-related injuries. Adolescents also have areas of the bone, including cartilaginous regions called growth plates, that have not fully formed and are much more susceptible to both overuse and traumatic injury. Poor technique and excessive training during this vulnerable time can lead to more injuries. Due to a wide variation of athlete skill, maturation stage and body types, it is often difficult to determine which athlete is more susceptible to such injuries.

Although back injuries may occur in any sport, they seem to be most common in sports that require extensive twisting and extension types of back motion. These sports include gymnastics, cheer, soccer, field hockey, football, wrestling, weightlifting and lacrosse. Injuries also are more common in athletes who specialize in one sport during high school.  

“Athletic Energy Deficits” may also play a role in injury susceptibility. Most young athletes are not preparing their own meals, and they are often not very knowledgeable about their nutritional needs. They rely on their parent/guardian, friends or advertising to make these choices for them. Other athletes rely on the school itself for their nutritional needs. This may leave the athlete with an “athletic energy deficit” as it pertains to taking in the appropriate nutrients through his or her diet to offset the stress placed on the body through athletics. Another danger is that some athletes are encouraged to maintain a lower-than-healthy body weight to participate in a sport.

The most common injuries to the low back are from strains of the back muscles. These injuries are localized to the region of the back and may or may not be associated with muscle spasm. Muscle strains are self-limiting and typically heal within one to two weeks with simple treatments such as relative rest, ice, stretching and gradual return to training and sport activity as the symptoms resolve.

It is easy for the athlete, coach and parents to brush off these muscular back injuries, but failure to recognize and treat these minor injuries can be serious. A muscular injury may be the first warning sign that may lead to a progression of more severe injuries that involve the bones. When these occur, it may take three to six months of proper treatment for the injury to heal completely.  

The most common bone injury of the lower back in young athletes is a spondylolysis. Some studies have shown that up to 50 percent of young athletes that present to a doctor with low back pain have this condition. Spondylolysis is a stress fracture of the part of the vertebrae in the low back that is called the pars interarticularis. This injury is usually seen at times of adolescent growth and is caused by repetitive stress applied to the low back that involves extension (backward bending) and rotation (twisting).

These injuries can occur on one side of the bone (unilateral) or on both sides (bilateral). The pain is usually reported just to the side of the spine and not directly in the midline of the spine. This condition is often difficult for a physician to diagnose, because it is not seen on standard x-rays when it is in the early stages. When there is suspicion of this condition, a physician often orders more advanced imaging such as an MRI or bone scan in order to diagnosis this type of stress fracture.

Although either unilateral and bilateral, spondylolysis is concerning and needs to be properly treated. The unilateral condition can lead to bilateral injuries, and the bilateral injuries are more concerning as they can lead to a permanent slipping of one spine bone over the one just below it. When the bony injury progresses to this stage, it is called spondylolisthesis. With this condition, some slippage can progress to even more slippage in the teenager. A physician must monitor this condition very closely because progression of the condition may require surgery. Unfortunately, spondylolisthesis often leads to complications with the low back throughout adulthood.

Disc injuries can also occur in young athletes, but they are much less common in adolescents than in adults. At this stage of life, the cartilage of the discs is still in generally good condition and has a higher ability to withstand forces; however, some adolescents can still develop disc-related injuries from either repetitive motion or a single incident that causes this damage.

No athlete, parent, coach or administrator wants to lose an athlete from participation for any length of time. There are things that you can do to help prevent these overuse injuries in your athletic program:

  • Coach proper technique (in sport and in the weight room)
  • Protect against excessive training (Age Rule: Age of student- athlete = total hours a week spent training)
  • Be mindful of periods of rapid growth with your student- athletes. (Every individual is different, but rule of thumb can be student-athletes in 9th and 10th grades.)
  • Make sure that flexibility is a part of your workouts. (Hamstring and hip mobility lessen the chance of back injuries.)
  • Be mindful of training teams vs. training positions. (Do not train every position on a team the same because they are playing that sport. Train the individual position within the sport/team.)
  • Athletic Energy Deficits (Be mindful of your athletes’ nutritional needs and if they are nutritionally ready to respond to the energy demands of your workout for the day.) The NFHS Learning Center has a free online education course – Sports Nutrition – available at www.NFHSLearn.com.
  • Be mindful of excessive low-back hyperextension and rotation in sports (offensive lineman, cheer/gymnastics, volleyball, kickers football/soccer, hitters baseball/golfers/ softball, etc.)

Any time an adolescent complains of back pain, he or she should seek care from a certified athletic trainer or other healthcare professional, who can further evaluate and treat the condition, while keeping an eye out for concerning signs that may indicate a more serious injury and need for evaluation by a specialist. Coaches and administrators should watch for these concerning signs or symptoms:

  • pain from a hard fall or other traumatic event
  • pain that persists for more than two weeks
  • pain, numbness, tingling or weakness that extends down one or both legs
  • bowel or bladder dysfunction
  • fever * sudden weight loss
  • night pain that hinders sleep