Adolescent Lower Back Pain: Understanding Bone Stress Injuries

Why Is Lower Back Pain So Common in Young Athletes?

Lower back pain is a common complaint in adolescent athletes. While mild muscle soreness is expected during training, persistent pain may be a sign of something more serious, lumbar bone stress injury (LBSI). These overuse injuries are particularly common in sports that involve frequent bending, twisting, or arching of the spine, such as gymnastics, cricket, AFL, and tennis.

What Are Lumbar Bone Stress Injuries?

LBSIs affect the bones at the back of the lower spine, especially a small region called the pars interarticularis. These injuries occur gradually when repetitive stress overloads the area, leading to a stress reaction or even a stress fracture (commonly referred to as spondylolysis).

Young athletes are more susceptible due to rapid growth, changing biomechanics, and high training loads placed on an immature skeleton.

Common Symptoms

You or your child might notice:

• One-sided, dull lower back pain
• Pain that worsens with arching the back or twisting
• Discomfort during or after sport
• Pain that persists despite rest
• Tenderness when pressure is applied to the lower spine

These symptoms usually come on gradually and may fluctuate with training intensity.

Diagnosis: Not Just About Scans

Correctly identifying a bone stress injury requires a combination of clinical assessment, risk factor screening, and in some cases, imaging.

1. Clinical History

A physiotherapist or sports doctor will ask about:

• When the pain started and how it has changed
• Recent changes in training load
• Type of sport and movement patterns
• Recent growth spurts
• Any previous injuries or back pain

2. Risk Factor Screening

• Low energy availability (LEA): When an athlete isn’t eating enough to match their training demands, it affects bone health and healing.
• High training volumes (often >15 hours per week)
• Single-sport specialisation from a young age
• Rapid physical growth or peak height velocity
• Poor core or lumbo-pelvic control
• A history of previous back pain or stress injury

Screening for these factors helps determine the likelihood of a bone stress injury and whether imaging is appropriate.

3. Physical Examination

The clinician will assess:

• Movement patterns and pain triggers
• Core and hip strength
• Muscle flexibility and posture
• Spinal tenderness on palpation
  
  

4. Imaging

If a bone stress injury is suspected:

• MRI is the first choice – it detects early stress reactions and avoids radiation exposure.
• CT scans are used if a fracture needs confirmation, but involve radiation and are used selectively.
• X-rays are often the first step but may miss early-stage injuries.
  

Management: The Four Pillars

1. Load Management

Initially, athletes need to reduce or modify activities that aggravate their symptoms, typically spinal extension and rotation movements. This doesn’t mean full rest, pain-free cross-training is usually encouraged.

2. Rehabilitation

A progressive rehab plan includes:

• Core stability and lumbo-pelvic control training
• Strengthening of the glutes and lower limbs
• Mobility work for the hips and upper back
• Gradual reintroduction of sport-specific tasks

This process usually spans 6–12 weeks, depending on the severity of the injury and athlete’s progress.

3. Education and Monitoring

Athletes and families are educated on:

• Load management and energy intake
• Early warning signs of overload
• The importance of sleep, nutrition, and recovery
• Monitoring symptoms and progress

4. Return to Sport

A gradual return is only recommended once:

• Pain has resolved during daily and sporting tasks
• Strength, mobility, and control have normalised
• Sport-specific drills can be performed without symptoms

Your physiotherapist will guide this based on objective criteria.

Can These Injuries Be Prevented?

While not all LBSIs can be prevented, key steps to reduce the risk include:

• Balancing training loads and avoiding rapid spikes
• Ensuring adequate energy intake to match training demands
• Prioritising strength and control, especially in the core and hips
• Avoiding early sport specialisation
• Encouraging rest and recovery, particularly during growth spurts

Lumbar bone stress injuries are a leading cause of ongoing lower back pain in adolescent athletes. The good news is, with early diagnosis, targeted rehab, and proper risk screening, including nutritional factors like energy availability, most young athletes make a full recovery.

At Coast Sport, we specialise in managing adolescent sports injuries. If your child or athlete has persistent back pain, contact us for a comprehensive assessment and expert care.