Common, mostly from the muscles, and it settlesStrong evidence
About 12% of children and teenagers have back pain at any one time, 34% over a year and 40% at some point (59 studies). It is uncommon before school age and climbs through the teens towards adult levels by about 18: in Danish children, low back pain in the past month went from 4% at 9 to 22% at 13 and 36% at 15. Girls report it a little more often than boys (in surveys of 650,851 adolescents in 33 countries and regions, 21.9% of girls and 17.8% of boys reported back pain that the surveys counted as chronic), and in North-West England few children with it sought care.
Most of it is non-specific: it comes from the back's muscles and other ordinary structures, not from a disease, and it settles. In one clinic, 78% of 73 children with pain for 3 months or more had no specific diagnosis 2 years later; in a children's emergency department, 76.8% of 177 visits had no underlying cause; and 0.4% of 25,130 children sent home from US emergency departments with back pain had a serious diagnosis within 30 days. In 615 Brazilian schoolchildren, 83% of those with back pain had recovered within a year.
Sources 1, 2, 3, 4, 5, 6, 7, 8, 9, 10
The causes by ageEmerging evidence
NHS children's physiotherapists and Paediatric Musculoskeletal Matters, a teaching resource for doctors, say the same thing: most back pain in children comes from the muscles and the ordinary structures of the back, and serious causes are rare, but the younger the child, and the more sudden the pain, the more likely an underlying cause. In children's orthopaedic clinics a specific cause turns up in about a third (36% of 87 in one series), more often than in adults.
Under 5, back pain is uncommon, and an infection of a disc or bone (discitis) or, rarely, a tumour or leukaemia is more likely than at other ages. A toddler with discitis may refuse to walk, stand or sit, keep the back stiff, or cry when their nappy is changed, often without a high temperature. From 5 to 10, strains from play and sport are common, and the things to rule out are an infection (including a kidney infection), arthritis and, rarely, a tumour. A German guideline treats back pain in the first 10 years of life as a warning sign in itself, and the American Academy of Orthopaedic Surgeons says a young child's back pain that lasts more than several days or keeps getting worse should always be seen by a doctor.
From 10 to 18, non-specific back pain is by far the commonest, often with training, sport or a growth spurt. Less often it is a stress fracture of the spine in a young athlete; Scheuermann's disease, the commonest cause of upper back pain in teenagers; inflammatory back pain (ankylosing spondylitis tends to start in the teens or early adulthood, the NHS says); a slipped disc, which is rare and often follows an injury; or, rarely, a harmless bone growth (an osteoid osteoma) with dull night pain that eases with anti-inflammatory painkillers, or a bone tumour.
Sources 11, 12, 13, 14, 15, 16, 17, 18
Young athletes: a stress fracture of the spineStrong evidence
In young athletes the picture shifts. In a US sports clinic, a stress fracture of the spine (spondylolysis) explained the back pain of 47 of 100 adolescent athletes, against 5 of 100 adults; in 1,025 non-elite athletes aged about 15 with low back pain, 30% had one, most often in boys' baseball, American football and hockey and in girls' gymnastics. It typically hurts more arching backwards, standing or after sport, and builds over weeks.
The same crack is common and usually painless in the general population: 4.4% of children have one by the age of 6, and 6% of adults, and people followed for 45 years did as well as everyone else. Our spondylolisthesis guide covers the scan and the plan.
Sources 19, 20, 21, 22, 23
A rounded back or a curveEmerging evidence
Scheuermann's disease, a stiff, rounded upper back that doesn't straighten when standing tall or lying flat, affects about 3 in 100 (2.8% in Danish twins) and is diagnosed more often in boys; exercise helps the pain but doesn't straighten the curve. Scoliosis, a curve to one side, usually isn't very painful and isn't caused by posture, bags or sport, the NHS says. But in 2,442 children with scoliosis, 23% had back pain when first seen, and 9% of those had another cause, so a curve that hurts needs checking.
Sources 24, 25, 26, 27, 28
Causes outside the back muscles, and their signsEmerging evidence
Rarely, back pain in a child comes from somewhere else: a urine or kidney infection (pain in the lower tummy or the back just under the ribs, a high temperature, wetting themselves or being sick); an infection of a bone or disc; leukaemia (bone or back pain with tiredness, looking pale, fevers, bruising or swollen glands); or a bone tumour (pain that is worse at night, or a lump or swelling). These are why the warning signs come first. The National Institute for Health and Care Excellence (NICE) asks GPs to offer a very urgent blood count to a child with persistent or unexplained bone pain, and to consider a very urgent X-ray for unexplained bone pain or swelling.
Sources 29, 30, 31, 32, 33, 34, 11
When a scan or test helpsStrong evidence
Most children don't need one. The American College of Radiology says constant, night or radiating pain lasting 4 weeks or more should prompt imaging, and without such warning signs imaging is likely not needed; an abnormal nerve examination, or signs of an infection or a tumour, need imaging straight away. X-rays come first, then magnetic resonance imaging (MRI). Computed tomography (CT) scans and some extra X-ray views carry more radiation, which matters more in children. Blood tests are used for young children and for night pain or feeling unwell.
Scan findings can mislead: signs of disc wear showed up in about a third of 439 Danish 13-year-olds. The warning signs aren't perfect either: in children scanned for pain lasting more than 4 weeks, a cause was found in 42% of those with constant pain, 38% with night pain and 8 of 9 with an abnormal nerve examination. For a suspected stress fracture of the spine, the NHS describes an X-ray, with an MRI scan if there are leg symptoms, and NHS inform says most back problems don't need an X-ray or MRI.
Sources 35, 36, 17, 16, 13, 34, 37, 38, 23, 39
How it usually goesEmerging evidence
An NHS children's physiotherapy page says simple back pain should ease in 2 to 4 weeks and settle by 6 weeks, and NHS inform expects most new back problems to begin to settle within 6 weeks. In Brazilian schoolchildren, 83% of those with back pain had recovered within a year, though 31% of those who recovered within 6 months had it again by a year. In 178 English schoolchildren with low back pain, 26% still had it 4 years later, more often after long episodes, pain spreading down a leg or problems with friends, and a German guideline estimates that it keeps coming back or lasts in 10% to 30%.
Teenagers with long spells of back pain were more likely to have back pain as adults (in 9,600 Danish twins), but in 1,249 young people followed from 17 to 22, more than half stayed low throughout and 15% improved. A stress fracture of the spine takes longer: in one trial, the median return to sport was 74 days. No one can promise a timescale.
Sources 40, 39, 10, 41, 16, 42, 43, 44
