Published: February 3, 2026
Back pain among adolescents has become increasingly common in pediatrics, particularly in primary care. Once relatively rare, it now affects an estimated 28% to 48% of school-age children, with higher rates among adolescents and athletes.“Adolescent back pain is now common and often multifactorial, with posture-related pain now representing a significant proportion of cases,” said Kent L. Walker, D.O., pediatric orthopedic surgeon with Norton Children’s Orthopedics of Louisville, affiliated with the UofL School of Medicine.Understanding common causes and red flags helps providers differentiate benign conditions from those requiring referral.
One of the strongest associations is prolonged sedentary activity, particularly screen time. Adolescents who spend more than two hours per day studying, watching television or using devices are at higher risk of back pain.Athletes are more likely to have true underlying injuries, most commonly from overuse such as spondylolysis, or disc-related pathology.
When a pediatric patient presents with back pain, a detailed history remains the most critical evaluation component, including:
Timing: Distinguish acute (less than six weeks’ duration) versus chronic pain (more than six weeks’ duration).
Activity association: Pain during sports that limits participation is more concerning than pain after activity. Voluntary withdrawal from sports may indicate significant underlying issues.
Location: Upper/mid-thoracic pain is often posture-related; midline pain raises concern for disc pathology; off-midline pain may indicate muscle strain or spondylolysis.
Red flags: Pain waking the patient at night, radiating pain, morning stiffness or systemic symptoms warrant closer attention.
Providers should be familiar with common etiologies of pediatric back pain:Posture-related pain: Poor posture from prolonged device use (“text neck”) is now one of the most common contributors. Adolescent round back (postural kyphosis) is flexible and correctable with effort, unlike rigid Scheuermann’s kyphosis. Initial management includes physical therapy, ergonomic education and frequent position changes. Imaging may be unnecessary unless symptoms persist.
Muscle strain: Typically presents off-midline and as activity-related. Imaging is not routinely needed, but rest is essential as early return to activity delays healing.
Spondylolysis or spondylolisthesis: A stress fracture of the pars interarticularis is common in athletes involved in hyperextension sports (football, gymnastics, cheerleading, weightlifting, etc.). Clinical features include pain with lumbar extension, hamstring tightness and positive stork test. Initial imaging includes two-view lumbar spine radiographs; MRI is preferred for further evaluation. Most patients improve with temporary sports cessation, bracing and structured physical therapy.
Disc pathology: This presents with midline pain worsened by flexion and sitting. A herniated disc causes more severe pain with true radicular symptoms. MRI is indicated when disc pathology is suspected.
Vertebral fractures: Severe pain, inability to continue activity and difficulty walking require urgent evaluation with appropriate imaging.
Immediate evaluation is needed for:
These may indicate discitis, vertebral osteomyelitis, epidural abscess, neoplasm, transverse myelitis or tethered cord syndrome. Laboratory studies (complete blood count, erythrocyte sedimentation rate, C-reactive protein) and MRI with contrast are essential.
Routine referral is appropriate when:
Urgent referral is warranted for suspected infection, neoplasm, fracture or neurological compromise.
Although most cases improve with conservative management, recognizing red flags helps ensure timely referral, prevents delayed diagnosis of serious conditions and helps improve patient outcomes.