Low back pain at 14: why in a young athlete it is not what it is in an adult

42% of athletes aged 10-19 report low back pain over twelve months, and female sex appears among the reported risk factors. The difference almost nobody knows about is the cause: in adolescence, sport-related low back pain is far more often a stress fracture of the spine and far more rarely a disc problem or a muscle strain. The data, the limits of the data, and why immediate physiotherapy now beats rest.

There is one sentence that usually ends the conversation in the gym: "her back is a bit sore, must be a muscle strain." Said of a thirty-five-year-old, it is often true. Said of a fourteen-year-old training five times a week, it is statistically the least likely explanation on the list. An adolescent athlete's back breaks in different ways from an adult's — and that difference is not a specialist detail: it changes what you look for, how long you wait, and how she gets back on the field.

In brief

  • Low back pain in young athletes is common: estimated prevalence of 42% over the previous 12 months (95% CI 29-55%) in athletes aged 10-19 (Wall et al., 2022; 80 studies, very high heterogeneity).
  • Reported risk factors include training volume and intensity, concurrent lower-limb pain, overweight, older adolescent age, family history and female sex (Wall et al., 2022).
  • The most frequently described cause in this age group is spondylolysis: a stress fracture of the pars interarticularis, not a disc problem and not a muscle strain.
  • In a historical comparison of 100 adolescents and 100 adults, spondylolysis explained 47% of cases in adolescents versus 5% in adults; the disc 11% versus 48% (Micheli and Wood, 1995 — specialist clinic sample, therefore selected).
  • In non-elite adolescent athletes with low back pain, the proportion with spondylolysis is 30%; among girls the highest figures are in gymnastics (34%), marching band (31%) and softball (30%) (Selhorst et al., 2019).
  • Returning to sport after spondylolysis is the rule, not the exception: 92.2% with conservative treatment (Overley et al., 2018).
  • The most recent evidence: starting physiotherapy immediately rather than resting first meant 38 fewer days to return to sport and 3% versus 29% recurrences at 12 months (Selhorst et al., 2026 — a single trial, 64 participants).

How common is low back pain in young athletes?

Around four in ten report it over a year. The broadest synthesis available pooled 80 studies in athletes aged 10-19, across 60 sports and 23 countries. The aggregate estimates are these (Wall et al., 2022):

The limitation has to be stated up front, because it is large: heterogeneity between studies reaches I² = 96-98%. The main reason is that there is no agreed definition of low back pain in adolescent athletes — some studies define it as "pain that caused missed training", others as "pain reported at least once", others require a diagnosis. The authors themselves close by recommending that future research adopt one. So: the order of magnitude — tens of percent, not a handful of isolated cases — is solid. The precise number is not.

On sport profiles, the review could not run a discipline-by-discipline meta-analysis, but it flags a recurring pattern: generally higher levels in ballet, gymnastics and rowing, generally lower in soccer and martial arts. These are the sports where the lumbar spine repeatedly works in extension — arched backwards — and in rotation.

Are girls more at risk?

Female sex appears on the list of risk factors — but it is a list, not a risk estimate. In the same review, the risk factors reported by the included studies are: sport participation itself, training volume and intensity, concurrent lower-limb pain, overweight or high BMI, older adolescent age, female sex and a family history of low back pain (Wall et al., 2022).

This needs reading precisely: the authors call them potential risk factors and list them from the primary studies rather than pooling them into a single relative risk. In other words, the signal is there, and it is consistent with what is seen in the general adolescent population — where recurrent musculoskeletal pain is more common in girls, as we described when writing about how pain changes at puberty — but there is currently no clean number of the form "girls have X times the risk".

One distinction is worth adding, because it often gets lost. Having low back pain and having spondylolysis are not the same thing and do not necessarily follow the same profile by sex: in the non-elite case series, the highest proportions of spondylolysis among those presenting with low back pain were found both in male sports such as baseball (54%) and in female sports such as gymnastics (34%) (Selhorst et al., 2019). On this we prefer to say less and get it right: the robust point is that low back pain in a young athlete deserves to be taken seriously, not that a well-quantified hierarchy of risk by sex exists.

Why a fourteen-year-old's back pain is not an adult's

Because in the adolescent the pain far more often comes from the back of the vertebra, and in the adult far more often from the disc.

The work that made this difference explicit is a direct comparison: 100 young athletes aged 12-18 (mean age 15.8) attending an adolescent sports medicine clinic, versus 100 adults aged 21-77 (mean age 31.9) attending an acute low back pain clinic. The result (Micheli and Wood, 1995):

Final cause of pain Adolescents Adults
Spondylolysis (pars stress fracture) 47% 5%
Discogenic pain 11% 48%
Muscle-tendon strain 6% 27%
Spinal stenosis and osteoarthritis 0% 10%

In the adolescent group, 62% had a derangement of the posterior elements of the vertebra associated with the onset of pain. That is the exact reverse of the common intuition: in adults we think "disc" or "strain" and are usually right; in a fourteen-year-old athlete, those two hypotheses together cover fewer than one case in five.

Two indispensable caveats, because this figure is quoted everywhere without context. First: it is a 1995 retrospective study, and the two groups come from two different clinics — one specialising in adolescent athletes. Anyone who reaches that clinic is already selected: their pain was serious enough for someone to send them down a specialist pathway. Second, and consequently: 47% is not the probability that your daughter's back pain is spondylolysis. It is a proportion within an already filtered population.

What happens if you look at a less selected population? The number falls, but stays large. In 1,025 non-elite adolescent athletes (mean age 15 ± 1.8) presenting to a hospital sports medicine clinic with low back pain, 308 — 30% — were diagnosed with spondylolysis (Selhorst et al., 2019). And in a single-arm meta-analysis of 9 studies and 835 athletes with low back pain, the pooled estimate was 41.7% (95% CI 28-55%), with the authors flagging small samples and low representativeness (Li et al., 2023).

Three estimates, three different populations, a range running from 30% to 47%. The message is not the figure: it is that a cause that is a rarity in adults is, in this age group, among the first to consider.

What spondylolysis is, in plain terms

It is a stress fracture of the spine. The pars interarticularis is a thin bony bridge connecting the posterior joints of a vertebra, almost always involved in the lower lumbar levels. When the back arches backwards and rotates, that bridge takes repeated compression. If load accumulates faster than the bone can repair it, first a stress reaction and then a true defect develops.

It is exactly the same logic as stress fractures of the leg and foot, applied to a bone almost nobody associates with stress fractures. And like those, it shares three features that make it hard to spot on the sideline:

The typical movement behind it is no mystery: the backbend, the artistic gymnastics arch, the landing off the beam, the serve and the spike in volleyball, the high jump, the cambré in dance, the repeated throwing rotation. It is no coincidence that the systematic review finds the highest levels of low back pain in dance, gymnastics and rowing (Wall et al., 2022).

The historical gymnastics figure conveys the order of magnitude: in 100 young high-level gymnasts studied radiographically, 11% had a pars defect and 6% a spondylolisthesis — around four times the rate reported in their non-athletic peers (Jackson et al., 1976). It is a 1976 study, radiographic, in elite athletes: it is not an estimate you can transfer to a girl doing gymnastics twice a week at a local club. But it is why, even then, the authors wrote that low back pain in a young gymnast should be treated as a warning sign.

When to have back pain assessed, and why not to wait

A clear premise is needed here: nothing that follows allows a diagnosis, and that is not the intent. Telling spondylolysis from muscular pain is clinical work, involving an examination and, if indicated, imaging. What can be said is when to stop waiting.

These are good reasons to ask a healthcare professional for an assessment:

The practical reason not to wait is about bone, not bureaucracy: as with all bone stress injuries, an injury caught early follows a different path from one dragged out for months. And there is a side effect of slowness that is easily overlooked: the longer pain goes without a name, the more "normal" it becomes — and at that point it stops being mentioned at all.

Rest, or physiotherapy straight away? The evidence has moved

The most recent data say: physiotherapy immediately, not rest first. For years the standard approach to active adolescent spondylolysis was to stop, wait for symptoms to settle, then rehabilitate. A multicentre randomised trial published in 2026 tested that sequence.

The design: 64 adolescent athletes aged 10-19 with active lumbar spondylolysis (median age 14.2, 40% girls), randomised to immediate physiotherapy — started within 7 days and progressed according to pain and function — or to rest before physiotherapy, starting rehabilitation once symptoms resolved and progressing by time. The results favoured the immediate group (Selhorst et al., 2026):

The stated limits: it is one trial with a small sample (64 participants, 40% of them girls — around 26 female athletes). That is not enough to rewrite a guideline on its own. But the direction is consistent with what is seen in other adolescent musculoskeletal pain, where load management beats complete rest: stopping everything is rarely the best strategy, dosing almost always is. And, as ever, the treatment decision belongs to the clinician caring for the athlete, not to an article.

And does she play again?

Yes, in the large majority of cases — and that is the best reason to get assessed. A meta-analysis pooled 11 studies and 376 adolescent patients with a pars defect without vertebral slippage (spondylolysis without spondylolisthesis), estimating return to competition at 92.2% with conservative treatment and 90.3% with surgery (Overley et al., 2018).

Two readings, both useful. The reassuring one: spondylolysis is not the end of sport for a fourteen-year-old. The less comfortable one: that 92% is the outcome of a pathway — diagnosis, load modification, rehabilitation, graded return. It is not what happens to someone who lives with the pain, calling it a muscle strain, for two seasons.

"Back pain is part of sport"

The missing piece is not clinical. It is cultural, and it has been studied directly.

A qualitative study interviewed athletes aged 10-19 who had had an episode of sport-related low back pain in the previous year. Three themes emerged (Wall et al., 2023):

  1. The culture of normalising low back pain in sport negates safeguarding measures designed to protect adolescent athletes from pain and injury.
  2. Low back pain changes how athletes are perceived by others and how they perceive themselves.
  3. It has broad effects on well-being, physical and psychological.

The study's title is a participant's own quote — "back pain is part of sport… I'm just gonna have to live with it" — and it captures the mechanism better than any statistic. It is the same pattern we found in ankle sprains, in knee pain that lasts months and in urinary leakage during jumps: a symptom so frequent it looks normal, and for exactly that reason never reported. With one aggravating factor here: when the frequent symptom is hiding a stress fracture, time works against you.

What changes in the gym, concretely

This is not a clinical protocol. These are the points the sources cited above converge on, translated into decisions a club can take.

BAB's role

Pain that lasts weeks can only be recognised if someone records it while it lasts. That is exactly what BAB puts in the athlete's hands: a private space to note where it hurts, how much and when — so that an isolated symptom becomes a readable pattern, taken to a professional as a precise description instead of a vague memory. To the club, BAB gives only aggregated, anonymous signals: how many athletes are reporting pain, not who. That is enough to notice that something in the training load is off, without anyone having to expose herself in the changing room.

Because the point of this article is exactly that: in a fourteen-year-old's back, what separates "a muscle strain" from "a stress fracture" is not how bad the pain is. It is how much time passes before someone looks.

Sources

This article is for information only and is not medical advice or a clinical assessment. Back pain lasting weeks in an adolescent athlete, pain that worsens on arching backwards, night pain, or pain with pins and needles or loss of strength in the legs should be assessed by a healthcare professional.

How common is low back pain in young female athletes?

Far more common than most people assume. In a systematic review with meta-analysis of 80 studies in athletes aged 10-19, the estimated prevalence of low back pain over the previous 12 months was 42% (95% CI 29-55%), over the previous 3 months 46% (95% CI 41-52%), and point prevalence 16% (95% CI 9-23%) (Wall et al., 2022). Heterogeneity between studies is very high (I² up to 98%) because there is no agreed definition of low back pain: the order of magnitude is reliable, the exact figure is not.

Is an adolescent's back pain different from an adult's?

In the available data, yes — and the difference is the cause. Comparing 100 young athletes aged 12-18 with 100 adults with acute low back pain, 47% of the adolescents had spondylolysis — a stress fracture of the pars interarticularis — versus 5% of the adults; conversely, discogenic pain explained 48 of 100 cases in adults versus 11 in adolescents, and muscle-tendon strain 27% versus 6% (Micheli and Wood, 1995). Note: this is a 1995 study of patients who reached two specialist clinics, so already a selected population; it is not a snapshot of every girl with back pain.

What is spondylolysis?

It is a stress fracture of the pars interarticularis, the thin bony bridge connecting the posterior joints of a vertebra, almost always in the lower lumbar spine. It does not come from a single trauma but from repeated loading of the spine in extension and rotation: the backbend, the gymnastic arch, the volleyball spike, the serve, the high jump. It is the same logic as other stress fractures, applied to the back instead of the shin or the foot.

Which sports carry the highest rates in girls?

In a study of 1,025 NON-elite adolescent athletes presenting to a clinic with low back pain (mean age 15), 30% had spondylolysis; among girls the highest proportions were in gymnastics (34%), marching band (31%) and softball (30%) (Selhorst et al., 2019). The authors explicitly warn against transferring that ranking elsewhere: their own list did not match the published literature, and geographical region and athlete level change the picture considerably. In elite gymnasts, a historical radiographic study of 100 girls found pars defects in 11% — around four times the rate reported in their non-athletic peers (Jackson et al., 1976).

When should a girl's back pain be assessed by a professional?

This article is educational and cannot tell one cause from another: that is a clinician's job. There are, however, situations that are good reasons to ask for an assessment rather than wait: low back pain that has lasted weeks and is not improving, pain that flares when the back arches backwards, pain always in the same spot and on one side only, pain that wakes the athlete at night, pain with pins and needles or loss of strength in the legs, or pain that is making her miss training. The practical reason not to wait is that when there is a bone injury, catching it early changes the pathway.

After a diagnosis of spondylolysis, is rest required?

The most recent evidence points the other way. In a multicentre randomised trial of 64 adolescent athletes aged 10-19 with active spondylolysis (median age 14.2, 40% girls), those starting physiotherapy within 7 days were significantly better at one month on pain and disability, returned to sport 38 days sooner, and had far fewer recurrences of low back pain over the following 12 months (3% versus 29%), with no adverse events (Selhorst et al., 2026). It is a single trial with a small sample (64 participants): it indicates a direction, it does not settle the question — and the decision remains with the clinician treating the athlete.

Can a girl with spondylolysis go back to sport?

In the large majority of cases, yes. A meta-analysis of 11 studies and 376 adolescent patients with a pars defect without vertebral slippage estimated return to competition at 92.2% with conservative treatment and 90.3% with surgery (Overley et al., 2018). The message is not 'it is not serious': it is that the pathway works when someone sets it up, and that this is a reason to get assessed rather than live with the pain.

Why do so many girls not mention back pain?

Because in sport, back pain is treated as part of the game. A qualitative study of athletes aged 10-19 with sport-related low back pain identified exactly this as its first theme: the culture of normalising low back pain negates safeguarding measures designed to protect adolescent athletes from pain and injury. The other two themes are just as concrete: low back pain changes how athletes are perceived and how they perceive themselves, and it has broad effects on well-being (Wall et al., 2023). The study's title is a participant's own words: back pain is part of sport, so you live with it.