Clinical Review & Education

JAMA Pediatrics | Review

Musculoskeletal Low Back Pain in School-aged Children

A Review
James MacDonald, MD, MPH; Emily Stuart, MD; Richard Rodenberg, MD

Supplemental content
IMPORTANCE Low back pain (LBP) in children and adolescents is a common problem. The
differential diagnosis of LBP in this population is broad and different from that seen in the
adult population. Most causes of LBP are musculoskeletal and benign in their clinical course.
Clinicians should have an understanding of the relevant anatomy and the most commonly
encountered etiologic factors of LBP in children and adolescents to provide effective care.

OBSERVATIONS Low back pain is rarely seen in youth before they reach school age.
Subsequently, rates of LBP rise until age 18 years, at which age the prevalence of LBP is similar
to that in adults. The differential diagnosis of LBP in this population is broad, and individual
etiologic factors are most often associated with musculoskeletal overuse or trauma. Sinister
etiologic factors are rare. The patient’s history and physical examination are the foundation of
evaluating a child with LBP. The indication for and timing of specific imaging or other studies
Author Affiliations: Division of
will vary depending on the etiologic factor of concern. Most treatment of LBP in this
Sports Medicine, Department of
population is centered on relative rest, rehabilitation, and identification of predisposing risk Pediatrics, Nationwide Children’s
factors. Pharmacologic treatment may be used but is typically a brief course. Orthopedic, Hospital, Columbus, Ohio
rheumatologic, and other subspecialty referrals may be considered when indicated, but most (MacDonald, Rodenberg); The Ohio
State University College of Medicine,
of these patients can be managed by a general pediatrician with a good understanding of the Columbus (MacDonald, Rodenberg);
principles described in this article. Department of Orthopedics,
Children’s Hospital Colorado,
Orthopedic Institute, Aurora (Stuart);
CONCLUSIONS AND RELEVANCE Low back pain in children and adolescents is a common
University of Colorado School of
problem. It is most often nonspecific, musculoskeletal, and self-limiting. Pediatricians should Medicine, Aurora (Stuart).
recognize the importance of a proper history, physical examination, and general knowledge Corresponding Author: James
of the lumbar spine and pelvic anatomy relevant to the child in their evaluation with this MacDonald, MD, MPH, Division of
presenting symptom. Sports Medicine, Department of
Pediatrics, Nationwide Children’s
Hospital, 584 County Line Rd,
JAMA Pediatr. 2017;171(3):280-287. doi:10.1001/jamapediatrics.2016.3334 Westerville, OH 43082
Published online January 30, 2017. (james.macdonald
@nationwidechildrens.org).

L
ow back pain (LBP) in school-aged children is a common oc-
currence; nevertheless, it is often underappreciated.1 The
prevalence of LBP rises with age: 1% at age 7 years, 6% at
age 10 years, and 18% at ages 14 to 16 years.2 By age 18 years, the
lifetime prevalence rates of LBP approach those documented in
adults, with an estimated yearly prevalence of 20% and a lifetime
prevalence of 75%.3 More than 7% of adolescents experiencing LBP
will seek medical attention.1
The effect of LBP on this population can be considerable and
may significantly restrict instrumental activities of daily living for this
population, such as attendance at school and gym or sports
participation.4 Low back pain in this age group is a significant risk
factor for developing LBP as an adult.5
Several potential risk factors for developing LBP in school-
aged children have been investigated. The prevalence of LBP cor-
relates with participation in sports and level of competition.4,6,7 There
is a U-shaped association between physical activity and the inci-
dence of LBP in school-aged children, with both low and high levels
of physical activity associated with a higher risk.8,9 Female sex,
growth acceleration, adverse psychosocial factors, increasing age,
previous back injury, and family history of LBP are all potential risk
factors for school-aged children to develop LBP.9-12 Although there
has been concern about a potential association of LBP and back-
packs, the evidence pointing to use of backpacks as a risk factor is
weak.9 No single risk factor for a first episode of LBP in school-aged
children has been definitively validated (level of evidence, 1).13
Historically, it has been taught that most LBP in school-aged chil-
dren has an identifiable diagnosis. More recent research has chal-
lenged this thinking. A high-quality prospective study of 73 pediat-
ric patients with LBP (level of evidence, 2) followed up for 2 years
found that nearly 80% had no definitive diagnosis.14 Most cases of
LBP in school-aged children are nonspecific and self-limiting.15,16
Discussion and Observations
Relevant Anatomy
Pediatricians need a basic but solid understanding of the anatomy
of the lumbosacral spine to provide effective care to school-aged chil-
dren with LBP. The lumbar spine is composed of 5 vertebrae

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 Musculoskeletal Low Back Pain in School-aged Children
(L1-L5), with an intervertebral disc between each vertebra and be-
tween L5 and the sacrum. The sacrum articulates with the ilium of
the pelvis at the sacroiliac (SI) joint, a diarthrodial joint with limited
motion.15
The most significant components of the vertebra are the body
and the posterior elements, which include the pars interarticularis and
the spinous and transverse processes.17 The vertebrae themselves
articulate posteriorly at the zygapophyseal facet joints. In the pedi-
atric spine, the superior and inferior portions of the vertebral body
and the spinous processes are composed of physeal cartilage and are
secondary ossification centers that become radiographically appar-
ent between ages 8 and 12 years and fuse by adulthood.18,19 Before
that fusion occurs, these areas are more prone to injury than is the
solid bone of an adult (Figure 1).
The spinal nerves will bilaterally exit the foramina of the lum-
bar spine below their corresponding vertebral body level. For ex-
ample, the L2 nerve root exits below L2 through the foramen be-
tween L2 and L3. This anatomical feature is important to remember
in the evaluation of potential radiculopathies that may be associ-
ated with LBP and their associated findings on neurologic exami-
nation (discussed in the Evaluation section).
Differential Diagnosis and Pathophysiological FIndings
The differential diagnosis of LBP in school-aged children is broad and
different from that seen in an adult population (Table 115,18,20-36 and
eTable 1 and eTable 2 in the Supplement).37 The most common cause
of LBP is acute or subacute musculoskeletal pain with no identifi-
able pain generator.38 A tight thoracolumbar fascia results as a con-
sequence of rapid growth and can be compounded by existing in-
flexibility, which results in a hyperlordosis, producing a flat midback
and thoracic kyphosis, which can lead to a syndrome known as
hyperlordotic LBP. This term is used synonymously with the terms
posterior overuse syndrome, mechanical LBP, or muscular LBP.7,23
In general, when the clinician is able to identify a specific etio-
logic cause for LBP in school-aged children, it involves injury to the
posterior elements of the spine, such as spondylolysis, which is
much more common than pathologic disc characteristics in this
population.15,37 The remainder of this section briefly discusses the
pathophysiological features of the more common, specific diagno-
ses affecting the posterior elements of the spine; Table 115,18,20-36
and eTables 1 and 2 in the Supplement contain an in-depth discus-
sion of other diagnoses, including herniated nucleus pulposus
(HNP), apophyseal ring fractures, atypical Scheuermann disease,
lumbar facet syndromes, compression fractures and transverse
process fractures, SI joint dysfunction, and benign hypermobility
syndrome.
Spondylolysis is a condition in which there is a defect in the pars
interarticularis of a lumbosacral vertebral body.39 There are differ-
ent types of spondylolyses, including congenital: in 1 series of 500
children, 4.4% of the study group had a pars defect at age 6 years.39
Isthmic spondylolysis, an acquired overuse injury of the pars inter-
articularis, is the most common type among school-aged children
with LBP who present to the pediatrician.40,41 It is often sympto-
matic, especially in young athletes, and the incidence is higher in the
athletic population.37,42 The most common sites are L5 and, less of-
ten, L4.43 Isthmic spondylolysis is often bilateral, affecting both the
right and left pars of an individual vertebral body and can be acute
or chronic (Figure 1 and Figure 2).
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Review Clinical Review & Education
Key Points
Question What is the most common cause of low back pain in
school-aged children?
Findings This review discusses the causes of low back pain in
school-aged children and finds that most cases are
musculoskeletal and have a benign clinical course. Although
pediatric training has historically emphasized that low back pain in
this population is caused by specific etiologic factors, most cases
of low back pain in this age group have no identifiable pain
generator.
Meaning Pediatricians should be vigilant for identifiable and
serious causes of low back pain, but most presentations are
self-limiting and will respond to conservative treatment.
Figure 1. Bony Anatomy of Lumbar Spine
A L5 Spondylolysis seen on CT scan B Lateral radiograph of lumbar
spine with L4 apophyseal ring
fracture
A
A
B
B C
C
A, Classic spondylolytic lesion at the left pars interarticularis of the L5 vertebra
seen on computed tomography (CT) scan (arrowheads); also shown are the
vertebral body (A), right pars interarticularis (B), and spinous process (C).
B, Apophyseal ring fracture at the superior vertebral end plate of the L4
vertebra (arrowhead) seen on lateral radiographs taken while the patient was
standing; also shown are the vertebral body (A), pars interarticularis (B), and
spinous process (C).
Spondylolisthesis may occur with bilateral pars defects, allow-
ing a forward translation of a vertebral body over the body subja-
cent to it (Figure 2). Spondylolisthesis is graded, with the grade based
on the percentage of slip of the superior body over the inferior one
(grade I, 0%-25%; grade II, 26%-50%; grade III, 51%-75%; grade IV,
76%-100%; and grade V, >100%, which is also known as spondy-
loptosis). The condition is further divided into low-grade slips (grades
I and II) and high-grade slips (grades III, IV, and V), with high-grade
slips at risk for higher degrees of pain and the presence of radicular
or neurologic symptoms. Slips can progress, although this is un-
usual after skeletal maturity.39 Spondylolisthesis most often oc-
curs at the level of L5 and S1.22,44,45
Although historically adolescent idiopathic scoliosis was thought
not to be associated with higher rates of LBP, more recent studies
have found this not to be so and demonstrate as much as a 2-fold
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 Clinical Review & Education Review Musculoskeletal Low Back Pain in School-aged Children

Table 1. Differential Diagnosis of LBP in School-aged Children: Clinical Presentation and Potential Diagnostic Tools
Diagnosis
Isthmic spondylolysis
Spondylolisthesis
Atypical Scheuermann disease
Discogenic disease and
herniated nucleus pulposus
Apophyseal ring fracture
Hyperlordotic back pain
Facet arthropathy
Sacroiliac pain
Benign hypermobility
Transitional vertebrae
Inflammatory conditions
Tumors
Infections
Abbreviations: AP, anteroposterior; CBC, complete blood cell count;
CRP, C-reactive protein; CT, computed tomography; ESR, erythrocyte
sedimentation rate; FABER, Flexion-Abduction-External Rotation;
Common History and
Defining Characteristics Examination Findings
Stress fracture of the pars interarticularis Pain with extension;
often owing to repetitive loading or extension-based, twisting
trauma athlete; positive result of
Stork test (sensitivity,
50%-73%; specificity,
17%-32%)20
Anterior slip of superior vertebrae in Pain with extension;
relation to inferior vertebrae positive result of Stork
test; step-off on palpation
(sensitivity, 60%-88%;
specificity, 87%-100%)20;
tight hamstrings
Schmorl nodes, vertebral end-plate Dull, achy pain at AP and lateral
flattening, narrowing of disk spaces23-25 thoracolumbar junction; radiographs will show
tight thoracolumbar characteristic findings
fascia; may have flattening
of lumbar lordosis
Protrusion or rupture of a disc; may have Pain worse with flexion or
degenerative disc disease without true Valsalva maneuver; 5% of
herniation school-aged children have
leg pain without LBP26;
35% of children have
radiating sciatic pain27
Fracture of the cartilaginous ring Presents similar to disc
apophysis herniation; positive result
of straight leg raise test;
tight hamstrings
Increased lordosis, mechanical LBP Weak core; positive
Trendelenburg sign;
increased lumbar lordosis
with thoracic kyphosis
Inflammation of the facet joints Extension-based pain or
pain with axial loading;
presents similar to
spondylolysis
May have a sprain or joint degeneration Pain in the medial
buttocks and posterior
thigh; LBP recreated with
FABER test
Generalized hypermobility; often a Beighton score >4 of
diagnosis of exclusion 934,35
Inflammation of a variant in which the Nonspecific LBP; insidious
lumbar transverse process fuses with onset
the sacrum
Spondyloarthropathies, including Morning stiffness >30 min,
conditions positive for HLA-B27, pain that wakes child from
enthesitis, or juvenile idiopathic arthritis sleep, alternating buttock
pain, pain that improves
with exercise; may have
positive result on modified
Schober test
Benign (eg, osteochondroma) or Fevers, weight loss,
malignant (eg, leukemia, lymphoma, malaise, night pain, bowel
or osteosarcoma) or bladder dysfunction
Discitis, vertebral osteomyelitis, Irritability, limping, fever,
epidural abscess back pain or abdominal
pain; decreased motion
and prefer one position
over another15
LBP, low back pain; LDH, lactate dehydrogenase; MRI, magnetic resonance
imaging; NA, not applicable; SPECT, single-photon emission computerized
tomography.
Diagnostic Tools Comments
AP and lateral More frequent at L5 than at
radiographs (sensitivity, L4; may be bilateral;
72%-78%), SPECT scan typically insidious onset;
(sensitivity, 84%), MRI MRI used more frequently
(sensitivity, 92%), or CT for diagnosis21
scan (sensitivity, 90%)21
Standing AP and lateral Grading based on slip; in
radiographs; repeat females, high-grade slips,
radiographs every 3-6 and increased growth
mo until patient is velocity increase risk of
skeletally mature to progressive slip
determine if slip is
progressing22
NA
MRI (sensitivity, 75%; Typically at L4 and L5 and
specificity, 77%), with L5 and S1; most are
positive predictive value centrolateral26; straight leg
of 84% and negative raise test has sensitivity of
predictive value of 67%-91% and specificity
64%28 26%29
May be seen on Occurs in 28% of
radiograph or CT scan school-aged children with
but best visualized on CT disc herniations27
scan30,31
Diagnosis based on NA
results of clinical
examination as all results
of imaging are normal
SPECT scan or CT scan NA
will show irregularities of
the facet joints or
hypertrophy32
Results of radiographs NA
are typically normal; MRI
may show joint
degeneration or sacral
stress fracture33
Results of all imaging May have instability in
studies will be normal other joints (eg,
subluxation or dislocation
events)
Radiographs have NA
accuracy of 76%-84%;
SPECT scan shows
increased uptake of
radiotracers; CT scan will
show any abnormal
anatomy32,36
MRI of the pelvis with May have a family history
intravenous contrast will of autoimmune conditions
show early inflammation
of the sacroiliac joints15
CBC, ESR, CRP, LDH; MRI NA
or CT scan may be
required15,18
CBC, ESR, CRP, blood NA
culture; bone scan may
show early changes, but
an MRI is more
specific15,18

increase in LBP in school-aged children with adolescent idiopathic Pediatrician training has traditionally focused the evaluation
scoliosis.46,47 A detailed description of scoliosis is beyond the scope of LBP in children on the need to identify serious pathologic
of this article. conditions, such as infection or malignant neoplasms.15 Although

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 Musculoskeletal Low Back Pain in School-aged Children
pediatricians must be vigilant in their evaluations to exclude more
serious pathologic conditions, such as spondylodiscitis, vertebral os-
teomyelitis, and neoplasm, these conditions are uncommon, and
most school-aged children will have a mechanical, musculoskeletal
etiologic cause for their LBP.15,16,48
Evaluation
Children with LBP require a thorough clinical evaluation based on
the history and physical examination. A complete history including
onset, duration, frequency, location, and severity of pain, as well as
factors that alleviate or aggravate pain, should be elicited.26 Acute-
onset pain is typically caused by trauma, while insidious-onset pain
may be caused by muscular, bony, inflammatory, or biomechanical
issues.49 Pediatricians should inquire about the child’s activities and
sports participation as well as how much the pain is affecting these
activities. Visual analog scales for pain and pediatric-oriented func-
tional disability scales may be used to assess the degree to which
LBP is affecting the child’s life.50 Although clinicians should probe
for “red flags,” including pain while sleeping, bowel or bladder dys-
function, radicular symptoms, saddle paresthesia, fever, and weight
loss, a Cochrane Database review of LBP in patients of all ages indi-
cates that there is insufficient evidence regarding the diagnostic ac-
curacy of these signs and symtpoms.51 Finally, clinicians should ask
about family history of scoliosis, autoimmune conditions, and ma-
lignant neoplasms.
Four questions have been shown to correlate with an inflam-
matory cause of LBP in patients younger than 45 years with symp-
toms that have lasted longer than 3 months:
1. Does back stiffness in the morning last more than 30 minutes?
2. Does back pain awaken you during the second half of the night?
3. Does the pain alternate from one buttock to the other?
4. Does pain improve with exercise but not with rest?
When a patient with prolonged symptoms answers 2 of the 4
questions positively, the sensitivity and specificity for an inflamma-
tory etiologic cause reach 70% and 81%, respectively. When an-
swers to 3 of 4 questions are positive, the sensitivity drops to 33%
while specificity approaches 100%.52,53
There should be adequate exposure of the spine during the
physical examination. It is crucial that clincians directly inspect the
back for signs of significant modifying conditions associated with LBP,
such as deformities (eg, spondylolisthesis), rashes (eg, psoriasis), hair
tufts (eg, spina bifida occulta), or asymmetry of the spine (eg, sco-
liosis). The patient should be examined both in the coronal and sag-
ittal planes while standing, sitting, and walking.54 Abnormal spinal
alignment, scapular asymmetry, or pelvic obliquity may suggest sco-
liosis or leg length discrepancy, while a kyphotic deformity may sug-
gest atypical Scheuermann kyphosis.26 A positive Trendelenburg
sign, indicated by a downward pelvic tilt to the unaffected side, may
suggest decreased core strength or a neurologic deficit, which could
be contributing to the LBP; patients with a positive Trendelenburg
sign should have a complete hip examination to further evaluate any
underlying issues of the lower extremity.49
The clinician should palpate for tenderness over the spinous pro-
cesses, paraspinal musculature, and SI joints. Tenderness of the spi-
nous process may suggest fracture or ligamentous injury, while ten-
derness of the paraspinal musculature is more indicative of muscle
spasm but can also be nonspecific.26 Range of motion is checked in
flexion, extension, lateral bending, and rotation. Pain that is worse
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Review Clinical Review & Education
Figure 2. Imaging of Spondylolysis and Spondylolisthesis
A Bilateral L5 spondylolysis lesions B Severe grade 3-4 spondylolisthesis
(L5 on S1)
A, Uptake of technetium 99-m as seen classically on acute spondylolytic lesions
with single-photon emission computerized tomography imaging (yellow
arrowheads). B, High-grade spondylolisthesis (grade 3-4) at the L5 on S1
vertebrae (red arrowhead) seen on a lateral lumbar radiograph taken while the
patient was standing.
when the back is in extension is typically owing to involvement of
the posterior elements (as in spondylolysis), while flexion-based pain
is suggestive of HNP.26,49
A complete neurologic assessment including lower extremity
sensation, motor strength, and deep tendon reflexes should be in-
cluded in the examination. The reflexes of the patellar tendon (L4)
and Achilles tendon (S1) should be elicited, and sensation in the der-
matomes of T12 and S1 and motor function of the hip flexors (L2 and
L3), quadriceps (L3 and L4), and extensor hallucis longus (L5) should
be assessed.26 Patients who are unable to walk on their heels or toes
and those with abnormal sensation of the medial (L4), dorsal (L5),
or lateral (S1) aspect of the foot may have injury to the nerve root in
the absence of a lower-extremity injury.55 The straight leg raise and
slump tests can be performed for nerve root compression, and ab-
normal Babinski or abdominal reflexes suggest a pathologic condi-
tion of the upper motor neurons.26
Finally, the clinician should perform any indicated special tests.
The stork test is performed by having the patient stand on 1 leg and
hyperextend his or her back (Figure 3A). A positive test result is in-
dicated by re-creation of LBP and suggests spondylolysis.49 The
straight leg raise test is performed by passively flexing a supine pa-
tient’s hip with the knee extended. The test result is positive if the
patient has pain radiating into the posterior thigh and knee and is
typically positive in those with HNP.15 The slump test is slightly less
specific but more sensitive than the straight leg test in adults with
HNP.56 This test is performed with a seated patient rounding the back
while flexing the head forward. The examiner passively extends the
knee with the foot flexed; the test result is positive if the patient ex-
periences radicular pain. The Flexion-Abduction-External Rotation
(FABER) test, which suggests a pathologic condition of the SI joint
if the patient develops SI pain, is performed by passively placing the
supine patient’s leg into a figure-4 position while gently pressing on
the knee and the opposite anterior iliac crest; the test result is posi-
tive if the patient experiences pain in the contralateral SI joint to the
knee in the figure-4 position.15 The modified Schober test is per-
formed by making marks 10 cm proximal and 5 cm distal to the pos-
terior superior iliac spine on a patient who is standing. The patient
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 Clinical Review & Education Review
Figure 3. Stork Test and Thoracolumbar Spinal Orthosis
A Stork test performed on the right leg B Rigid thoracolumbar spinal orthosis
A, Stork test is performed if a clinician suspects a spondylolysis. It is performed
with the patient standing on 1 leg with the clinician guiding the patient’s lumbar
spine in extension. A positive test result is one that reproduces the patient’s
pain. B, Rigid thoracolumbar spinal orthosis, a type of brace sometimes used in
the treatment of spondylolysis.
flexes forward at the hips with the knees extended and the marks
are remeasured: a distance less than 21 cm suggests a spondyloar-
thropathic condition, although this test may have a positive result
in other disorders in which a patient has limited forward flexion (eg,
HNP).15 Evaluation of overall mobility can be assessed with the Beigh-
ton criteria, with a score of 5 or higher suggestive of global joint
hypermobility.34 Although all these examination maneuvers may be
performed on any patient with LBP, they are specifically indicated
on the basis of suspected diagnoses (Table 115,18,20-36 and eTable 2
in the Supplement).
Anteroposterior and lateral radiography should be considered in
children with LBP, especially if pain has been present for more than 3
weeks.7 Thelateralviewshouldbeperformedwhilethepatientisstand-
ing, as a spondylolisthesis may not be revealed on a recumbent exami-
nation. Owing to increased radiation with little increase in diagnostic
utility, oblique radiography is best avoided.18 If results of radiography
arenonrevealing,advancedimagingmaybeconsidered.Single-photon
emissioncomputerizedtomographyscan,computedtomography,and
magnetic resonance imaging have had changing roles in the workup
of pediatric patients with LBP. Although single-photon emission com-
puted tomography scans are useful for identifying subtle bony injuries,
especially in the acute setting, they contain a nuclear isotope (techne-
tium-99) and expose organs throughout the body to higher doses of
radiationthananyothertypesofimagingstudies.21 Resultsofcomputed
tomography can provide exquisite bony and cartilage detail, but it also
exposes patients’ bone marrow and colon to higher doses of radiation
than do radiography or magnetic resonance imaging.15,21,57 Although
computedtomographyandsingle-photonemissioncomputedtomog-
raphy scans can be excellent diagnostic tools, increased concerns with
radiation, especially in pediatric patients, have led to decreased use in
recentyears.18,21 Magneticresonanceimaging,whichhastypicallybeen
used in the evaluation of soft-tissue pathologic conditions, is also now
used more frequently for evaluation of bony pathologic conditions21
(Table2).Althoughthereisgoodliteratureregardingthesensitivityand
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Musculoskeletal Low Back Pain in School-aged Children
specificity of computed tomography and magnetic resonance imaging
for common conditions, such as spondylolysis and HNP, there is little
published about the diagnostic accuracy of advanced imaging tools for
less common causes of pediatric LBP.21,57,58
A complete blood cell count and tests for erythrocyte sedimen-
tation rate and C-reactive protein level may be indicated if there is
high suspicion for an inflammatory, infectious, or malignant
process.19 Laboratories may include tests for antinuclear antibody,
rheumatoid factor, and HLA-B27, but these tests should be or-
dered cautiously and are most helpful when a rheumatologist is con-
firming a suspected autoimmune diagnosis, as up to 20% of the gen-
eral population may have positive results for antinuclear antibody.59
As there are a variety of etiologic causes of LBP in children, there
are notable specific history, examination findings, and imaging re-
sults that are suggestive of certain conditions (Table 115,18,20-36 and
eTable 2 in the Supplement).
Treatment
The specifics of treatment for individual etiologic causes of LBP can
vary widely (eTable 1 in the Supplement). This section discusses gen-
eral principles the pediatrician should keep in mind when caring for
this population.
The foundations of treatment are accurate diagnosis when pos-
sible and an understanding of the nuances of the spinal anatomy of
children, who are skeletally immature. Most school-aged children
present with nonspecific and self-limiting symptoms and will re-
spond to conservative treatment, including relative rest from of-
fending activities causing pain and often some form of physical
therapy.7,14-16 Several rehabilitation programs have been described
for children with LBP based on specific diagnoses, but, to our knowl-
edge, there is little evidence in the literature supporting their use.
These rehabilitative programs tend to be empirically driven.24 Re-
habilitation is a multifactorial process and relies first on the treat-
ment of the effects of the acute injury, including losses in mobility
and function, as well as recognition of any deficits in biomechanical
function leading to alterations in technique or performance of a spe-
cific activity that could promote injury (eg, the proper mechanics of
throwing a baseball).24,60
Rehabilitation progresses through specific stages that initially
focus on preserving and promoting range of motion and strength.
Hip flexibility is crucial and promoted by emphasizing exercises to
stretch the hip flexors and hamstrings.61 Strength and motion re-
covery is coupled with proprioceptive training, which then leads to
correcting deficits noted in the kinetic chain, motion patterns, and
neuromuscular control.60 A mainstay of therapy is core stabiliza-
tion, which refers to improving neuromuscular control, strength, and
endurance of the muscles central to maintaining dynamic spinal and
trunk stability. These muscle groups include the abdominals, lum-
bar multifidi, and erector spinae, as well as other paraspinal, pelvic,
and cervicothoracic musculature.60,61 The literature is unclear as to
which exercises are best to rehabilitate the core musculature.61
Therapy for issues such as spondylolysis (associated with pain on
back extension) traditionally revolves around a flexion-based therapy
program (Williams flexion–based therapy program), whereas con-
ditions such as HNP (associated with pain on back flexion) are treated
with an extension-based therapy program (McKenzie extension–
based therapy program). 61,62 Last, the patient focuses on a
functional progression aimed at correcting biomechanics and
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 Musculoskeletal Low Back Pain in School-aged Children
Table 2. Principal Diagnostic Imaging Tools Available and Considerations for Use
Imaging Modality Best Use Advantages
Radiographs Fractures, including Low cost, fast,
spondylolysis and fractures of readily available
the spinous process and
transverse process
CT scan Apophyseal ring fracture; bony Fast; specific for
pathologic features, including bony pathologic
any suspected fractures features
Bone scan or SPECT scan Bony pathologic features, Highly specific for
including suspected fractures bony pathologic
features
MRI with intravenous Disc pathologic conditions, No radiation;
contrast indicated if masses, ligamentous and detailed soft-tissue
inflammatory condition soft-tissue pathologic findings
suspected conditions; pain associated with
neurologic symptoms
activity-specific techniques, which allows for a controlled and pain-
free progression back to activity (sport, play, or work) or activities
of daily living.60 Any program must be reinforced with a home ex-
ercise routine that the patient performs during therapy and then as
maintenance after its completion. It is the clinician’s challenge to mo-
tivate the pediatric patient to adhere to this home exercise routine.
Bracing can be used in the treatment of LBP and includes soft
lumbar corsets as well as rigid braces, such as thoracolumbar spinal
orthoses (Figure 3B). One of the major controversies noted in the
care of school-aged children diagnosed with acute spondylolysis is
whether to use thoracolumbar spinal orthoses or other rigid
bracing.43 The current evidence does not support the use of rigid
bracing in spondylolysis: a meta-analysis revealed that most pa-
tients have a successful clinical outcome with conservative treat-
ment (83.9% treatment success rate) regardless of bracing or no
bracing (level of evidence, 4).40 Some clinicians will use rigid brac-
ing or soft lumbar corsets to provide analgesia by further restrict-
ing any extension activity in patients not responding to rest alone,
although there is no evidence to support this use of bracing.63
To our knowledge, there are no specific evidence-based stud-
ies examining oral medication in the treatment of LBP in school-
aged children. Most populations studied are adults or do not specify
an age. A Cochrane review revealed that nonsteroidal anti-
inflammatory drugs are effective for short-term symptomatic pain
relief for both acute and chronic LBP.64 Another Cochrane review
assessing the use of muscle relaxants in nonspecific LBP found they
are effective in the treatment of pain, but clinicians must take care
in prescribing these medications owing to their associated central
nervous system adverse effects, including drowsiness and
dizziness.65 Systemic glucocorticoid treatment may provide par-
tial pain relief for select patients with acute lumbosacral radiculopa-
thy, but existing evidence suggests that systemic glucocorticoid
therapy has limited or no benefit.66
Consultation may be considered by the pediatrician in the
uncommon instance that a patient’s LBP is not responsive to con-
servative treatment. Surgery and other invasive interventions are
rare treatments for the conditions described in this article. Surgical
repair of the pars is infrequently used for a painful nonunion of a
spondylolytic lesion that has failed to respond to conservative
therapy for a year.67 Watchful waiting of the asymptomatic child
with a high-grade spondylolisthesis is safe and does not lead to
complications.68 Surgical fusion may be indicated in individual
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Review Clinical Review & Education
Disadvantages
Radiation; high false-negative
rates for many causes of back pain
Radiation
Radiation; injections (pain);
nuclear medicine imaging
provides physiological
information but poor anatomical
detail
Costly; time consuming; potential Abbreviations: CT, computed
need for sedation in younger tomography; MRI, magnetic
children resonance imaging; SPECT,
single-photon emission
computerized tomography.
patients with a high-grade spondylolisthesis who have persistent
radicular or neurologic symptoms.67 Conservative treatment is
less effective in pediatric vs adult HNP, but it is still first-line treat-
ment owing to fear of the skeletally immature pediatric spine
being more vulnerable to surgical trauma and iatrogenic
deformity.69 Long-term success with conservative care is esti-
mated at 25% to 50% for HNP without neurologic deficits.69
Occasionally, pediatric patients with musculoskeletal LBP will have
no identifiable etiologic cause but will have persistent, recalcitrant,
high levels of pain; consultation with rheumatology and pain spe-
cialists may be considered if the clinician suspects amplified mus-
culoskeletal pain.15
Prevention
Skeletally immature individuals are more vulnerable to trauma and
explosive muscle contractions, especially during periods of rapid
growth.41 Preventive programs aimed at improving age-associated
deficits in flexibility have been used to reduce injury, but no causal
relationship between flexibility and risk of injury has been docu-
mented, to our knowledge.7,41 More evidence exists to support pre-
season sports conditioning programs and neuromuscular training in
reducing injury rates.41 Children should begin strength and condi-
tioning programs several weeks before the start of a sport season,
allowing for gradual increases in frequency and intensity of training.7
Appropriate rest from training and specific repetitive motions (eg,
tumbling in gymnastics) allows for proper recovery.7,41 Most back in-
juries, and overuse injuries in general, can be avoided if the pedia-
trician keeps a simple, evidence-based rule of thumb in mind: young
athletes should not participate in more hours of sports in a week than
their number of age in years.70 Finally, LBP lingering longer than 2
to 3 weeks in this population is not normal; if persistent, the child
should be evaluated by a pediatrician.7
Conclusions
Lowbackpainiscommoninschool-agedchildrenandiscausedbyava-
riety of individual conditions, most of which are of a benign, musculo-
skeletalorigin.Specificsoftheevaluation,workup,andtreatmentofLBP
in this population will vary with the specific underlying cause. Ongoing
research is needed to establish evidence-based best practices for the
treatment of many of the diagnoses discussed in this review.
(Reprinted) JAMA Pediatrics March 2017 Volume 171, Number 3 285
 Clinical Review & Education Review
ARTICLE INFORMATION
Accepted for Publication: August 27, 2016.
Published Online: January 30, 2017.
doi:10.1001/jamapediatrics.2016.3334
Author Contributions: Dr MacDonald had full
access to all the data in the study and takes
responsibility for the integrity of the data and the
accuracy of the data analysis.
Study concept and design: MacDonald, Rodenberg.
Acquisition, analysis, or interpretation of data:
Stuart, Rodenberg.
Drafting of the manuscript: All authors.
Critical revision of the manuscript for important
intellectual content: All authors.
Administrative, technical, or material support: All
authors.
Study supervision: MacDonald.
Conflict of Interest Disclosures: None reported.
Additional Contributions: We thank the patient
illustrated in Figure 3 for granting permission to
publish this information.
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