Back Pain in Children and Teens

Anyone who has spent time with children knows that some of them can bend themselves into positions that defy logic. A teenager may think nothing of dropping into full splits in front of the television. A child with extra flexibility may love impressing her friends by bending her thumb all the way back to her wrist.

Dexterity is a good thing. But it can go too far, even in kids. Children and teenagers can end up with chronic back pain for any number of reasons, including injuries from sports or stressing overly flexible joints. In rare cases, they may be born with spinal problems. Whatever the cause, it's important to recognize the signs of a problem.

What puts stress on kids' backs?

Some kids may strain their backs from lugging around their schoolbooks. A survey of 1126 school children aged 12 to 18 published in the journal Spine found that chronic low back pain was associated with the weight of their school bags. A later study in the same journal found that carrying school bags on just one shoulder may also play a role in lower back pain.

However, a University of Michigan study suggested that instead of overweight backpacks, the problem might be overweight kids. Researchers with the University of Michigan Health System asked 184 grade school and middle school children to describe their use of backpacks and to list any problems with back pain. Later, the researchers weighed the children and their backpacks. About a third of the students complained of sore backs, but other kids whose backpacks weighed about the same were free of pain. This led researchers to believe that being overweight or out of shape might be more of a problem for kids than toting a heavy backpack.

Still, lightening the load kids carry isn't a bad idea. A small backpack with a hip strap will distribute the weight more evenly. Packing heavier items closer to the back and encouraging your child to wear both straps over the shoulders will also minimize the possibility of strain, according to a book published by the American Academy of Orthopedic Surgeons. Although there are no official guidelines for how much weight your child should carry, estimates range from between 10 and 20 percent of his or her body weight. You can also take the obvious step: ask your child if the pack is too heavy, or watch to see if she's leaning forward or arching her back to compensate for the weight.

When over-flexibility becomes a problem

It may come as a surprise, but over-flexibility is common in children, and could put them more at risk for straining or injuring their backs, according to Mary Rimsza, M.D.,a pediatrician and director of Health for Arizona State University.

"If they can get their thumb to their forearm, their knees beyond straight, their palms flat on the floor, and have flexible backs, they may be at a greater risk for back problems," says Rimsza. The reason, she explains, is that this super flexibility is a result of super flexible joints, which are more vulnerable to injury. It doesn't mean your child can't enjoy athletics, you may just have to set limits: "If a dance teacher wants your kids to do the contortions, tell her no, they're not going to do it, and try to discourage your child from showing off to friends."

What are common back injuries from sports?

If your teen is athletic and involved in sports, back pain could be a sign of a so-called stress fracture in one of the bones in the low back. A stress fracture, also called a stress injury, is a minute crack in the surface of a bone. It's caused by repeated movements that put stress on the lower back, explains John Sarwark, M.D., a professor of orthopedic surgery at Northwestern University Medical Center in Chicago.

"If a gymnast is doing walkovers or hyperextensions of the back repetitively, it can cause a stress injury. It's like taking a wire hanger and bending it backwards and forwards over and over," Sarwark says. Typical symptoms of stress injuries are pain in the low back that feels like muscle strain. Your child could feel pain more sharply when sitting or bending backwards. Usually, taking anti-inflammatory medication like ibuprofen and avoiding sports until symptoms disappear is enough to allow your child's back to heal. If those measures don't work, your doctor may suggest physical therapy.

But the good news is that you can help prevent your child from getting a stress injury by having her evaluated annually by a doctor before she participates in sports, Sarwark says. Your doctor should test for tight hamstrings or loss of mobility in the low back and knee area. Physical therapy or stretching exercises tailored to your child could keep her back healthy and prevent a stress injury.

What about problems in my child's spine?

In rare cases, a child may be born with spinal disorders or develop them later in childhood. Sometimes back problems show up around puberty, when the spine is going through a growth spurt. One of the most common conditions is scoliosis, an abnormality of the spine that causes an exaggerated lateral, or "S"-shaped curve. Scoliosis is more common in girls than in boys, and it's typically not painful. However, if the curve is severe, your doctor may recommend that your child wear a hidden brace to prevent the curve from becoming more pronounced as she or he grows. (If your child has scoliosis, her shoulders or waist may appear uneven or she may lean to one side.)

According to the American Academy of Orthopaedic surgeons, chronically poor posture during adolescence can in rare cases stretch the ligaments and give rise to a curved or slightly humped back, a condition called kyphosis. It's correctable through exercise, rarely causes pain, and is more common in adolescent girls.

Scheuermann's disease is another type of curved spine that also appears during the teen years. Unlike scoliosis, Scheuermann's disease is more common in boys than girls, and it's more serious. This condition is a developmental disease caused when the vertebra don't grow normally, causing disks in the back to wedge, or herniate. Scheuermann's kyphosis is differentiated from posture-linked kyphosis by x-ray, which reveals the telltale irregular wedged-shaped discs in the spinal column; in addition, the curve in the spine is greater than 40 degrees.

Scheurmann's kyphosis can cause moderate to severe pain. In most cases, pain medication and physical therapy help. A child will not outgrow the curve, but a back brace may lessen the curvature or keep it from getting worse. In rare cases, if the curve is extreme, Scheurmann's kyphosis is treated with corrective surgery.

What are less common causes of back pain?

Back pain can also be a sign of a problem unrelated to the spine. Kidney problems can cause low back pain, on either side of the spine. Usually your child would also have difficult or painful urination, according to Rimsza.

Staph infections can also cause symptoms of back pain, says Rimsza. In this case, a child will usually have a fever as well as pronounced tenderness in a certain area of the back. This requires immediate medical treatment.

In very rare cases, back pain may be caused by a tumor. Before starting a treatment program for a child's back pain, doctors will do tests to rule out infection, fractures and cancer.

How can I keep my child's back healthy?

  • Remind your kids to sit up straight. Make sure your child's backpack isn't overloaded. And, says Rimsza, if back pain is keeping your child up at night, waking her from sleep, or interfering with daily activities, see a doctor.
  • Educate yourself about sports injuries. For example, children under 6 should never play on a trampoline, and even those over 6 should always have an adult present when there's somebody on it.
  • Supervise your child when she's playing on swings or other playground equipment. Teach her not to walk or run in front or back of the swings -- or stand on them.
  • Stress safety when your child takes up a new sport. For example, a child who begins skiing, skating, or snowboarding should take lessons to learn good technique, including the proper way to fall.
  • Suit up. Children riding bicycles or riding scooters should always wear helmets. For contact sports, kids should use helmets in addition to face masks, and mouth guards. Skateboarders and skaters should have a helmet in addition to wrist and knee guards.
  • Finally, seatbelts and child safety seats are the best protection for children riding in cars. Babies and small children should have their own child safety seats. And protests aside, kids should always sit in the back seat until they are 13 years old.

References

Dr. Mary Rimsza, a pediatrician in general practice and the director of health at Arizona State University in Tempe, Arizona

Viry, P, Creveuil C, et al "Nonspecific back pain in children. A search for associated factors in 14-year-old schoolchildren," Rev Rhum Engl Ed 66(79):381-8

Kyphosis. American Academy of Orthopedic Surgeons.

Interview with Dr. John Sarwark, professor of orthopaedic surgery, division of pediatric orthpedic surgery, Northwestern University Center, Chicago, Illinois.

Negrini, S and Carabalona, R. Backpacks on! Schoolchildren's perceptions of load, associations with back pain and factors determining the load. Spine 27 (2): 197-195.

American Academy of Pediatrics online fact sheet. Back to School tips: Backpack Safety.

Children's Hospital of Pittsburgh. For Kids: Trampolines, Playgrounds, Skiing, & Snowboarding and Kids in Cars. Online fact sheets.

University of Michigan Health System. Press Release. Kids' backpacks may not cause back pain after all. .

Sheir-Neiss, GI, et al. The association of backpack use and back pain in adolescents. Spine 28(9): 922-30.

Skoffer, B. Lower back pain in 15- to 16-year old children in relation to school furniture and carrying of the school bag. Spine 32(24): E713-7.

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