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| Apr 01, 2024

Don't Ignore Low Back Pain in Young Athletes

By Kellie Loehr & Daniel Hague

This article was created by MedStar Health, which serves as the trusted medical provider for the U.S. National teams.

Healthcare and sports medicine providers have recently seen an increase in lacrosse-related low back pain. One of the most common types of low back pain in lacrosse is called spondylolysis. This condition is a fracture of the bone that may arise at any segment of the spine, but it is most common in the lowest segments of the Lumbar spine, primarily L4 and L5.

In the general public, the incidence of debilitating low back pain across the lifetime is between 70-84%, with the prevalence of spondylolysis is 8% in the general population. However, in the adolescent athlete, spondylolysis is the cause of back pain in 47% compared to only 5% in the adult athlete. This affects boys more than girls, and virtually all cases occur before the age of 20.

Children are most susceptible to low back injuries during the adolescent growth spurt. According to the Cleveland Clinic, growth spurts occur between ages 9-15 for females and 12-17 for males, with normal full maturation occurring by 20 years of age.    

Causes of Low Back Pain     

In lacrosse, spondylolysis is typically the result of repetitive stress through the wind-up phase or reach back and follow-through phases of shooting or passing the ball. This movement pattern is comprised of high velocity rotation and back extension which may take the spine to its end range. Over time, particularly with excessive number of shots on goal, this repetitive microtrauma breaks down part of the vertebral bone segment called the pars interarticularis.     

If both sides of the pars interarticularis fractures, this is called a bilateral spondylolysis. A unilateral spondylolysis occurs when only one side of the pars interarticularis is fractured. These are commonly known as a low back stress fracture. There are grades of progression of this condition. Grades I-II are considered "low grade" and are more common, often caused by repetitive trauma to the pars interarticularis, particularly in young athletes. Grades III-V are termed "high grade" and are more likely to progress in severity.   

A recent study that followed 20 elite men's sixes lacrosse players for the British men's team over the course of their 9-month training cycle found the incidence of low back injuries was 9%.  A contributing factor is believed to be due to players playing in multiple formats/teams (i.e., sixes and field), resulting in an increase in training volumes and progressive overload injury. This phenomenon is expected to increase with sixes added to the Olympic games in 2028, and strategies need to be implemented to mitigate risk.   

Signs and Symptoms of Low Back Pain   

It is not uncommon that individuals, especially kids, have difficulty pinpointing the source of their back pain. Some general symptoms may include soreness in the lower back and reduced range of motion. Many people with low back pain tend to lean away from the side of injury or pain and appear to be shifted to one side.   

They may also present with compensatory pelvic tilt (think pulling the belt buckle to sky) to offload the affected segment of spine. Significant symptoms can include changes in sensation, leg weakness, abnormal walking patterns, and, in severe cases, changes in bowel and bladder control. Those who experience these “red flag” symptoms should schedule an evaluation by a physician.   

Treatment Options   

Conservative treatment of an acute pars injury in athletes had excellent results of return to sport within 6 months when the return to play is done gradually. Non-operative treatment showed a pooled success rate of 83.9%, with no significant difference between braced and non-braced subjects.    

Physical therapy: Physical therapists can analyze movement patterns to identify and treat specific mobility restrictions, weakness, or coordination deficits with the goal of modifying specific movements to optimize function and reduce risk of harm. Interventions may include manual therapy, pain education, posture/ergonomics corrections, and lumbar stabilization exercises.    

Bracing: Currently there is not strong evidence for or against this treatment option.   

Medication: Non-steroidal anti-inflammatory medications (NSAIDS) can be helpful for acute pain relief.   

Surgery: May be indicated when patient has documented evidence of persistent fracture or remains symptomatic greater than one year of conservative management, abnormally healed fracture, and has a , with a strong desire for return to sport.

Recommendations for Participation in Sport for Adolescent and Young Athletes   

The National Athletic Trainers’ Association recommends the following for participation in sport for adolescents and young athletes:

  • Athletes should delay specializing in a single sport as long as possible and should avoid playing a single sport more than eight months per year.
  • Athletes should participate on one team at a time, as having a higher cumulative volume of any organized sport is associated with higher injury risk.
  • Athletes should avoid participating in organized sport and/or activity more hours per week than their age (For example, a 9-year-old should not have organized team activities > 9 hours each week). 
  • Plan for at least two days off per week from organized training and competition for recovery.

Other General Recommendations  

Nutrition: It is important to maintain a good, balanced diet and provide proper fuel and aid in bone health. Reach out to your local registered dietician for a diet tailored to athletes’ needs. 

Sleep: Athletes should be getting at least 7 hours of sleep a night. This not only contributes to an improved healing rate but also aids in shot accuracy. For athletes with current back pain, it is best not to sleep on the stomach, as this puts lumbar spine into extension.  

Gradual increase in activity: Athletes should avoid sudden drastic increase in loading/activity. 

Key Take Aways   

Do not ignore the symptoms! Low back pain lasting longer than one week in an adolescent should be considered for structural injury and be evaluated by a medical professional. 

More is not always better. Consider quality over quantity when it comes to training volume.  

Give your body time to recover.


Andersson, Gunnar Bj. “Epidemiological Features of Chronic Low-Back Pain.” The Lancet 354, no. 9178 (August 1999): 581–85.

Cleveland Clinic. “Growth Spurts & Baby Growth Spurts,” November 19, 2021.

Collier, Matthew, Nicholas Ripley, Tom Wenham, and Seth O’Neill. “Injuries in International Men’s Sixes Lacrosse: Injury Surveillance of the British Lacrosse Men’s National Team During a 9-Month Training Cycle Leading up to and Including The World Games 2022.” JOSPT Open 1, no. 1 (July 1, 2023): 63–69. https://doi.or0.2519/josptopen.2023.0008

Cunningham, Bryan W., Kyle B. Mueller, Jessica B. Hawken, and Nicholas P. Rolle. “Biomechanical Considerations and Mechanisms of Injury in Spondylolisthesis.” Adult Lumbar Spondylolisthesis 32, no. 3 (September 1, 2020): 100803. 

Gallagher, Brian, Bradley Moatz, and P.Justin Tortolani. “Classifications in Spondylolisthesis.” Adult Lumbar Spondylolisthesis 32, no. 3 (September 1, 2020): 100802. 

Kukreja, Mohit, Andrew C. Hecht, and P.Justin Tortolani. “Spondylolysis and Spondylolisthesis in the Adolescent Athlete.” Adult Lumbar Spondylolisthesis 32, no. 3 (September 1, 2020): 100804. 

Soriano, Edward, and Elizabeth Bellinger. “Adult Degenerative Lumbar Spondylolisthesis: Nonoperative Treatment.” Adult Lumbar Spondylolisthesis 32, no. 3 (September 1, 2020): 100805.

Walker, Bruce F. “The Prevalence of Low Back Pain: A Systematic Review of the Literature from 1966 to 1998:” Journal of Spinal Disorders 13, no. 3 (June 2000): 205–17.