Stress Fractures in Children and Teens

“I have treated patients as young as five with stress fractures,” said Matthew Wagner, MD, Catholic Health Pediatric Orthopedic Surgeon. “Parents are often surprised that stress fractures can happen at such a young age and are the cause of their child’s back pain. However, they are quite common in children and teens.”

He explained the highest risk factor for stress fractures is overuse caused by participating in sports that put repetitive stress on the back, like gymnastics, tennis, weightlifting, baseball, golf and football. Some stress fractures can happen even without participation in sports, typically because of genetics.

“Children and teens do not have to stop playing sports or reduce their activity level to avoid stress fractures,” said Dr. Wagner. “But it is helpful for parents to be familiar with the risk factors and to know when to meet with a pediatric orthopedist, especially when stress fractures affect the quality of life for their child.”

What is a stress fracture?

When talking to a pediatric orthopedist, you will hear medical terms that explain what is happening in your child’s spine and leading to a stress fracture.

Spondylolysis is the clinical term for a stress fracture. A stress fracture is a tiny crack in a bone. It occurs between two vertebrae in the spine, typically in the lower back, and develops through the pars interarticularis.

Pars interarticularis is a tiny, thin part of the vertebrae that connects the upper and lower facet joints. The facet joints provide stability and control the spine’s movements. Pars interarticularis is the weakest part of the vertebra, which increases the risk of injury from sports that require repetitive movements.

Spondylolisthesis occurs when untreated spondylolysis worsens and progresses. In this spinal condition, a vertebra slips out of alignment with the rest of the spine because a fracture has weakened it. For children and teens, it most often occurs during a growth spurt.

What are the symptoms of a stress fracture?

“Low back pain is the most common symptom of a stress fracture (spondylolysis),” said Dr. Wagner. “Some patients do not show symptoms, and a stress fracture goes undetected until they get an imaging test for other reasons.”

Low back pain may:

Radiate to other parts of the body, especially the buttocks and back of the thighs
Feel like a muscle strain
Worsen with physical activity
Improve when resting

Spondylolisthesis may cause additional symptoms, including:

Muscle spasms in the hamstrings
Tightness in the hamstrings
Numbness or tingling in the foot

What causes a stress fracture?

Stress factors occur for several reasons, including:

Overuse. Children and teenagers who play sports that put repetitive stress on their bodies, especially their lower back, are prone to overuse injuries and are most at risk for a stress fracture.

Genetics. Some children are born with thin vertebrae that increase the risk of a stress fracture.

Growth spurts. Stress fractures can happen when a child or teenager experiences rapid physical growth.

How is a stress fracture diagnosed?

Your pediatrician will recommend you to a pediatric orthopedist if your child or teen is experiencing back pain. An orthopedist will review medical history, complete a physical examination, ask about symptoms, and order imaging tests.

“Imaging tests are crucial to diagnosing spondylolysis,” said Dr. Wagner. “The images will show the extent of the stress fracture and any other concerns in the spinal area and surrounding vertebrae.”

He explained that since X-rays do not always show a stress fracture, an orthopedist may order additional imaging tests, such as a CT scan, MRI or bone scan.

How is a stress fracture treated?

“When imaging exams confirm the presence of a stress fracture (spondylolysis), we can start tailoring treatment plans based on the severity of the fracture,” said Dr. Wagner.

Nonsurgical treatments

Stress fractures diagnosed when mild or moderate typically do not require surgery. Nonsurgical treatments include:

Physical therapy. A physical therapist or sports medicine specialist can teach proper techniques to avoid repetitive stress movements, including stretching before and after playing and taking the time to rest between activities.

Bracing. A brace keeps the spine upright, limits movement and allows the stress fracture to heal. Your orthopedist will recommend the type of brace and how long your child or teen should wear it.

Surgical treatment

“Surgery is typically only recommended for a child or teen whose spondylolysis has progressed into spondylolisthesis where severe vertebrae slippage is occurring, and pain is worsening,” said Dr. Wagner. “For those patients, we recommend spinal fusion, which realigns the vertebrae and strengthens the spine.”

A pediatric orthopedic surgeon performs the spinal fusion and will provide instructions for recovery, which includes physical therapy. Your doctor may also recommend wearing a brace to help with healing. Most children and teens can return to normal activities, including competitive sports, within a few months.

Will a stress fracture recur?

“A stress fracture can happen again, especially in young athletes,” said Dr. Wagner. “We do not, however, want them to give up their sport to prevent stress fractures. We will explore options like keeping up with physical therapy or joining a sports recovery clinic to minimize the risk of an overuse injury.”

Learn more about sports recovery in student-athletes.