Young Athletes Getting Too Many Back Scans Too Soon, Study Finds

If your teenage athlete complains of back pain after sports, there's a good chance their doctor will order imaging tests right away. But a new study suggests that approach might be doing more harm than good—at least when it comes to unnecessary radiation exposure and healthcare costs.

Researchers surveyed 397 sports medicine physicians about how they evaluate young athletes (ages 6–18) with extension-based low back pain—the kind where pain gets worse when bending backward. The findings were striking: nearly 68% of doctors reported they always or most of the time order X-rays on the first visit. Even more concerning, 13.1% ordered advanced imaging like MRI or CT scans on that first visit, with another 27.2% ordering them within four weeks.

Why So Much Imaging?

Extension-based low back pain in young athletes is often associated with spondylolysis, a stress injury to the spine's pars interarticularis (a small part of the vertebra). The L5 vertebra is most frequently affected, accounting for 74.6% of cases, followed by L4 at 21.4%. Because regular X-rays often miss early spondylolysis, doctors frequently turn to more advanced imaging like MRI (preferred by 69.3% of surveyed physicians), SPECT scans (19.2%), or CT scans (5.0%).

The problem? These tests come with real costs—both financial and physical. SPECT and CT scans expose young athletes to ionizing radiation, which increases cancer risk. And here's the kicker: most cases of extension-based low back pain improve with conservative management like rest, physical therapy, and activity modification.

The Disconnect Between Imaging and Actual Pain

One of the study's most important findings challenges a fundamental assumption doctors make: that what shows up on imaging directly causes the pain. Research shows that pain from extension-based low back pain doesn't always correlate with what imaging reveals. Some athletes continue experiencing pain even after their fractures heal on X-rays, while others have complete symptom relief despite never achieving bony healing.

Even more striking: approximately half of young athletes with extension-based low back pain have completely negative imaging for spondylolysis, yet their clinical presentation is identical to athletes whose scans show a defect. These imaging-negative cases may involve other structures in the spine and have been called hyperlordotic back pain or mechanical low back pain—but they're rarely discussed in treatment guidelines.

What Should Change?

The research suggests that less emphasis should be placed on bony healing and diagnostic imaging, and more on addressing muscle atrophy and loss of motor control in the lumbar multifidus muscles—the deep stabilizer muscles of the lower back. In fact, one study found that greater fatty infiltration of these muscles was associated with longer recovery times, regardless of whether imaging showed a defect.

Current guidelines for adults with low back pain recommend withholding X-rays during the first six weeks of management, but no such guidelines exist for young athletes. The study authors argue that establishing clearer, evidence-based guidelines could reduce unnecessary imaging while maintaining quality care.

The bottom line: if your young athlete has back pain, don't assume they need imaging right away. A thorough physical exam, conservative treatment, and targeted muscle-strengthening exercises may be exactly what they need—without the radiation exposure or extra cost.