Teenage pain often dismissed as growing pains

teenage child back hip neck chronic pain

A common belief is that pain in children will just go away or be forgotten when life takes over.

In the absence of an identifiable injury such as a sprain or fracture, childhood and adolescent pain is often disregarded – by doctors and parents alike.

The most common type of pain is spinal (back or neck), and many more adolescents complain of pain than is commonly recognised. Between one-third and half of all adolescents aged 13 and over report back pain about every month or even more often1. In fact, the prevalence of these conditions rises so sharply in early adolescence the rates approach adult levels by 18 years.

It’s becoming increasingly clear so-called non-specific “musculoskeletal conditions”, the leading causes of disability worldwide, are significant health issues in children.

Non-specific conditions mean that pain cannot be attributed to a defined and diagnosable anatomical cause. In adults, these conditions are recognised as complex disease states that have biological, psychological and socioenvironmental underpinning.

For a significant proportion of adolescents, non-specific pain has extensive impacts on health and quality of life. For example, in a study in Western Australia, about 20% of 17-year-olds reported either missing school, seeking health care, taking medication, interference with normal activities, or interference with physical/sporting activities due to back pain2. There is also evidence that persistent pain symptoms in adolescence predict chronic pain problems in adulthood3.

The blame for pain in kids is often directed at school bags, computer and small-screen device usage, posture, and/or other biomechanical targets. It is also sometimes believed (permanent) damage is being done to the spine, with lifelong consequences.

However, there is little evidence this is true.

Studies show socioeconomic, lifestyle, cognitive and psychological factors are just as strongly, or even more strongly, related to pain (particularly chronic pain) as physical factors4. These societal beliefs about “physical” causes of pain may be not only incorrect, but detrimental if they cause worry about the spine being fragile and discourage children from physical activity.

To date the complex interaction between painful events, the growing body, health influences, social or environmental influences from family, health care providers and schooling is not fully understood. In particular, very little is known about what brings on initial episodes of painful conditions and whether this underpins the link with future chronic pain.

Given wide recognition that early life events are critical in shaping health as people grow older, understanding the context of common painful conditions in early life is critical to inform future health.

It is important to provide effective treatment to those at risk of developing persistent pain. It is also important not to create medical problems out of transient aches and pains, i.e. not every child needs to be sent off for diagnostic imaging and intensive treatments. But a shift away from the narrow and outdated focus on school bags, posture and damaged spines as the only source of problems is a must.

Efforts to update the narrative around pain are as important for children as for adults.


  1. Kamper, S.J., et al., Musculoskeletal pain in children and adolescents. Braz J Phys Ther. http://dx.doi.org/10.1590/bjpt-rbf.2014.0149
  2. Beales, D.J., et al., Low back pain in 17 year olds has substantial impact and represents an important public health disorder: a cross-sectional study. BMC Public Health, 2012. 5 (12): p. 100.
  3. Hestbaek, L., et al., The course of low back pain from adolescence to adulthood: eight-year follow-up of 9600 twins. Spine, 2006. 31(4): p. 468-72.
  4. Chambers, C.T., et al., The epidemiology of chronic pain in children and adolescents revisited: a systematic review. Pain, 2011. 152(12): p. 2729-38.

Rib pain referral patterns

Costovertebral (rib) joints are starting to be recognised as a source of pain.

Mid-back pain is often misdiagnosed as either spinal (vertebral) pain or muscular pain. The figure below depicts pain referral patterns of various costovertebral joints – where the rib head joins the spine. This is a joint that when subluxated can induce its own pain patterns.

rib pain referral


Young, B.A., et al., Thoracic costotransverse joint pain patterns: a study in normal volunteers. BMC Musculoskelet Disord., 2008. 9 (1): p140.

Squat Essentials

How you squat (or not) can yield valuable clinical information

A properly executed squat uses a combination of several joints and muscles, including ankles, knees, hips, spine, abdominal muscles and tons of core strength! While a normal squat will follow normal functional movement, an abnormal squat may lead to additional stress and cause more strain to an already problematic area. Muscle weakness or tightness, instability and reduced joint motion can all be determined with this valuable diagnostic tool called the squat.

One reason the squat is a good evaluation tool is because it is a normal motion pattern – a part of the activities of daily living. We squat hundreds of times a day: getting in and out of the car, sitting in a chair, accessing items from the floor or shelves, exercising, and using the toilet. The inability to do these basic tasks is what may ultimately lead to infirmity and the need for assisted living.

There are several methods for evaluating the squat. For simplicity, it is good to start with the fundamental “air squat”. Prior to doing this though, ensure you can safely perform the squat by ruling out any joint injury with your chiropractor first.

How to do an air squat


  1. Stand with your heels shoulder-width apart and toes pointed forward or slightly out (not more than 10˚ of external rotation).
  2. Squat down until your thighs are at least parallel with the ground. You may extend your arms forward as a counter lever, but it is not required.
  3. Perform three repetitions while the chiropractor observes from the front; then three repetitions while observed from the side; and finally three more while observed from behind.


Characteristics of a normal, stable, solid squat

  • Symmetry, i.e. you do not sway to one side.
  • Your heels and toes remain on the ground; feet unmoved.
  • Your knees do not travel forward beyond your toes.
  • The lumbar curve is maintained throughout the squat.
  • Your head and eyes remain up, neutral to slightly extended (never hyperextended!).
  • Normal ankle dorsiflexion is maintained.
  • Hip and knee motion should be fluid, pain free, and demonstrate good movement throughout the ranges required to perform the squat.
  • Your knees should descend in alignment with the lower leg bones and not drift inward.

squat 2

What does your squat say about you?

Poor head alignment and gaze: Possibly indicative of a spinal joint problem or loss of flexibility of the spine if you are unable to control your head appropriately during the squat. Spinal adjustments supported by strengthening and/or mobility exercises will assist this.

Thoracic spine and chest: The thorax should remain stiff and neutral throughout the squatting motion and is best evaluated from the side. The chest should be held upward. Forward curling of the thoracic spine may indicate a motor/muscle control issue or spinal joint fixation.

Lumbar spine: The lumbar spine should be held in a natural, curved position throughout the squat. The inability to achieve this may be due to weakness of muscles, or a spinal, hip or sacroiliac problem.

Hip position: Excessive abduction (outward movement) of the hips may indicate a femoral head problem, imbalance of the gluteal muscle complex, or reduced dorsiflexion of the ankles.

Knee motion: If a knee is twisted outward during the squat it is indicative of weakness of the gluteus maximus and/or other rotators of the hip. Knees should not drift inward either.

Foot motion: If the feet turn outward during the squat it is strongly associated with loss of normal ankle dorsiflexion. Both feet must remain planted firmly when squatting. Stretching and/or foot adjustments may be indicated.

Squat assessments are a valuable clinical tool for identifying biomechanical deficits and can help determine which sites would benefit from adjustments, exercise, neuromuscular or mobility training. Squats are particularly beneficial for analysing people who wish to participate in rigorous activities. The squat is a functional movement complex used in many activities of daily living as well as athletics.

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