Back pain in children and young athletes is very different from back pain in adults. Macrotrauma must be carefully evaluated and managed, even in the absence of definitive radiographic findings. Microtrauma must be suspected in at-risk athletes. These athletes require persistent diagnostic evaluation and may require SPECT bone scan to uncover a posterior element stress reaction. Atraumatic back pain requires the elimination of neoplastic, infectious, rheumatologic, or congenital causes.