Back injuries have been the ‘Achilles heel’ of fast bowlers in cricket for the last 150 years, although it has been the last 40 years when it has been recognised that the signature lesion is the lumbar stress fracture. Historically, almost every elite level fast bowler expected that back pain must be tolerated for one’s entire career. With a modern approach, they still take a considerable toll on teenage fast bowlers but, if managed well early, can be less of a problem throughout a bowler’s mid and late career. Australia has led the paradigm shift from one of resignation and acceptance to a model of early diagnosis and early unloading with a goal of bony healing and maintenance of normal lumbar anatomy. The elite Australian fast bowlers of the modern era are missing as much time during their teenage years and early 20s due to back injuries as fast bowlers did in bygone days but have less time being missed from the mid-20s onwards. It is apparent that contemporary fast bowlers are achieving longer careers that last into their mid-30s compared to the fast bowlers of previous eras, who often may have struggled beyond the age of 30 due to chronic low back pain. This review is a personal historical reflection detailing some of the players and the medical staff members who have led to the paradigm shift in Australia over the last 40 years.