Overview of Red Flags that may be identified in Physical Therapy

1. Medical RED FLAGS
Recognition and Referral
By Shawn Houck
April 25, 2010

2. What are RED FLAGS?
Definition:
1) “signs and symptoms of certain conditions that may warrant referral to another
health care provider” (Flynn et al. 2008)
2) “any potential signs and symptom that would indicate the problem is not a
musculoskeletal one or a more serious problem that should be referred to the
appropriate health care professional.” (Magee 2007)
Why do we screen for RED FLAGS?
-For the patients
-For the future of our profession (autonomous practice)
Leerar et al. (2007). “Documentation of Red Flags by Physical Therapists For Patients with Low Back
Pain”. Journal of Manual & Manipulative Therapy, 15(1), 42-49.
One-hundred and sixty clinic charts from 6 different outpatient PT clinics were collected and
analyzed for overall red flag documentation for patients with low back pain. After data collection, the
results indicated that seven of the 11 red flag items were documented over 98% of the time. “Regularly
documented” items included age over 50, bladder dysfunction, hx of cancer, immune suppression, night
pain, hx of trauma, saddle anesthesia, and lower extremity neurological deficit. Red flags that were “not
regularly documented” included weight loss, recent infection, and fever/chills. Authors concluded that
PTs should verbally verify with the patient during the evaluation any possible red flags (since pts may
not thoroughly understand how conditions can be linked). Also, more comprehensive patient self-
report questionnaires should be used to accurately identify red flag items.

3. HEAD, NECK, AND BACK
Common RED FLAGS for Back Pain (Goodman & Synder 2007)
• Age less than 20 or over 50
• Previous hx of cancer
• Fever, chills (infection)
• Unexplained weight loss
• Recent urinary tract infection
• Night pain not relieved by rest and/or worse with recumbency (cancer)
• Progressive, neurologic deficit (e.g. saddle anesthesia)
• Abdominal pain radiating to midback; sx associated with food, worse after NSAIDs (pancreatitis, GI
disease, peptic ulcer)
• Significant morning stiffness with limitation in all spinal mvmts (ankylosing spondylitis or other
inflammatory disorder)
• Skin rash (inflammatory disorder, e.g. Crohn’s disease, ankylosing spondylitis)
• Back pain relieved by sitting up and leaning forward (pancreas)
• Back pain in athletic teenager (epiphysitis, juvenile discogenic disease,
spondylolysis/spondylolisthesis)
• Sudden, localized back pain that does not diminish by 2 weeks in postmenopausal or osteoporotic
women (compression fracture)
Cauda Equina Syndrome
• Low back pain • Changes in bowel/bladder function
• Unilateral or bilateral sciatica • LE motor weakness/sensory deficits
• Saddle anesthesia or perineal • Diminished or absent LE DTR’s
hypoesthesia
Oncologic Spine Pain
• Severe weakness w/o pain • Progressive neurological deficits
• Weakness with full range • Signs/sx associated with visceral
• Sciatica caused by metastases to pelvis, systems
lumbar, or femur • Positive percussive tap test to one or
• Constant pain (does not vary with more spinous process
position/activity • Palpable mass in neck/upper torso with
• Skin temperature differences L/R occipital HA and neck pain

4. Aortic Aneurysm
• Rapid onset of severe neck/back pain • Pain not relieved by change in position
• Pain radiating to chest, shoulders, back • “Tearing” or “ripping” pain
(between scapulae), abdomen, or post. • Cold, pulseless lower extremities
thighs
GI Dysfunction
Anterior neck or back pain accompanied by:
• Esophageal pain • Bloody stool/diarrhea
• Epigastric pain with radiation to the • Fecal incontinence
back • Melena (dark, abnormal stool caused by
• Dysphagia (difficulty swallowing) oxidized blood)
• Odynophagia (pain with swallowing)
Location of Systemic Thoracic/Scapular Pain (Goodman & Synder 2007)
Cardiac
Myocardial infarct Midthoracic spine
Aortic aneurysm Thoracic spine; thoracolumbar spine
Pulmonary
Basilar pneumonia Right upper back
Empyema Scapula
Pleurisy Scapula
Pneumothorax Ipsilateral scapula
Renal
Acute pyelonephritis Costovertebral angle (posteriorly)
Gastrointestinal
Esophagitis Midback between scapulae
Peptic ulcer Sixth through tenth thoracic vertebrae
Gallbladder disease Midback between scapulae; right upper scapulae or subscapular area
Biliary colic Right upper back; midback between scapulae; right interscapular/subscap
Pancreatic carcinoma Midthoracic or lumbar spine
Other
Acromegaly Midthoracic or lumbar spine
Breast cancer Midthoracic spine or upper back

5. CHEST/RIBS
Common RED FLAGS Associated with Chest/Ribs (Goodman & Synder 2007)
• Sudden onset on acute chest pain with difficulty breathing (pulmonary embolism,
myocardial infarction, ruptured abdominal aneurysm)
• Pain occurring without exertion, lasting longer than 10 min, not relieved by
rest/nitroglycerin (unstable anginaheart attack)
• Chest pain relieved by antacid (reflux esophagitis)
• Chest, neck, or shoulder pain aggravated by physical exertion, precipitated by working
with arms overhead (>5 min), light-headedness, profuse perspiration (cardiovascular)
• Chest/rib pain eliminated when lying on involved side, known as “autosplinting”
(pleuropulmonary)
• Persistent cough, dyspnea, and symptoms that increase in the supine position
(abdominal contents push up on diaphragm and against parietal pleura)
(pleuropulmonary)
Myocardial Ischemia
Men Women
• “Squeezing, fullness” pressure/discomfort • Classic chest discomfort
under sternum, mid or entire chest region • Dyspnea (at rest or with exertion)
• Pain may occur in jaw, upper neck, • Weakness and lethargy
midback, or down arm without chest pain • Indigestion or heart burn
• Pain in arm (usually left, sometimes both) • Lower abdominal pain
• Anxiety/depression
is most often along the ulnar nerve
• Sleep disturbances
distribution
• Isolated midthoracic back pain
• Isolated right biceps ache
• Sensation of “inhaling cold air”

6. Gastrointestinal Disorders
• Chest pain that may radiate to the back • Pain on swallowing or associated with
• Symptoms aggravated in meals
supine/relieved in upright position • Jaundice
(upper GI problem) • Heartburn/indigestion
• Nausea, vomiting • Dark urine
• Blood in stools
Anabolic Steroid Use
• Chest pain • Gynecomastia (breast tissue
• Elevated BP development in males) and breast
• Ventricular tachycardia tissue atrophy in females
• Weight gain (10-15 lbs in 2-3 weeks) • Frequent hematoma or bruising
• Peripheral edema • Personality changes “steroid psychosis”
• Acne on face, upper back, chest • Females: development of secondary
• Delayed tissue healing times male characteristics
• Jaundice (chronic)

7. SHOULDER/UPPER
EXTREMITY
Common RED FLAGS Associated with the Shoulder/Upper Extremity (Goodman & Synder
2007)
• Hx of rheumatic disease, recent (1-3 mo) myocardial infarction (chronic regional pain
syndrome), previous cancer especially breast/lung (metastasis), recent
pneumonia/upper respiratory infection/influenza (diaphragmatic pleurisy)
• Hx of diabetes mellitus, hyperthyroidism, ischemic heart disease, infection, and lung
diseases such as tuberculosis, emphysema, chronic bronchitis, Pancoast’s tumors (all are
at risk for adhesive capsulitis)
• Presence of abnormal (hard, fixed) lymph nodes (cancer)
• Shoulder pain in a woman of childbearing age of unknown cause associated with missed
menses (rupture of ectopic pregnancy)
• Left shoulder pain within 24 hours of abdominal surgery, injury, or trauma (Kehr’s sign,
ruptured spleen)
• Shoulder pain relieved by leaning forward, kneeling with hands on floor, sitting upright
(pericarditis)
• Shoulder pain unaffected by position, breathing, or movement (myocardial infarction)
• Shoulder pain accompanied by dyspnea, toothache, belching, nausea, or pressure
behind sternum and relieved by nitroglycerin or antacid drugs (angina)
• Persistent, dry or productive cough, with shoulder pain aggravated in the supine
position (diaphragmatic or pulmonary component)

8. Shoulder/Upper Extremity (cont.)
Location of Shoulder Pain
Systemic origin Left shoulder Systemic Origin Right Shoulder
Lymphatic: Gastrointestinal:
Ruptured spleen L shoulder (Kehr’s) Peptic ulcer Lateral border, R scapula
Cardiovascular: Cardiovascular:
Myocardial ischemia L pectoral/L shoulder Myocardial ischemia R shoulder, down arm
Aortic aneurysm L shoulder Aortic aneurysm R shoulder
Endocrine/GI: Hepatic/Biliary:
Pancreas L shoulder Acute cholecysistitis Between scapulae or
R subscap. area
Pulmonary: Liver abcess R shoulder
Pleurisy Ipsilateral R shoulder, Gallbladder R upper trap, R shoulder
upper trap Liver disease R shoulder, R subscap area
Pneumothorax (same as above) (hepatitis, cirrhosis, tumor)
Pancoast’s tumor (same as above)
Pneumonia (same as above) Pulmonary:
Pleurisy Ipsilateral R shoulder,
Urinary: upper trap
Kidney involvement Ipsilateral shoulder Pneumothorax (same as above)
Pancoast’s tumor (same as above)
Other: Pneumonia (same as above)
Infectious mononucleosis L shoulder/L upper trap
Ectopic pregnancy L shoulder (Kehr’s) Urinary:
Post-op laparoscopy L shoulder (Kehr’s) Kidney involvement Ipsilateral shoulder

9. SACRUM/SACROILIAC AND PELVIS
Common RED FLAGS Associated with Sacroiliac/Sacral Pain or Sx (Goodman & Synder 2007)
• Insidious onset or SI pain without hx of trauma or increased activity levels
• Hx of cancer or GI disease (ulcerative colitis, Crohn’s disease, irritable bowel syndrome)
• Risk factors such as osteoporosis (insufficiency fracture), STDs, long-term use of antibiotics
• Lack of objective findings (negative special tests)
• Anterior pelvic, suprapubic, or low abdominal pain at level of the sacrum
• Pain relieved by passing gas/bowel movement (GI involvement)
• SI radiating around the flank (bladder/urologic dysfunction)
• Presence of other GI, gynecologic, or urologic signs/sx
Common RED FLAGS Associated with Pelvic Pain or Sx
• Hx of reproductive/colon/breast cancer, dysmenorrhea, ovarian cysts, pelvic inflammatory
disease, endometriosis, chronic bladder/UTIs/IBS, previous pelvic or bladder surgeries
• Clinical presentation of
o Poorly localized (diffuse) pain
o Pain aggravated by increased intra-abdominal pressure (e.g. standing, walking,
coughing, intercourse, Valsava maneuver--- GI involvement)
o Pain not affected by specific movements
o Pain that gets at end of day or after prolonged standing (vascular)
o Temporary relief with position change (nerve entrapment, gynecologic dysfunction)
o Pain radiating around flank/genitalia/ant-med thigh (urogenital)
o Positive McBurney’s sign (palpation for appendicitis), Blumberg sign (rebound
tenderness), Positive Iliopsoas/Obturator sign (perforated appendix, inflamed
peritoneum)
o Dyspareunia (pain/difficult intercourse) and/or discharge from vagina/penis

10. LOWER QUADRANT
Common RED FLAGS Associated with the Lower Extremity (Goodman & Synder 2007)
• Hx of cancer, renal/urologic disease, trauma/assault
• Infectious/inflammatory condition (Crohn’s disease, diverticulitis, PID, Reiter’s syndrome,
appendicitis)
• Gynecologic condition (recent pregnancy, multiple births)
• Alcoholism (hip osteonecrosis)
• Long-term use of immunosuppressants (osteonecrosis)
• Heart disease (arterial insufficiency, peripheral vascular disease)
• Hematologic disease (sickle cell anemia, hemophilia)
• Hip or groin pain alternating or occurring simultaneously with abdominal pain at same level
(aneurysm, colorectal cancer)
• Hip pain in young adult that is worse at night and relieved by activity/aspirin (osteoid osteoma)
• Painless neurological deficit(s) (spinal cord lesion)
• Hip/groin pain (insidious onset) in men 18-24 years of age, with any other cancer red flags
(testicular cancer)
Stress Reaction/Stress Fracture in Femur
• Aching/deep aching pain that increases • Pain reproduced by
with activity/improves with rest, translational/rotational stress
possible night pain • Thigh pain (sharp) reproduced by the
• Pain localized to specific area of bone, fulcrum test
reproduced with WB • Increased tone of hip adductors (limited
• Compensatory gluteus medius gait hip abduction)
Buttock, Hip, Groin, or LE Pain Associated with Cancer
• Bone pain (esp. with WB) and localized • Pain relieved disproportionately by
tenderness aspirin
• Antalgic gait • Fever, weight loss, bleeding, skin lesions
• Night pain which is constant/intense • Vaginal/penile discharge
and unrelieved by change in position • Painless, progressive enlargement of
inguinal and/or popliteal lymph nodes

11. Psoas Abscess
(caused by any infectious/inflammatory process in ab/pelvic region)
• Pain confined to psoas fascia, but may • Positive psoas sign (pain with passive
extend to the buttock, hip, groin, upper stretch)
thigh, or knee • Fever, sweats, loss of appetite or other
• Pain located in anterior hip/medial GI symptoms
thigh area (femoral triangle) • Leg resting position of IR
• Psoas spasm (leading to functional hip • Palpable mass in ant. hip or groin (psoas
flexion contracture) abscess, hernia)
Osteonecrosis
• Hip pain (mild at the beginning and • Tenderness to palpation over the hip
progressively worse with time), worse joint
with WB • Hip joint stiffness and problems with
• Possible groin/ant-med. thigh pain dislocation
• Limited hip range of motion (internal • Possible “click” in hip with sit to stand
rotation, flexion, abduction) movements
Hip Hemarthrosis
• Pain in groin/thigh • Limited motion in hip flexion,
• Fullness in hip joint (anterior in groin abduction, and ER (allows for most
and over greater trochanter) room for blood in jt. capsule)
Sickle Cell Anemia
• Athlete slumps to ground • Presence of gross hematuria
• Complaints of general muscle weakness • Severe left upper quadrant pain (splenic
(possible swelling) infarction)
• Mild to moderate pain • May lead to acute exertional
• Palpation=normal muscle tone rhabdomyolysis
• No significant rise in core temperature

12. References
Flynn, T., Cleland, J., & Whitman, J. (2008). The Users’ Guide to the Musculoskeletal Examination:
Fundamentals for the Evidenced-Based Clinician. Evidence in Motion: Louisville, KY.
Goodman, C., & Snyder, T. (2007). Differential Diagnosis for Physical Therapists: Screening for Referral,
4th Ed. Saunders: St. Louis, Missouri.
Leerar et al. (2007). “Documentation of Red Flags by Physical Therapists For Patients with Low Back
Pain”. Journal of Manual & Manipulative Therapy, 15(1), 42-49.
Magee, D (2008). Orthopedic Physical Assessment: Musculoskeletal Rehabilitation Series, 5th Ed.
Elsevier Health Sciences, pg 2.