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Screening for Red Flags by an Orthopedic Manual Physical Therapist

Red Flag

How Does an Orthopedic Manual Physical Therapist perform Medical Screening for Red Flags?

Orthopedic manual physical therapy is performed with the goal of reducing pain and improving movement in the spine and/or at any location throughout the neuromusculoskeletal (or orthopedic) system. In rare cases, however, pain that seems to be of an orthopedic nature may have a different origin. Does this mean that prospective patients should seek out a medical physician before scheduling an examination with a doctor of physical therapy?

No, patients have direct access to physical therapists in Illinois and do not require a physician referral (though patients are advised to contact their insurance company to inquire about whether or not a referral is required for insurance reimbursement). Doctors of physical therapy are trained in differential diagnoses and will refer to more appropriate health care providers if there is suspicion that a patient's symptoms are not of an orthopedic origin. An orthopedic manual physical therapist is to be vigilant to signs and symptoms ("red flags") that either indicate a medical emergency or are suggestive of sinister pathology. As both lie outside of a physical therapist’s scope of practice, patients presenting with these signs and symptoms warrant a referral to a medical physician.

An orthopedic manual physical therapist must always inquire of the presence of any symptoms that may be suggestive of these red flags. Depending on each patient's unique presentation, the physical therapist would directly inquire about such things as severe trauma, unexplained weight loss, history of cancer, dizziness, loss of consciousness, clumsiness walking or handling objects, unexplained weakness, nausea, fever, chills, night sweats, change in bowel or bladder function, change in symptoms after eating or drinking, paresthesia or anesthesia, difficulty speaking, difficulty swallowing, and change in vision (though this is not all-inclusive). The following outline provides a brief overview of conditions that commonly present with pain or dysfunction that may be incorrectly interpreted as having an orthopedic origin or that may warrant further medical work-up.


  • History Cluster (sensitivity of 100%)

  • Age >50

  • Previous history of cancer (+LR 23.7)

  • Unexplained weight loss (>10 pounds in 3 months)

  • Failure to improve after 1 month of treatment

  • Relentless night pain

  • Non-mechanical pain – not relieved with positioning or rest

  • PB KTLL – “Lead Kettle” pneumonic for cancers likely to metastasize to bone: Prostate, Breast, Kidney, Thyroid, Lung, Lymph

  • Must refer to physician for ESR / hematocrit testing

  • Elevated ESR (+LR 18.0)

  • Reduced hematocrit (+LR 12.1)

Upper Cervical Instability[2] [3] [4]

  • Positive Sharp-Purser test

  • Positive alar ligamentous instability

  • Headaches

  • “Bobble head” that feels unstable – patient needs pressure/support to feel relief

  • History of Down’s Syndrome, Rheumatoid Arthritis, Ankylosing Spondylitis, throat infection, Ehlers-Danlos Syndrome

  • UCI tests have not been studied sufficiently, but seem to be highly specific. (Cannot rule out when negative, however.)

  • Refer to physician for open mouth, flexion/extension plain films

Cervical Arterial Insufficiency[5] [6]

  • Typically unilateral posterior neck pain with suboccipital pain or headache around temple (these symptoms may precede an ischemic event by a few days to several weeks)

  • Contralateral vertebral artery stressed with cervical rotation (In healthy adults, the cerebral vasculature can compensate for unilateral decrease of blood flow; strokes may be more resultant of decreased compensatory capacity of the system and not isolated VBI)

  • Assess for 5 D’s & 3 N’s (especially dizziness) and Ataxia

  • Dizziness

  • Diplopia

  • Drop Attack

  • Dysarthria

  • Dysphagia

  • Nystagmus

  • Nausea

  • Numbness

  • Cranial nerve palsy with Horner’s syndrome (pathognomonic for internal carotid artery)

  • Vomiting, hoarseness, memory loss

  • Hearing loss / tinnitus

  • Pupillary changes, photophobia

  • Facial numbness

  • Vision changes

  • Blood pressure changes (typically higher)

  • History: smoker, cardiovascular dysfunction, previous MVA, diabetes, blood clotting disorder, post-partum, long-term steroid use, recent infection, history of trauma, oral contraceptives

  • Medical emergency. May need Doppler assessment with rotation and extension or angiography.

Cervical myelopathy – Clinical Prediction Rule (>3 to rule in, <1 to rule out) [7]

  • Gait deviation

  • Hoffman’s

  • Inverted supinator sign

  • Babinski

  • >45 years of age

  • Though not a medical emergency, the physical therapist must refer to a physician if unchanged after a reasonable amount of treatment and discuss options based on presentation; MRI is best for suspicion of cord compression. (Myelopathy is the most common spinal disorder >55 years of age, and surgery is rarely needed.)

Pulmonary Dysfunction (Pneumothorax, Pulmonary Embolism)

  • Sharp, localized pain

  • Pain may also be present in abdomen, neck, shoulder, posterior thorax

  • Pain aggravated by breathing, coughing, sneezing, laughing

  • Better in upright position, worse recumbent

  • Dyspnea / Shortness of breath

  • Persistent cough

  • Fever / chills

  • Malaise

  • Weak, rapid pulse

  • Low blood pressure (pneumothorax)

  • Palpitations

  • Bloody sputum

  • Cyanosis

  • History of DVT, prior pulmonary embolism, COPD, CHF, oral contraceptives, hormone replacement, pregnancy, TKA/THA, lower extremity fractures, abdominal/pelvic surgery or malignancy.

  • Medical emergency

Infection / Osteomyelitis / Discitis

  • Increased temperature

  • Erythema / Streaking

  • Malaise

  • Disproportionate tenderness

  • Systemic changes

  • Chills / Night sweats

  • Severe night pain

  • Unexplained weight loss of >10 pounds in 3 months

  • Recent bacterial infection

  • Dental abscesses

  • Transplant

  • IV drug abuse

  • Prolonged steroid use

  • Age >50

  • Visible redness

  • Palpable increased warmth

  • Positive spinal percussion

  • "The current evidence surrounding red flags for spinal infection remains small, it was not possible to assess the diagnostic accuracy of red flags for spinal infection, as such, a descriptive review reporting the characteristics of those presenting with spinal infection was carried out. In our review, spinal infection was common in those who had conditions associated with immunosuppression. Additionally, the most frequently reported clinical feature was the classic triad of spinal pain, fever and neurological dysfunction." [xvi]

  • Must refer to physician for imaging and lab tests or send to emergency department as appropriate.

Cauda Equina Syndrome

  • Urinary retention (Sp=0.95, +LR=18)

  • Bowel dysfunction

  • Saddle paresthesia / anesthesia

  • Ataxia

  • Hyporeflexia

  • Significant/progressive neurological changes in lower extremities at multiple spinal levels

  • Patients in their 40’s and 50’s

  • Reports of sciatica in one or both lower extremities

  • Reports of sexual dysfunction

  • Positive straight leg raise

  • Medical emergency. Patient must receive immediate evaluation and neurosurgery as appropriate within 48 hours.

Spinal Fracture[8] [9]

  • Positive Tap Test or Closed Fist Percussion Test

  • Unrelenting pain

  • Altered sensation from trunk down

  • Age >68

  • Trauma

  • History of osteoporosis, osteopenia, corticosteroid use

  • Unable to lie supine

  • Refer to physician for imaging

Abdominal Aortic Aneurysm

  • Pain in abdomen, chest, low back, groin, posterior thighs

  • Pain worse with exertion

  • Excruciating, sharp, pulsating, throbbing

  • Pain greater in supine

  • Non-mechanical back pain

  • Tearing sensation during rupture

  • Cold, pulseless lower extremities

  • Width of abdominal pulse >3cm to palpation

  • Neurological changes

  • Age >50

  • Symptom onset during exertion

  • Recent initiation of weight lifting program

  • Smoking, obesity, family history, high cholesterol, high blood pressure

  • Medical emergency

Thoracic Aortic Aneurysm

  • Knife-like, tearing, excruciating pain

  • Pain in thoracic spine, chest, neck

  • Sense a heartbeat in supine

  • Hoarseness

  • Difficulty swallowing

  • Difficulty breathing

  • Clammy skin

  • Nausea / vomiting

  • Elevated heart rate

  • Elevated blood pressure

  • Positive family history

  • Medical emergency

Deep Vein Thrombosis - Wells criteria (≥2 points DVT likely, <2 DVT unlikely) [10, 18]:

  • Active cancer (treatment ongoing, within 6 mo, or palliative) +1

  • Paralysis, paresis, or recent plaster immobilization of lower extremities +1

  • Recently bedridden for 3 d or more, or major surgery within 12 wk requiring general or regional anesthesia +1

  • Localized tenderness along distribution of deep venous system +1

  • Entire leg swollen +1

  • Calf swelling at least 3 cm larger than asymptomatic side +1

  • Pitting edema confined to symptomatic leg +1

  • Collateral superficial veins (non-varicose) +1

  • Previously documented DVT +1

  • Alternative diagnosis at least as likely as DVT -2

  • Medical emergency. D-dimer testing is first recommended step. If positive, ultrasound is required. If negative, DVT is unlikely.

Pulmonary Embolism

  • Signs and symptoms

  • SOB/cough

  • Chest pain

  • Dizziness, fatigue

  • Loss of lung sound(s)

  • Cyanosis

  • Excessive sweating

  • Irregular heartbeat

  • History

  • Recent surgery

  • Family history of PE

  • Recent history of traveling / flying

  • Medical emergency

Myocardial Infarction / Angina

  • Pain in left upper quarter, i.e. neck, chest, jaw – or right biceps area in females)

  • Chest or abdominal pain / tightness

  • Heartburn

  • Heart palpitations

  • Difficulty breathing / shortness of breath

  • Pale, clammy, sweating

  • Pain worse with exertion, after heavy meals, or with arm / trunk movement

  • Not relieved with rest

  • Nausea / vomiting

  • Vision / speech impairments

  • Chest pain in a patient with a history of stent

  • Medical emergency


  • Sharp pain in similar location pattern to MI

  • History of fever / chills

  • Pain worse with deep breathing, laughing, belching, coughing, swallowing, neck / trunk movements, lying down

  • Pain eased with holding breath, leaning forward, sitting upright

  • Medical emergency


  • Hip avascular necrosis, more common in pediatric (aged 4-14) males

  • Hip, knee, or groin pain

  • Leg length inequality

  • Pain with hip range of motion, especially internal rotation

  • Antalgia

  • Refer to physician for X-ray, bone scan, or MRI

Slipped Capital Femoral Epiphysis (SCFE)

  • Most common adolescent hip disorder in prepubescent (aged 10-17) males

  • Obesity is significant risk factor

  • May have knee pain, hip pain or buttock pain

  • Leg length inequality

  • Decreased hip range of motion, especially internal rotation

  • May maintain hip in external rotation while weight bearing

  • Immediately make patient non-weight bearing and refer to surgeon

Femoral Neck Stress Fracture

  • Overuse or after initiating / increasing activity

  • Groin, thigh, or knee pain

  • More common in females

  • Family history of osteoarthritis

  • History of smoking

  • Pain in end-ranges of motion, with weight bearing, positive hop test, positive FABER, positive fulcrum test

  • Need to refer to physician for bone scans with recent onset (100% sensitivity and almost 100% specificity) as plain films will not detect fractures for 3-4 weeks

Septic Arthritis

  • History of fever

  • Non-weight bearing gait

  • Increased sedimentation rate (>40mm/hr)

  • Increased serum WBC (>12,000)

  • Deadly. Need bacteria culture for definitive diagnosis; may need antibiotics and/or invasive procedures

Inflammatory Arthritis

  • Severe morning stiffness >1 hr

  • Pain not relieved (or worse) with rest

  • Improvement in pain with exercise

  • Chronic duration

  • Decreased spinal range of motion

  • Decreased chest wall expansion

  • Fever

  • Weight loss

  • Fatigue

Ankylosing Spondylitis

  • Morning stiffness >30 minutes

  • Improvement in pain with NSAIDs

  • Night pain (during second half of night)

  • Alternating buttock pain

Digestive System Disorders

  • Difficulty swallowing

  • Heartburn

  • Indigestion

  • Specific food intolerances

  • Changes in appetite

  • Bowel dysfunction (dark, tarry stools are typically suggestive of upper GI involvement but may involve lower GI as well – possibly Crohn’s disease, prolonged use of NSAIDs; blood in the stool may indicate colon cancer, anal fissures, hemorrhoids)

  • Urinary dysfunction (hematuria, pain, change in frequency)

  • Abdominal distension

  • Fevers / chills / sweats

  • Nausea / vomiting

  • Rebound tenderness

  • Pain relieved by sitting forward (pancreatic etiology)

  • Pain not relieved with rest or positioning

  • Change in symptoms after eating (0-30 minutes implicate stomach, duodenum, upper GI; 2-4 hours implicate intestines, colon, lower GI)

  • Refer to physician (or ask if physician is aware of these symptoms and if the symptoms have changed in any way since seeing the physician)

Reproductive Organ Disorders

  • Change in menstruation (frequency, pain, discharge)

  • Change in bladder function (frequency, hesitancy, blood)

  • Sexual dysfunction, pain, or bleeding

  • Abdominal, thoracic, or lumbosacral pain

Major Depressive Disorder

  • Depressed mood most of the day, nearly every day for 2+ wks

  • Diminished interest or pleasure in most activities

  • Significant weight loss or gain

  • Insomnia or hypersomnia

  • Psychomotor agitation or retardation

  • Fatigue / loss of energy

  • Feelings of worthlessness / excessive guilt

  • Diminished ability to concentrate or make decisions

  • Recurrent thoughts of death or suicide

  • Use PHQ-2 first to screen for it (Kroenke 2003 Medical Care)

  • Use PHQ-9 to rule it in – high sensitivity and specificity (Kroenke 2002 Psychiatric Annals)

  • If score >10 on PHQ-9, 7-13.6x more likely to have major depression

  • Refer for psychiatric evaluation

Suicide Risk

  • History of major depression

  • History of substance abuse

  • Expressed suicidal ideation

  • Giving away of personal possessions

  • Recent calmness (do not prematurely conclude that depression is resolving)

  • Plan to take life and/or taking steps to enact a plan

  • Family history of suicide attempts

  • Previous suicide attempt

  • History of progressive illness

  • Recent loss (family member, job, financial)

  • Presence of firearms at home

  • Contact emergency department to arrange for transport

There is a low percentage of red flags presenting as common orthopedic conditions as noted in this systematic review that considered the prevalence of red flags in patients seen in the Emergency Department for low back pain:

"We analyzed 22 studies with a total of 41,320 patients. The prevalence of any requiring immediate/urgent treatment was 2.5%-5.1% in prospective and 0.7%-7.4% in retrospective studies (0.0%-7.2% for vertebral fractures, 0.0%-2.1% for spinal cancer, 0.0%-1.9% for infectious disorders, 0.1%-1.9% for pathologies with spinal cord/cauda equina compression, 0.0%-0.9% for vascular pathologies). Examples of red flags which increased the likelihood for a serious condition were suspicion or history of cancer (spinal cancer); intravenous drug use, indwelling vascular catheter, and other infection site (epidural abscess). We found a higher prevalence of serious spinal pathologies in the ED compared to the reported prevalence in primary care settings." [17]

However, I cannot overemphasize the fact that not only is this list not all-inclusive, there still remains considerable uncertainty around the identification of red flags for serious pathologies, and each health care professional must weigh each patient's unique presentation carefully when deciding how to proceed. [11-18]

Further Information on Orthopedic Manual Physical Therapy

Click on any of the following links for more information:

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Dr. Damon Bescia is a fellowship-trained Doctor of Physical Therapy, board certified in orthopedics and sports physical therapy, who specializes in Orthopedic Manual Physical Therapy and serves Naperville and its surrounding communities by way of his Concierge Practice, providing private one-to-one orthopedic manual physical therapy for his clients. For more information, please visit

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