Red Flag Sign of Serious Pathology


Symptoms for which a patient has presented to Physiotherapy treatment may be associated with a medical condition. Sometimes pain referred can be from another body part.

It is well established that what seems like pain in our back can come from our kidney, or pain in our shoulder can be actually caused by lung cancer.

The Physiotherapist is expert in treating pain from muscles, joints and nerves that tends to be related to movement.

But, how does a Physiotherapist determine if the problem is something really serious??

One of the early things that is drilled into us as Physiotherapy university students, is that we should always have our “antennae up and alert for serious pathology”.

In the medical profession there are a system of “flags”:

Red Flag

Red Flag

Sign of serious pathology

Orange Flag

Psychiatric symptoms; clinical depression, personality disorder

Yellow Flag

Yellow Flag

Pain beliefs, emotional response, pain coping strategies

Blue Flag

Perceptions about the relationship between work and health

Black Flag

Black Flag

Contextual obstacles; litigation, heavy work that cannot be modified

If a red flag is suspected, seek urgent medical attention.

As Physiotherapists, to determine if there is a serious problem we clarify topics such as:

Cord/Cauda Equina Syndrome

Pins and Needles or numbness in hands or feet in both sides at once and especially if there are associated Bladder/Bowel changes.

Bowel or Bladder Dysfunction

Not being able to urinate, not being able to open the bowels or losing control of either function


If the trauma involves a collision, rotation or at high speed we suspect a bone break so refer the patient for an XR. This is particularly important in a woman who has been through menopause as their bones are generally weaker.


There are certain cancers that are common in certain populations.

Osteosarcoma- in boys in long bones.

Breast Cancer – can present as shoulder pain however the shoulder doesn’t follow usual joint/muscle pain patterns.

Brain Cancer – can present as a headache but the headache tends to be sudden onset, severe and unrelenting pain.

Unremitting night pain
This is when pain is severe enough to prevent sleep and make the patient get up out of bed. Obviously if they have hurt their back the day before it is normal to have pain at night for a few days. This naturally is markedly different from ongoing and unremitting night pain that is not related to a specific injury.
Sudden and significant weight loss
We are talking about weight loss that is not associated with any dieting. When people are seriously unwell, they often lose weight very quickly, 5kg a month.
Previous History of Cancer
A previous episode of cancer means that it is possible to have secondary cancer in another part of the body that can cause musculoskeletal pain.
In Summary

At Active Solutions Physiotherapy we always refer you back to your GP for further investigations of we identify a red flag. The occasions for these referrals do not occur often. Anecdotally, our staff with a combined working experience of 50 years have described having a patient with a red flag that needs a medical referral on average 1 x 3 years.

These are some of our stories of red flags in our careers:

Physiotherapists are experts at treating musculoskeletal pain but are well aware that sometimes serious pathology can be present.

Therefore, we have a set of screening questions that we always ask which help us identify if a patient might have a serious illness. In addition to this, injuries have common pain and movement patterns. If these patterns are unusual and do not respond to treatment, we are immediately concerned. In these circumstances we refer the patient back to their GP for further investigations. These events are very serious and require careful and prompt action, however thankfully they are rare.

You can trust Active Solutions Physiotherapy to perform an accurate assessment of your pain. If there is a positive response to the screening questions or an injury doesn’t follow the usual pattern, we will refer for a medical review.

Click on the links below to book online for a physiotherapy assessment and treatment or give us a call on 0438 648 884.

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