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Red Flag Screening

While this book has mentioned some of the harms of medical imaging (X-rays, MRIs, etc.), they do have their place. To determine if a patient needs to be sent to another provider for an X-ray, MRI or other form of medical imaging, we want to be certain a red flag is not present. We know this based on the information you provide us and the results of a physical exam. This is not a guessing game and there are very clear indicators when a patient needs to be referred to another provider. Here are some of the features we look for:

Metastatic Cancer:

  • History of cancer (especially prostate, breast, kidney, thyroid and lung cancer)
  • Night pain or pain at rest
  • Unexplained weight loss
  • Age >50 or <17 years old
  • Failure to improve over the predicted time interval

Cauda Equina Syndrome:

  • Urinary retention 
  • Saddle anesthesia 
  • Sensory or motor deficit in the feet 

Undiagnosed Vertebral Fracture:

  • Serious trauma
  • Older age
  • Prolonged use of steroids 
  • Difficulty weight bearing 


  • Recent infection
  • Immunocompromised 
  • Fever, malaise and swelling 

Dangerous Abdominal Aortic Aneurysm:

  • Cardiovascular history, especially history of atherosclerotic vascular disease 
  • Pulsing mass in the abdomen
  • Throbbing, pulsing back pain at rest 
  • History of smoking
  • Increased abdominal girth 
  • Aortic pulse > 5 cm 

Some of these findings are more critical than others. For example, if you have a history of prostate or breast cancer with a new onset of low back pain, medical imaging would be warranted due to the chance of these cancers metastasizing to the spine. Cancers metastasizing to bone is more common than primary bone cancers, especially in adults. However, the finding of someone being older than 50 or younger than 17 by itself would not result in the need for medical imaging. All the findings above are just part of the greater picture of each individual patient’s unique presentation. This is why we have you  complete a medical questionnaire and ask lots of questions at your first visit. If we are not certain a red flag condition is NOT present, we will send you off to the appropriate provider and wait to start physical therapy when these above red flags have been ruled out. 

Further, we will look at any possible adverse side-effects from medication. Medication-specific concerns includes:

  • Steroids: (risk of osteoporosis)
  • Anti-coagulants: (risk of bleeding)
  • Immunosuppressants: (risk of infections)


  1. Delitto, A., George, S., Van Dillen, L., Whitman, J., Sowa, G., Shekelle, P., Denninger, T. and Godges, J., 2012. Low Back Pain. Journal of Orthopaedic & Sports Physical Therapy, 42(4), pp. A1-A57.
  2. Macedo, F., 2017. Bone Metastases: An Overview. Cancer therapy & Oncology International Journal, 4(3).

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