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When is PT not appropriate for thoracic spine pain?

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 100% certain a red flag is not present. We know this based on the information you provide us and the results of your physical exam. This is not a guessing game and there are very clear indicators when a patient needs to be referred to another provider for imaging. 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

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

Spinal Cord Injury:

  • Numbness and tingling in both hands and/or feet
  • Changes in walking including increased spasticity and needing a wide base of support
  • Clumsiness in the hands
  • Difficulty initiating urine
  • Incontinence
  • Inner groin numbness


  • Chest or abdominal pain
  • Shortness of breath
  • Palpitations
  • Nausea
  • Dizziness
  • Symptoms with exertion (i.e. walking or going up stairs)


  • Cough
  • Chest pain
  • Shortness of breath
  • Pain with deep breath
  • Symptoms with exertion (i.e. walking or going up stairs)


  • Symptoms associated with food consumption
  • Changes in bowel habits
  • Weight change since onset

Cauda Equina Syndrome:

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

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 or 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 you 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 once 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)


  • 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.
  • Macedo, F., 2017. Bone Metastases: An Overview. Cancer therapy & Oncology International Journal, 4(3).

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