Red Flags in Physiotherapy: A Screening Guide for PTs

Red flags in physiotherapy are findings in the history or examination that make a serious cause of the patient's symptoms more likely, such as cauda equina syndrome, cancer in the spine, spinal infection, a fracture or a problem with the arteries of the neck. Almost none of them is accurate enough on its own to confirm or rule out anything. Screening means asking every patient the right questions, weighing the answers against the patient's age and history and what you find on examination, and deciding how worried you are. That level of concern sets the route: emergency care, a same-day medical assessment, a routine letter to the doctor, or physical therapy with a clear safety net.

This guide is written for physical therapists (PTs) and physiotherapists working in outpatient and first-contact settings. You will find how screening works, the main serious conditions by body region, what the evidence says about how accurate red flags are, and how to document and pass on a referral. Treat it as education, not a protocol. Local pathways come first, as do your regulator's standards and your employer's policies.

What are red flags in physiotherapy?

In 2020 the International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) put out an international framework on red flags, written by Finucane and colleagues and published in the Journal of Orthopaedic and Sports Physical Therapy (JOSPT). It defines red flags as signs and symptoms that might raise suspicion of serious spinal pathology. Such pathology is rare, the framework says, but it can have devastating, life-changing or life-limiting consequences, so it has to be identified early. Four conditions get most of the attention: cauda equina syndrome, spinal fracture, spinal malignancy and spinal infection.

The neck has its own framework. The International IFOMPT Cervical Framework, led by Rushton and colleagues (2020, with a 2023 addendum, and published as a position statement in JOSPT in 2023), covers vascular problems of the neck before musculoskeletal treatment. Its list runs from dissection of the carotid or vertebral arteries to atherosclerosis, giant cell arteritis and subarachnoid hemorrhage. Other red flags come from general medicine: a clot in a leg vein, an abdominal aortic aneurysm, or heart pain felt in the arm or jaw.

Screening is part of routine care. When Lin and colleagues reviewed high-quality clinical practice guidelines for musculoskeletal pain in 2020, they found eleven recommendations the guidelines consistently shared, and one of them was to "screen for red flag conditions".

How does red flag screening work?

Start with the history

Most of the useful information comes from the history. The IFOMPT cervical framework sees the patient history as the way to establish, and test, hypotheses about whether a person is predisposed to a vascular problem in the neck or already has one, and the same reasoning holds further down the spine. Ask the screening questions at the first visit and write down the answers, negatives included. If the picture changes, ask them again.

A screen for the spine and neck usually asks about:

Any history of cancer, current or past, and unexplained weight loss.
Fever, chills or feeling generally unwell, reduced immunity (for example diabetes, HIV or long-term steroids), a recent infection, spinal surgery or another invasive procedure, and intravenous drug use.
Recent trauma, older age, long-term corticosteroid use and known osteoporosis.
Changes in saddle sensation or in bladder, bowel or sexual function, and any symptoms in both legs.
Walking and balance, and any loss of hand dexterity.
Before any neck treatment: headache, dizziness, changes in vision, trouble speaking or swallowing, and numbness or tingling in the face or limbs.
Night pain or rest pain that is steadily getting worse.

The physiotherapy assessment form template on this site includes spine and neck screening questions taken from both IFOMPT frameworks. Each is marked Not asked, No or Yes, so the record shows what you covered and what you did not.

Explain why you are asking; the IFOMPT red flags framework encourages it. People answer questions about their bladder, bowels or sex life more easily when they know the reason. For suspected cauda equina syndrome, NHS England's GIRFT national pathway says a digital rectal examination is not necessary. What it does want recorded is the patient's own report of feeling around the anus (subjective perianal sensation).

Add a systems review

In the documentation guidelines of the American Physical Therapy Association (APTA), the systems review gathers data on four systems. The examples the guidelines give:

System	Examples
Cardiovascular and pulmonary	Blood pressure, heart rate, respiratory rate, edema
Integumentary	Skin color and integrity
Musculoskeletal	Gross strength and range of motion
Neuromuscular	Balance and coordinated movement
May also cover	Communication, affect, cognition

The aim is to spot anything beyond the musculoskeletal problem that someone needs to look at.

Blood pressure matters in particular before neck treatment. The IFOMPT cervical framework calls blood pressure measurement reliable and valid if done well, and treats it as an important measurement for clinical reasoning, including to assess the risk of stroke.

Examine with a question in mind

Use the examination to test what the history suggested. A normal examination does not cancel out a worrying story. For suspected cauda equina syndrome, the GIRFT pathway states that "negative physical tests do not rule out CES if positive subjective symptoms are present." Davies and colleagues make the same point about degenerative cervical myelopathy: examination features have low sensitivity, so a normal finding does not exclude the disease, and high specificity, so an abnormal finding is highly suggestive of it.

Provocative positional testing of the neck is not recommended in the IFOMPT cervical framework. It says these tests lack the ability to predict who is at risk, and that there is some evidence against their use.

Decide on your level of concern and the route

The IFOMPT red flags framework works in three steps: judge your level of concern from the red flags and the patient's profile (age and sex are part of it), decide on the clinical action, then follow your local referral pathways. In practice that gives four routes:

Emergency: call emergency services or send the patient to an emergency department now. This covers suspected cauda equina syndrome, suspected spinal cord compression, a suspected fracture after a serious accident, signs of a stroke or a neck artery dissection, a suspected aortic aneurysm that is causing pain, and possible heart pain.
Same day: an urgent medical assessment today, for example for a possible blood clot in the leg, a possible spinal infection, back pain after a low-energy fall in someone with osteoporosis, or new back pain in someone who has had cancer.
Routine: a letter to the patient's doctor, such as for suspected inflammatory back pain that meets the referral criteria.
Treat with a safety net: nothing points to a serious cause. You go ahead with treatment, give written warning signs and screen again at later visits.

Why a single red flag is not enough

On their own, most red flags are weak tests. The IFOMPT framework says so directly: "Currently, there is an absence of high-quality evidence for the diagnostic accuracy of most red flags."

Henschke and colleagues' 2013 Cochrane review of red flags for malignancy included eight cohort studies. Six were set in primary care, where the prevalence of spinal malignancy ranged from 0% to 0.66%. Most of the red flags, including insidious onset, age over 50 and no improvement after one month, had high false positive rates. The exception was a previous history of cancer: individual studies gave some evidence that it meaningfully increases the probability of malignancy. The authors concluded that suspicion of spinal malignancy should not rest on the result of one single red flag question.

Fracture follows the same pattern. In the 2013 Cochrane review by Williams and colleagues, fracture prevalence in primary care ranged from 0.7% to 4.5%, and most individual red flags had poor diagnostic accuracy. In primary care, three flags looked potentially useful, though mostly with imprecise estimates: significant trauma, older age and corticosteroid use. Combining red flags appeared to improve performance. That review has since been replaced by Han and colleagues' 2023 Cochrane review of 14 studies, which comes to a similar view: only a few red flags are potentially useful, and combinations of red flags may be more useful than individual tests alone.

Cauda equina syndrome is harder still. The GIRFT pathway says it "does not have a set clinical pattern; no single symptom or combination of symptoms has good diagnostic accuracy." With so much at stake and so little time, the pathway does not wait for a cluster. Back or leg pain with the recent onset or worsening of any one of its listed symptoms is enough for an emergency referral.

In practice:

A single positive answer is a reason to ask more and look harder, unless the symptom on its own needs emergency action.
Weigh each flag against the patient's profile. A cancer history in someone with new spinal pain counts for far more than insidious onset in a 52-year-old.
A negative answer does not clear anyone. The IFOMPT red flags framework notes that fever is absent in about half of people with a spinal infection, and the cervical framework states that "an absence of risk factors does not necessarily rule out the risk of serious neuro-vascular event."
Follow the trend. When symptoms spread, get worse or stray from the expected course, screen again.

A scan does not replace this reasoning. NICE NG59 recommends against routinely offering imaging in a non-specialist setting for people with low back pain, with or without sciatica. Red flags tell you who needs a medical assessment; whether they need a scan is for the clinician you refer to.

Serious conditions to screen for, by body region

Lower back: cauda equina syndrome

The GIRFT pathway asks for emergency referral to the nearest hospital with emergency MRI when leg pain or back pain comes with the recent onset (14 days or fewer) or worsening of any of these:

Difficulty starting to pass urine, or reduced feeling of urine flow.
Altered feeling around the anus, perineum or genitals (the S2 to S5 dermatomes).
Severe or progressive loss of nerve function in both legs, such as major weakness of knee extension, ankle eversion or foot dorsiflexion.
Loss of the feeling that the rectum is full.
Sexual dysfunction, such as being unable to get an erection or ejaculate, or loss of genital sensation.

Sciatica that starts in both legs at once, or spreads from one leg to both, is a warning sign that cauda equina syndrome may follow. Without any of the symptoms above, the pathway asks for an urgent referral to a musculoskeletal (MSK) triage service, to be seen within two weeks, and makes it an emergency referral as soon as any of those symptoms appears or gets worse. If you cannot be sure the symptoms are absent, use the emergency route. The patient warning signs later in this guide are stricter and send a patient with sciatica in both legs to emergency care, as the NHS advice for the public does. If you do use the urgent route, tell the patient why and give them the cauda equina warning signs in writing: any one of them, or weakness or numbness in the legs that is severe or getting worse, means emergency care straight away.

Emergency MRI should be done as soon as possible, the pathway says, and certainly within four hours of the request to radiology. A bladder scan should not be used on its own to decide whether to request an MRI. Patients waiting for an urgent, non-emergency appointment need a safety net, and the pathway recommends the warning card and video from the Musculoskeletal Association of Chartered Physiotherapists (MACP), available in 35 languages. On this site, the sciatica and low back pain pages give patients the same signs in plain words.

Spine: cancer and metastatic spinal cord compression

Ask every new patient directly about cancer. It is the one flag in the Henschke review with some evidence behind it. Of the ways spinal cancer can present, metastatic spinal cord compression (MSCC) is the most urgent to recognize. NICE NG234 recommends an MRI for people with suspected MSCC as soon as possible, and always within 24 hours, and asks services to provide urgent MRI within 24 hours for everyone with suspected MSCC who has neurological signs and symptoms.

If a patient who has had cancer now has spinal pain with any symptom or sign of cord compression, use your local MSCC pathway or contact the patient's cancer team straight away, and send the patient to an emergency department if you cannot reach them. NG234 puts radicular pain in that group, as well as bladder or bowel dysfunction, difficulty walking, limb weakness, or sensory loss such as numbness or pins and needles. New spinal pain in someone with a cancer history, without any of these, still needs a medical assessment the same day. NG234 asks for advice through the MSCC coordinator within 24 hours when the pain has features that suggest spinal metastases, such as severe or progressive pain, pain on coughing or straining, or night pain that disturbs sleep.

Spine: infection

The IFOMPT red flags framework lists risk factors such as reduced immunity (from diabetes, HIV or long-term steroid use, for instance), an existing infection, spinal surgery or another invasive procedure, and intravenous drug use. Because fever is missing in about half of these patients, a normal temperature is not reassuring on its own. Back or neck pain with a fever or feeling unwell needs a same-day medical assessment. It needs emergency care if the patient is very unwell, you suspect sepsis, or there are new neurological symptoms or signs, the third part of the classic triad the framework describes (back pain, fever and neurological dysfunction).

Spine: fracture

Trauma, older age and corticosteroid use are the flags both Cochrane fracture reviews found potentially useful, though mostly from single studies with imprecise estimates. Back or neck pain after high-energy trauma, such as a road traffic collision or a fall from height, is an emergency. An older patient, or one with osteoporosis or long-term steroid use, whose back started hurting after a minor fall or strain needs a same-day medical assessment. So does someone with osteoporosis whose back pain came on suddenly after lifting, bending, a cough or a sneeze, even with no fall. The osteoporosis page gives patients these signs and has an exercise program that includes people with a past spinal fracture, once a doctor or physio has cleared them.

Take extra care with a stiff spine. In ankylosing spondylitis and similar conditions, a minor fall or jolt can cause a fracture that is easy to miss. PocketPhysio's patient pages treat new spinal pain after even a small injury in these patients as an emergency.

Back: inflammatory back pain (axial spondyloarthritis)

Not an emergency, but easy to miss. NICE NG65 says spondyloarthritis should not be ruled out on the strength of any one sign, symptom or test result, present or absent. For low back pain that started before age 45 and has lasted longer than 3 months, it recommends referral to a rheumatologist if 4 or more of these are also present:

Low back pain that started before age 35.
Waking in the second half of the night because of symptoms.
Buttock pain.
Improvement with movement.
Improvement within 48 hours of taking a non-steroidal anti-inflammatory drug (NSAID).
A first-degree relative with spondyloarthritis.
Current or past arthritis.
Current or past enthesitis.
Current or past psoriasis.

If exactly 3 are present, NICE recommends an HLA-B27 test, with referral if it is positive, so write to the patient's doctor, who can arrange the test. NG65 also reminds clinicians that axial spondyloarthritis affects a similar number of women and men and can occur in people who are HLA-B27 negative. For the exercise side, see the ankylosing spondylitis page.

Neck: cervical myelopathy

Degenerative cervical myelopathy is often mistaken for something else. Among its symptoms, Davies and colleagues list neck pain or stiffness, weakness, numbness or loss of dexterity in the arms, imbalance or unsteadiness, and bowel or bladder incontinence. They cite a study of 42 people who had surgery for it. On average those patients had 5.2 consultations before the diagnosis, and 43% had hands that were numb and painful and were first diagnosed with, and sometimes treated for, carpal tunnel syndrome. A Hoffmann sign, brisk reflexes or spasticity support the diagnosis, but a normal examination does not exclude it.

Refer as an emergency for new walking problems, new bladder or bowel trouble, or a sudden loss of hand dexterity. Clumsiness of the hands that has come on gradually, numbness in both hands or symptoms in both arms need a same-day medical assessment. Patients get the same signs on the neck pain and cervical radiculopathy pages.

Neck: cervical artery dissection and other vascular causes

The IFOMPT cervical framework lists risk factors including recent trauma, a vascular anomaly, current or past smoking, migraine, a recent infection and high blood pressure. Headache and neck pain top the framework's list of symptoms in dissection, and both are among the most common reasons people come to physical therapy. Other symptoms and signs in the framework include pins and needles in an arm, visual disturbance, unsteadiness, a drooping eyelid and arm weakness.

The framework recommends that the physical therapist "refers for immediate medical investigation" when the history and examination support a suspicion of vascular pathology. In practice that means emergency care, the same level as a suspected stroke. The framework also lists behavior to notice early in the encounter that can suggest upper cervical instability, such as anxiety or a patient supporting their own head.

Giant cell arteritis is on the same list. A new headache with tenderness at the temples or scalp, or jaw pain when chewing or talking, needs a same-day medical assessment, and any change in vision is an emergency.

Leg: deep vein thrombosis

NICE NG158 asks clinicians who see someone with signs or symptoms of a deep vein thrombosis (DVT), such as a swollen or painful leg, to take a general medical history and examine them to exclude other causes. If DVT is suspected, the doctor estimates the probability with the two-level DVT Wells score, and a likely score leads to an ultrasound scan, with the result available within 4 hours if possible. For a PT or physio, a possible DVT means a same-day medical assessment, and emergency services if the patient is also short of breath or has chest pain. Your concern should rise if the patient has recently had surgery or an injury, been immobilized in a cast or walking boot, traveled a long way or been much less mobile than usual.

Back and abdomen: abdominal aortic aneurysm

NICE NG156 asks clinicians to "think about the possibility of ruptured AAA in people with new abdominal and/or back pain, cardiovascular collapse, or loss of consciousness." Rupture is more likely, it adds, with an existing diagnosis of abdominal aortic aneurysm (AAA), age over 60, current or past smoking, or a history of high blood pressure. AAAs are also more likely to rupture in women than in men, and NG156 asks for an immediate bedside ultrasound when a symptomatic or ruptured AAA is being considered. If you suspect an aneurysm, for example new back or abdominal pain that does not behave like a movement problem in someone with a known AAA or those risk factors, send the patient to emergency care. The NHS tells the public to call 999 for sudden, severe pain in the tummy or back, struggling to breathe, pale or gray skin, or loss of consciousness, which can be signs of a rupture.

Referred pain from the heart and other organs

Among the symptoms of a heart attack, the NHS lists chest pain that may spread to the arm, neck or jaw, with shortness of breath, feeling sick or sweating. A patient who arrives with shoulder, arm, neck or jaw pain plus any of those features needs emergency services, not a shoulder assessment. Back pain with chest pain goes in the same group.

The aorta, covered above, can also send pain to the back. Whatever the source, pain that does not behave like a movement problem calls for questions about general health. When the answers do not fit, involve the patient's doctor as quickly as your level of concern calls for.

How to document and communicate an onward referral

In your notes

Record each screening question and its answer, negatives as well as positives. Then note your level of concern, why, what you did and at what time. If you decided against referral, give the reason. Notes that say nothing leave no way to show, months later, that the questions were asked.

For what an emergency referral record should contain, the GIRFT cauda equina pathway is a good model:

The patient's assessment details and the time and date of the assessment.
The examination findings (including power and sensation in the legs).
The signs and symptoms present, how long each has lasted, how often it occurs and how it has progressed.
Who the case was referred to in secondary care, and at what time.
If emergency referral was judged unnecessary, the advice received and who gave it.
The patient's own report of perianal sensation.

The same headings suit any urgent referral. The SOAP notes guide covers how the rest of the note is set out.

In the referral itself

What follows is suggested practice. For an emergency or same-day referral, phone the receiving clinician or service where your local pathway allows, then follow up in writing. Say what you suspect and why, which red flags are present and which relevant negatives you checked, when the symptoms began and how they are changing, the advice the patient has had from you, and how to contact you. A letter that says "please see, ?serious pathology" gives the receiving team nothing to act on.

Routine referrals, such as suspected inflammatory back pain, go to the patient's doctor as a letter with the same structure, listing the criteria you counted. US therapists working under direct access will find state rules on referral in the direct access guide, and what goes back to the physician in the plan of care guide.

With the patient

Tell the patient plainly what you found and what it might mean. Then tell them exactly where they need to go and how quickly. If the route is emergency care, check they know how they will get there, and write it down.

If you treat rather than refer, the safety net is part of the plan. The GIRFT pathway says a patient waiting for an urgent appointment needs to know how to recognize and act on any deterioration. Put the warning signs in writing, in plain words, with what to do for each, and note in the record that you did.

Warning signs to give patients

Each line below appears exactly as it does on PocketPhysio's condition pages. Borrow them for your own written safety net, or send the patient the page for their body area.

Emergency: numbness, tingling or altered feeling around or under your genitals, between your inner thighs, or around your bottom (anus), for example it feels different when you wipe after using the toilet. Call emergency services or go to an emergency department straight away. This can be a sign of pressure on the bundle of nerves at the base of the spine (cauda equina syndrome), which needs emergency treatment.
Emergency: you find it hard to start peeing, cannot pee, cannot feel yourself peeing or cannot control when you pee, or you do not notice when you need to poo or cannot control when you poo, and this is not normal for you. The same applies to a new change in how your genitals feel during sex, or new trouble getting an erection or ejaculating. Call emergency services or go to an emergency department straight away. These can also be signs of cauda equina syndrome.
Emergency: sciatica in both legs, or pain, tingling, numbness or weakness in both legs. The same applies if you lose feeling in one leg. Call emergency services or go to an emergency department straight away.
A leg or foot that is getting weaker, for example your foot drags, catches on the ground or slaps down when you walk (foot drop). Get medical advice the same day. If the weakness is getting worse by the hour, go to an emergency department.
Emergency: back or leg pain that started after a serious accident, such as a car crash or a fall from a height, or back pain with chest pain. Call emergency services.
Emergency: you have had cancer, now or in the past, and your back or neck pain feels like a tight band around your body, or comes with pain spreading down an arm or leg, weakness, numbness or pins and needles in your arms or legs, trouble walking, or trouble controlling your bladder or bowels. Call your cancer team's emergency number straight away, or go to an emergency department if you do not have one or cannot get through. This can be cancer pressing on the spinal cord (metastatic spinal cord compression), which needs treatment straight away.
Back or leg pain with a fever, or you feel hot, cold, shivery or generally unwell. Get medical advice the same day, and go to an emergency department if you feel very unwell.
Back pain after a minor fall or strain if you are older, have low bone density (osteoporosis) or have taken steroid tablets for a long time. Get medical advice the same day.
Emergency: new problems walking, for example your legs feel stiff, heavy or weak or you have become unsteady on your feet, new trouble controlling your bladder or bowels, or hands that suddenly become clumsy, for example you can no longer do up buttons. Call emergency services straight away. These can be signs of pressure on the spinal cord in the neck.
Emergency: any sign of a stroke, even if it goes away. That means a face that droops on one side, an arm you cannot lift or keep up, slurred or muddled speech, weakness or numbness on one side of your body or face, sudden blurred vision, double vision or loss of sight, trouble swallowing, sudden dizziness with unsteadiness or falling over, a sudden severe headache, or a sudden fall where your legs give way but you do not black out (a drop attack). Call emergency services straight away. With neck pain, these can rarely come from a tear in an artery in the neck.
Emergency: a new headache, or new pain on one side of your face, jaw or neck, with a drooping eyelid or a smaller pupil on the same side, or with a new pulsing or whooshing sound in one ear that keeps time with your heartbeat. Call emergency services or go to an emergency department straight away, and do not drive yourself. This can be a tear in an artery in the neck (cervical artery dissection), which can lead to a stroke.
A calf or thigh that is newly swollen, warm, tender, red or darker than usual, has swollen veins that are sore to touch, or has a throbbing or cramping pain that does not fit your injury or condition, or that feels different from normal muscle soreness after exercise. This can be a sign of a blood clot (deep vein thrombosis), especially after surgery, an injury, time in a cast or boot, a long trip or a spell of being much less mobile than usual. Get medical advice the same day. If you are also short of breath or have chest pain, call emergency services.

It is a selection, not the full set. On the low back pain page you will also find unexplained weight loss and night pain, plus a line on a stiff spine condition. Among the extras on the neck pain page are slowly clumsy hands and meningitis, as well as temporal arteritis.

Red flags and the home exercise program

Most patients you screen have nothing serious going on, and their care carries on with advice and exercise. Put the warning signs with the home exercise program (HEP), because the HEP is what the patient keeps and reads at home. For choosing and dosing the exercises, see writing a home exercise program. The pain monitoring model gives patients a pain rule they can follow.

Both can go out together from PocketPhysio. You build the program from exercises that each have their own demonstration video and voice guide, choose sets, reps or hold times, and write your own cue where the patient needs one. It reaches the patient by text message (SMS), email, a shared link or inside Pocket Physio Care, the patient app. If they would rather use WhatsApp, that works as well. Each exercise page on this site lists its own stop signs, and if you share the condition page for the patient's body area along with the program, the written warning signs travel home with the exercises.

The short version

Red flags in physiotherapy are prompts to think harder, not a checklist that makes a diagnosis. Taken one at a time most are poor tests, with a few exceptions (a cancer history for malignancy; trauma, older age or steroid use for fracture), so read them together and against the patient's profile. Cauda equina syndrome breaks the rule about waiting for a cluster: any one of its symptoms, new or worsening, means emergency referral. Screen on day one and whenever the picture changes. Record the negatives along with the positives, match the route to your level of concern, and send every patient home with written warning signs they can act on.

References

Finucane LM, Downie A, Mercer C, Greenhalgh SM, Boissonnault WG, Pool-Goudzwaard AL, Beneciuk JM, Leech RL, Selfe J. International framework for red flags for potential serious spinal pathologies. Journal of Orthopaedic and Sports Physical Therapy. 2020;50(7):350-372. doi:10.2519/jospt.2020.9971
Rushton A, Carlesso LC, Flynn T, Hing WA, Rubinstein SM, Vogel S, Kerry R. International framework for examination of the cervical region for potential of vascular pathologies of the neck prior to musculoskeletal intervention: International IFOMPT Cervical Framework. Journal of Orthopaedic and Sports Physical Therapy. 2023;53(1):7-22. doi:10.2519/jospt.2022.11147
Rushton A, Carlesso LC, Flynn T, et al. International framework for examination of the cervical region for potential of vascular pathologies of the neck prior to orthopaedic manual therapy (OMT) intervention: International IFOMPT Cervical Framework. IFOMPT. 2020, with 2023 addendum. https://www.ifompt.org/wp-content/uploads/2026/09/IFOMPT-cervical-framework-final-2020-Add-2023.pdf
Getting It Right First Time (GIRFT), NHS England. National suspected cauda equina syndrome (CES) pathway. February 2023, updated March 2026. https://gettingitrightfirsttime.co.uk/wp-content/uploads/2026/04/National-Suspected-Cauda-Equina-Pathway-March-2026.pdf
Henschke N, Maher CG, Ostelo RW, de Vet HC, Macaskill P, Irwig L. Red flags to screen for malignancy in patients with low-back pain. Cochrane Database of Systematic Reviews. 2013;(2):CD008686. doi:10.1002/14651858.CD008686.pub2
Williams CM, Henschke N, Maher CG, van Tulder MW, Koes BW, Macaskill P, Irwig L. Red flags to screen for vertebral fracture in patients presenting with low-back pain. Cochrane Database of Systematic Reviews. 2013;(1):CD008643. doi:10.1002/14651858.CD008643.pub2
Han CS, Hancock MJ, Downie A, Jarvik JG, Koes BW, Machado GC, Verhagen AP, Williams CM, Chen Q, Maher CG. Red flags to screen for vertebral fracture in people presenting with low back pain. Cochrane Database of Systematic Reviews. 2023;(8):CD014461. doi:10.1002/14651858.CD014461.pub2
Lin I, Wiles L, Waller R, Goucke R, Nagree Y, Gibberd M, Straker L, Maher CG, O'Sullivan PPB. What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review. British Journal of Sports Medicine. 2020;54(2):79-86. doi:10.1136/bjsports-2018-099878
Davies BM, Mowforth OD, Smith EK, Kotter MR. Degenerative cervical myelopathy. BMJ. 2018;360:k186. doi:10.1136/bmj.k186
National Institute for Health and Care Excellence. Spinal metastases and metastatic spinal cord compression (NG234). Last reviewed 19 March 2026. https://www.nice.org.uk/guidance/ng234
National Institute for Health and Care Excellence. Low back pain and sciatica in over 16s: assessment and management (NG59). Published 2016, last updated July 2026. https://www.nice.org.uk/guidance/ng59
National Institute for Health and Care Excellence. Spondyloarthritis in over 16s: diagnosis and management (NG65). Last reviewed 4 March 2025. https://www.nice.org.uk/guidance/ng65
National Institute for Health and Care Excellence. Venous thromboembolic diseases: diagnosis, management and thrombophilia testing (NG158). Last reviewed 1 May 2026. https://www.nice.org.uk/guidance/ng158
National Institute for Health and Care Excellence. Abdominal aortic aneurysm: diagnosis and management (NG156). 2020. https://www.nice.org.uk/guidance/ng156
American Physical Therapy Association. Guidelines: Physical Therapy Documentation of Patient/Client Management. BOD G03-05-16-41, last updated 19 May 2014. https://www.apta.org/siteassets/pdfs/policies/guidelines-documentation-patient-client-management.pdf
NHS. Heart attack: symptoms. Last reviewed 31 March 2026. https://www.nhs.uk/conditions/heart-attack/symptoms/
NHS. Abdominal aortic aneurysm. Last reviewed 14 June 2023. https://www.nhs.uk/conditions/abdominal-aortic-aneurysm/
NHS. Sciatica. Last reviewed 3 December 2024. https://www.nhs.uk/conditions/sciatica/

Written and checked by the PocketPhysio editorial team. Last updated 2026-09-28.

Red flags in physiotherapy screening: what to ask, what the evidence says and when to refer