Physical Therapy: What Are Red Flags?

Physical therapists are trained to screen and recognize a wide variety of conditions. Sometimes, we discover symptoms aren’t what they seem. If we find a “red flag,” we may refer you back to your doctor for further evaluation to make sure you’re receiving the right treatment for your condition.

Not all red-flag symptoms indicate sinister conditions, but they may require a specialist referral. Read more about how physical therapists check that you’re appropriate for treatment.

What is a Red Flag?

A red flag is a sign or symptom that may warrant further examination by a physician. 

Typically, a red flag is due to an underlying sinister pathology that may be unrelated to a musculoskeletal condition and cannot be treated by a physical therapist. 

At an initial evaluation, your physical therapist will ask a series of questions to determine whether or not the signs and symptoms associated with your injury require further medical attention. 

These questions help provide the context of these signs and symptoms, including: 

  • Any concurrent medical issues that may be responsible for them
  • When they occur
  • Their intensity and frequency
  • How long they’ve been around

Context is very important when examining red flags, as these types of signs and symptoms alone may not warrant any further assessment or treatment! 

Some of the questions a physical therapist asks may involve sensitive topics, including:

  • The ability to participate in sexual intercourse
  • Urinating and defecating (using the bathroom)

It is critical that you answer all of these questions honestly to ensure you receive proper treatment. 

Signs and Symptoms We’re Careful to Screen

When you appear for an evaluation, your physical therapist may ask specifically about common symptoms associated with non-musculoskeletal conditions. These conditions may require a referral back to your doctor for further testing. 

If you’re in physical therapy for a back-related condition, we will ask about these specific symptoms:

  • Numbness or tingling within the saddle region (includes genitals, buttock, anus, groin, and upper thighs) 
  • Urinary retention (most common symptom with lumbar radiculopathy)
  • Urinary or fecal incontinence (inability to hold urine or stool) 
  • Sexual dysfunction 
  • Pain in the back or legs 
  • Weakness or paralysis of the legs 

If you’re in physical therapy for a neck-related condition, we will ask about these specific symptoms:

  • Unsteady gait 
  • Clumsiness of hands or feet 
  • Decreased manual dexterity 
  • Hyperactive reflexes including the Babinski reflex (involves stroking the sole of the foot to see if the big toe moves up) 

For all patients seeking physical therapy, we screen out general red flags. We’ll ask about: 

  • Excessive fatigue 
  • Weight loss or gain > 10% of body weight unrelated to diet or exercise
  • Fever, chills, or night sweats 
  • Constant pain that does not change with movement or activity, or pain at night
  • Recent trauma 
  • History of cancer 

If you are experiencing any of the above signs and symptoms outside of known illness or medical conditions, consider following up with your medical provider.

Referred Pain: What Does It Mean? 

In physical therapy, referred pain is pain that comes from a different area of the body. Your pain location may not be the true source of your symptoms. Instead, it could be something else mimicking muscle aches and pains.

At your initial evaluation, your physical therapist will take a series of range of motion measurements at specific joints, perform muscular strength and endurance testing, perform a palpatory exam, and perform a series of special tests that can indicate the presence of musculoskeletal pathology. 

They will also examine dermatomes (areas of skin innervated by specific spinal nerves), myotomes (muscles that are innervated by specific spinal nerves), and neural tension tests that can be indicative of a nerve-related dysfunction and the source of referred pain. 

Nerve related dysfunction without any red flag signs or symptoms can be safely and effectively treated by a physical therapist. See our blogs on pinched nerves, peripheralization versus centralization, physical therapy for herniated discs, and arm pain check the neck for more information on nerve related dysfunctions and how they are commonly treated by physical therapists. 

Organ Referral Patterns

If our tests and measures cannot recreate your familiar pain, we can suspect referred pain from a non-muscular source. Both organs and muscles can refer to pain in certain body areas. For example, kidney stones can cause pain in the lower back, which cannot be treated with physical therapy.

Referral patterns for organs include: 

  • Pain around the belly button can indicate an issue with the ovaries 
  • Low back, groin, or genital pain can indicate an issue with the kidneys 
  • Right lower abdominal pain can indicate an issue with the appendix 
  • Pain radiating from the chest down into the left arm can indicate an issue with the heart 
  • Pain at the top of the left shoulder can indicate an issue with the spleen 
  • Pain between the shoulder blades can indicate an issue with the stomach

Muscular Referral Patterns

It is possible that muscles create referred pain patterns. Muscular referral patterns are typically caused by trigger points (TrPs), which are irritable spots in bands of taut muscle. These areas are tender to touch and may cause your familiar referred pain. 

Pain patterns depend on the muscle. For example:

  • Infraspinatus TrPs on the back of your shoulder blade can refer into the hand or along the inside border of the shoulder blade 
  • Quadratus lumborum TrPs can refer pain down into your buttock or low back
  • Piriformis TrPs can refer pain down into the back of your thigh 
  • Gluteus minimus TrPs can refer pain down into your ankle 

If TrPs are the cause of your referred pain, your physical therapist can treat these areas with soft tissue mobilization, myofascial release, instrument assisted soft tissue mobilization, and or cupping. 

Reach Out

If you or someone you know is experiencing nerve related pain or possible referred pain from muscular trigger points after injury, we are here to help! 

Schedule your initial evaluation with JACO Rehab by calling (808) 381-8947. Mahalo!

Written by Jennifer Lewis, DPT

Contact Jaco

Call: (808)381-8947

Send An Email: