Red flags

Red flags is a concept which is used to identify potentially serious pathology by identifying key symptoms. It was originally used in low back pain but is now also used in other musculoskeletal conditions. Where relevant, they should be briefly explored at all consultations for the condition.

At the initial assessment it is critical to screen for red flags, which may help identify other physical conditions or serious conditions that may need to be considered or excluded.

Identify red flags in low back pain

  • features of Cauda Equina Syndrome (see below)
  • severe worsening pain, espesially at night or when lying down
  • significant trauma
  • weight loss, history of cancer, fever, being unwell or other related pathology
  • use of intravenous drugs, high dose steroids or immunocompromised
  • your patient is over 55 years old or under 20 at onset of pain
  • thoracic pain without obvious cause

Some information about red flags in knee and shoulder injuries can be found in the attached guide to assessing and managing red and yellow flags for workers compensation patients.

Recommended approach

If red flags are present, investigate and/or refer all workers as needed. Remember, red flag symptoms can be manifestation of referred pain in other areas.

Manage condition according to clinical findings and available test results. Note:

  • Unless there are red flags, radiological investigations in the first 4-6 weeks of an acute uncomplicated low back pain episode have not been shown to provide clinical benefit.
  • MRI scans are not indicated for non-specific low back pain
  • Radiological investigations may carry the risk of harm and should be avoided if not required for diagnosis or management eg, radiation related effects
  • When investigations for red flags identify a non-compensable cause of symptoms, these investigations are not usually reimbursed as part of a compensable claim.

When considering use of radiology, please refer to WorkCover's Imaging Guidelines.

Features of Cauda Equina Syndrome include some or all of these symptoms:

  • Urinary or faecal incontinence or retention, lax anal sphincter
  • Saddle area sensory disturbance which may extend down the back of the thigh

Cauda Equina, although rare, is a medical emergency and requires urgent attention from a spinal surgeon. The health provider must ensure that a neurosurgeon/spinal surgeon is contacted directly to ensure immediate action is taken. Concerned health practitioners are advised to urgently contact and refer the worker to ensure appropriate and timely care. The usual first contact would be a treating doctor.

More information about red flags in low back and other injuries:

A guide to assessing and managing red and yellow flags for workers compensation patients [268 KB]

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