RED FLAGS – When To Refer & When To Treat

Posted By: Andy Barker

Many therapists struggle when their patients present with red flags.

They understood the importance of asking those red flag questions during the subjective assessment but don’t really understand WHAT a positive answer is telling them and as a result sometimes lack the skills to know what to do next.

There is a BIG Misconception that the presence of red flags means urgent onward referral.
In some cases, this is true.

Twice I have had patients in private practice with symptoms that I sent straight to A & E.

They were in my clinic less than 5 mins.

Both had unexplained calf pain, no mechanism of injury, one had a history of vascular problems and both had just returned from holiday, with long haul flights.

I suspected they may have had a DVT.

They both did.

They both had an ultrasound doppler on arrival to A & E with confirmed their problem and both were managed by the staff at the hospital.

Had I not of asked those important subjective questions I may not have picked this up.

These are example of where quick onward referral was necessary.

But many times, even in the presence of red flags, patients don’t need referring, they need our help.

Particularly with New Grads, there is a worry that firstly you may miss a red flag during your assessment.

Secondly, that worry around red flags feeds into your treatment planning, in that when you do see a patient that may give you some red flag symptoms, there is that sense of worry about what to do next;

Do you carry on with your objective assessment?

Is it ok to use manual therapy?

Is it safe to prescribe rehab?

In this blog I want to make it clear why we ask these red flag questions and how our patient’s responses help us in what to do next.

The presence of red flag symptoms does NOT mean a hands-off approach, quite the opposite in many cases and by the end of reading this blog you will have a good understanding as to which patients need referring and which patients you can manage yourself in clinic.

Why Do We Ask RED FLAG Questions?

First and foremost, we ask those red flags questions because we want to know if our patients are in the right place.

Certain red flags symptoms that may include cauda equina symptoms (saddle anaesthesia, altered bladder/bowel control) or those with signs of malignancy (night pain/sweats or a history of conditions like cancer) need urgent onward referral.

Those patients I saw with a suspected DVT were the same.

Firstly, we want to be sure they are in the right place so they can get the best possible care for their current symptoms.

Its not to say that those patients won’t require therapy for their problems at some stage, we just might not be the best practitioner to treat them right at that time.

Secondly, we need to be sure that any of our proposed interventions are going to be safe and are appropriate for our patients.

This not only makes it safe for your patients but also ensures it is safe for you and that you are not going to make patient symptoms worse.

But there are many patients you will see in clinic in the NHS, private practice and even in sport that have red flags symptoms yet, do not need referring and can benefit greatly from therapy.

The key is to be determine which patients these are…

RED FLAG – WHAT Do You Do Next?

A patient may present in your clinic with unilateral neurology (radicular symptoms) or a reduced straight leg raise, both which are considered red flags for lumbar patients.

Are you going to send immediately to A & E?

Likely not, we see patients presenting like this frequently in clinic all the time.

Being older than 55 is also considered a red flag.

Again, just because a patient may present is the 58 years old, you are not going to send them for urgent onward referral.

The point I am trying to make is you need to consider the severity and presentation of each individual patient.

Multiple red flags together, or the presence of some of the more sinister symptoms need managing in the correct way.

But there are many patients with red flags symptoms we can help.

You refer or you reassure and then start your treatment plan.

A Red FLAG Does NOT Mean No Treatment

Clearly there are patients we can help even when they have active red flags.

Without question we need to be respectful of what they have reported and their symptoms but that does not mean we have to do nothing.

A red flag does not mean we can’t use hands-on treatment techniques or prescribe rehab.

Might your interventions need to be modified, yes.

But patients are still in pain, lack ROM, lack the ability to perform certain tasks and activities and we as therapists can help them.

Providing your interventions are appropriate, safe and are helping improve patient symptoms then it could be argued we are being negligent by NOT treating them.

If we are not referring, we need to reassure our patients and we need to start the rehab process.

Clearly, we need to be mindful of their symptoms, but as therapists we are in a great position to help these patients, even when they present with red flag symptoms.

Key Take-Aways

Why Do We Ask RED FLAG Questions?

Firstly, to make sure they are in the right place to get the best possible care at that time and to ensure that any proposed interventions are safe and appropriate for both your patient and you as a therapist


One of two options; Either refer on or reassure your patient and start your treatment plan.

A RED FLAG Does NOT Mean Hands-Off

Many patients can benefit greatly from your input as a therapist, even those with one or multiple red flag symptoms.

Andy Barker
The New Grad Physio Mentor

PS. I cover red flags and actual treatment techniques and rehab exercises you can use on patients with red flag symptoms on both my New Grad Physio Lower Limb & Upper Limb Courses.

I am just about to release details of these events so to make sure you do not miss them, visit to sign up to my exclusive wait list and be the first to hear about these events and get access to discounted tickets.