Red flag screening for low back pain: nothing to see here, move along: a narrative review

Br J Sports Med. 2018 Apr;52(8):493-496. doi: 10.1136/bjsports-2017-098352. Epub 2017 Sep 18.


Screening for red flags in individuals with low back pain (LBP) has been a historical hallmark of musculoskeletal management. Red flag screening is endorsed by most LBP clinical practice guidelines, despite a lack of support for their diagnostic capacity. We share four major reasons why red flag screening is not consistent with best practice in LBP management: (1) clinicians do not actually screen for red flags, they manage the findings; (2) red flag symptomology negates the utility of clinical findings; (3) the tests lack the negative likelihood ratio to serve as a screen; and (4) clinical practice guidelines do not include specific processes that aid decision-making. Based on these findings, we propose that clinicians consider: (1) the importance of watchful waiting; (2) the value-based care does not support clinical examination driven by red flag symptoms; and (3) the recognition that red flag symptoms may have a stronger relationship with prognosis than diagnosis.

Keywords: low back pain; orthopaedic; red flags; screening.

Publication types

  • Review

MeSH terms

  • Humans
  • Low Back Pain / diagnosis*
  • Low Back Pain / etiology*
  • Practice Guidelines as Topic
  • Watchful Waiting