Back Pain

Back Pain – Red and Yellow Flags

Usually, when a patient presents himself/herself with chronic back pain, the doctor enquirers regarding the nature and origin of pain. For this, the clinical practitioners divided the usually expressed symptoms into two broad categories.

The first category of symptoms, which are structural and pathological in nature, involving the spinal chord are called red flags. The second category of factors which are psychological in nature are called yellow flags.

Red Flags

The red flags are the most pertinent indicators of serious spinal pathology. They include the following:

  • Chest Pain
  • Consistent fever and asymptomatic weight loss
  • Infection of Urinary bladder
  • Infection of the bowels
  • Indications of carcinoma
  • Any other medical condition and presence of some undercurrent disorder
  • Progressive neurodegenerative disorder
  • Gait disturbances
  • Saddle anesthesia (lack of sense around buttocks)

The usual age of onset of the above symptoms is between 20 to 55 years.

Yellow Flags

Yellow flags are psychosocial factors which are essentially psycho-social in nature. These impede the progress of recovery. They include the following:

  • A misconception that back pain is potentially harmful and cripples the whole life.
  • Fear related withdrawal symptoms characterized by avoidance behavior.
  • An inhibition to undergo active treatment, instead preferring passive treatment.
  • Lack of esteem, vulnerability to depression, low morale.
  • Other problems pertaining to social and financial status of the individual.


However while arriving at the diagnosis based on above classification, the factors such as recent injury leading to spinal pathology and other associated psychiatric disorders must be considered for better evaluation.


During the course of normal physical examination the doctor looks for the following symptoms:

  • Reduction in the range of spinal movements
  • Deficits while rising the leg straight
  • Presence of any neurological deficit such as sensory, motor and reflex shortcomings
  • The distribution pattern of sensory loss
  • Reduced dorsiflexion (inability to turn the foot or toes upwards)
  • Deficits in ankle and knee reflexes

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