The never-ending continued propagating myth that perfect alignment is necessary is entirely wrong. Some of the more common types of hocus pocus that you’ll find on the internet and through google searches claim the ability to speculate that a majority of your joint pain and pathology is due to misalignment of the body. They state: for you to resolve your pain and pathology, you must be perfectly aligned. Otherwise, this will cause long term pain and issues as you get older. Some of the common myths that “cause your pain” include:
Your shoulders sit unevenly.
“Overpronation of the foot”, which causes knee collapse (valgus), which eventually leads to shoulder and neck pain
Leaning, slouching, favouring one side is the root of all your pain and dysfunction in your lower back and hips.
But one of my lungs is smaller than the other…
Unfortunately for the pundits, basic human anatomy already suggests that we are “out of alignment.” The anatomy of our body is already sufficient evidence to suggest that we can live and be alive without “perfect” and proper alignment. For example:
The left lung is smaller than the right due to the placement of the heart, which:
Is placed slightly to the left in an area named the cardiac notch
One interesting way that we can further elaborate on the complexity of the human body and the “asymmetries” that are present throughout is subdividing the ‘abdominopelvic cavity’ (basically the space from the abdomen/bottom of the sternum to the bottom of your pelvis). The subdivisions are named the right upper quadrant (RUQ), left upper quadrant (LUQ), right lower quadrant (RLQ) and left lower quadrant (LLQ) (Marieb & Hoehn, 2019).
RUQ: Right portion of the liver, gallbladder, right kidney, the smaller part of your stomach
LUQ: The left portion of your liver, larger portion of the stomach, the pancreas, spleen and left kidney
RLQ: Appendix, part of the small intestines, the cecum, right ureter
LLQ: Majority of the small intestine, some of the large intestine, left ureter
As you can see, the contents of each quadrant of the body are different. There isn’t an identical distribution and allocation of organs that perfectly balances and aligns the body. Around us, there are even more common sense examples of imperfect alignment being completely healthy, including:
Being right-handed or left-handed
Driving a car (especially a manual car)
Which hand we hold our coffee in
Getting out of your bed or sleeping on one particular side of your bed
Unbelievable, “imperfect” and amazing athletes
Adam Meakins is currently (as of 24/08/20) making a fantastic series on Instagram (@adammeakins) called: Amazing Asymmetries. The concept of the Instagram posts outlines individuals who are asymmetrical due to:
This is a fantastic representation of how those with predefined “imbalances” and “asymmetries” can perform at the very highest levels of their sport. Even without these imbalances, there are various examples of one-sided or one-handed sports. One of the most notable and evident is tennis. Some of the most famous tennis athletes including Rafael Nadal, Novak Djokovic and Roger Federer don’t switch hands when they play tennis to “optimise” their symmetry and are still able to dominate at their sport.
Not much… Trying to “optimise” and create perfect alignment is an imperfect practise and shouldn’t be pursued. Unfortunately, there are still many clinicians that strive by this mantra and will ask you to see them over and over again because they feel the need to achieve this impossible standard.
Instead, clinicians should be focusing on the root of your problem/issue and identifying the direct and clear reasons to why you may be suffering pain and pathology. Often, we may be directed to look away from just the pain and pathology site, as various factors can affect pain, including:
Stress (e.g. looking after three young children, or approaching deadline for work)
Sleep (e.g. less than 8 – 10 hours of sleep)
Other health concerns (e.g. heart health, liver health, kidney health)
Negative beliefs (i.e. Doctor told you you needed surgery, injections or multiple scans)
Go live your life without worrying that your left foot drifts slightly more than your right. Lift your kids into the air without worrying about that left arm that rotates internally marginally more than the other. Go and squat down to reach for something in the bottom drawer and disregarding the 2 degrees of scoliosis you have in your lower back.
Worrying about unnecessary and over-detailed analysis of every fault in your body is exceptionally detrimental, unhealthy and completely unnecessary. If your health practitioner directs you to do this and suggests that you come in every few weeks or months for a tune-up… Then a consultation with a new practitioner might be recommended.
Marieb, E. N., & Hoehn, K. (2019). Human anatomy & physiology (Eleventh edition.). Pearson Education, Inc.
LibreTexts, 2020. 1.4F: Abdominopelvic Regions. [online] Medicine LibreTexts. Available at: <https://med.libretexts.org/Bookshelves/Anatomy_and_Physiology/Book%3A_Anatomy_and_Physiology_(Boundless)/1%3A_Introduction_to_Anatomy_and_Physiology/1.4%3A_Mapping_the_Body/1.4F%3A_Abdominopelvic_Regions> [Accessed 16 August 2020].
I recently had a patient who had come in for a consultation with minimal knee pain. When he came to me, he was worried, distressed and anxious.
Because his doctor had told him that he might need a total knee replacement, as the cracking in his knees “…didn’t sound good”. However, this is an absurd notion, and this blog post is here to help you understand why. Fortunately, knee cracking, popping and snapping sounds in the knee are a common and completely normal process in the knees.
Physiological vs pathological sounds
The vital differentiation in knee sounds is the presence of ‘painful sounds’ versus ‘non-painful sounds’. In more formal terms, physiological (normal knee sounds) versus pathological knee noises (Song et al., 2018). In most cases, many individuals have normal physiological knee noises, which are associated with:
No worsening of sounds or increased symptoms (such as loss of ROM, increases in pain, decreases in functional ability)
No association with a history of injury
Sporadic or inconsistent noise characteristics (e.g. Usually the most common way to describe this is: “It sometimes cracks, but other times doesn’t.”)
Pathological noise is often associated with symptoms such as:
Swelling and effusion in and around the joint
On injury, a loud “POP” sound with pain was noticed
Consistent cracking with careful examination
A proper assessment and diagnosis will need to be completed by your physiotherapist to create an accurate diagnosis of your knee pain. In this situation, a trip to the doctor is not always necessary, as physiotherapists can assess and diagnose your knee pain and other surrounding tissues.
What EXACTLY causes noises in the knees?
Physiological Knee Noise
The exact origin of normal, physiological knee noises is variable. Some proposed mechanisms include:
Buildup or bursting of tiny bubbles in the synovial fluid
Ligaments and tendons may stretch as over a small bony lump and then snap back into place – causing the clicking sound
Catching of the synovium or physiological plica
(Song et al., 2018)
The buildup of cavitation bubbles in the synovial fluid of the knee joint is the commonly circulated explanation for knee joint noises. The sudden collapse of the bubble during regular joint movements can create the “popping” sound. The nature of this sound is sporadic due to the air buildup, which means that immediately after cracking your knee, it’s often hard to reproduce the same sounds again.
Pathological Knee Noise
There are many causes of pathological noise, which include degenerative changes (i.e. osteoarthritis), pathological plica, patellofemoral instability, pathological snapping knee syndrome and post-surgical crepitus (Song et al., 2018).
The Osteoarthritic Knee
The general characteristics of osteoarthritis may cause crepitus in the knee secondary to osteoarthritis—namely, gradual loss of cartilage, development of bony spurs and cysts. Crepitus in the knee can be synonymous with symptoms of patellofemoral osteoarthritis.
It comes at no surprise that greater severity of knee osteoarthritis is highly correlated with more significant pain levels and decreased functional abilities (Neogi et al., 2009; Sowers et al., 2011). Those with the highest pain had a higher likelihood and severity of pathological abnormalities such as:
Full thickness cartilage defects
Complex or mascerated meniscus tears
(Neogi et al., 2009; Sowers et al., 2011)
However, exercise can slow the progression and development of knee osteoarthritis (Bosomworth, 2009). In some cases, there is an associated improvement in pain and function in those who perform regular moderate exercise compared to those who engage in sedentary lifestyles (Bosomworth, 2009).
So what is the management of knee noises and/or osteoarthritis?
Managing ‘noisy knees’ really does depend on the underlying reason and the presence of physiological knee noise vs pathological knee noise. Like many other joints or spine-related pathology/pain, the most significant factor for knee noise may be the psychological factors associated with the sound or feeling. For those who don’t understand the fundamental reasoning behind knee noise, they may have anxious and negative thoughts, which can lead to decreased self-confidence, avoidance of movement/exercise and just general heightened sensitivity to any stimulus around the knee. Unfortunately, many times this may be compounded by your surrounding family and friends (unintentionally) when they make comments such as:
Those knees make you sound 20 years older
You have old people’s knees
Your knees sound arthritic
That doesn’t sound good for your knees
It is important to remember that knee noise isn’t something we need to worry about unless there are painful or functional changes to your knee. However, you should attend an appointment with your local physiotherapist if you have ongoing concerns.
Knee noises are scary if you don’t know what causes them. Most noise in your knee is generally non-painful physiological noises, which are naturally occurring sounds that happen in almost every person’s knees. If you have ongoing pain or functional limitations associated with the noise, then the recommendation would be to seek out your local health practitioner to get it checked.
In the meantime, it’s important to keep moving and keep exercising as you can! As this has the best chance of delaying chronic conditions like osteoarthritis of the knees.
Do you have noises in your knee?
Bosomworth N. J. (2009). Exercise and knee osteoarthritis: benefit or hazard?. Canadian family physician Medecin de famille canadien, 55(9), 871–878.
Neogi, T., Felson, D., Niu, J., Nevitt, M., Lewis, C. E., Aliabadi, P., Sack, B., Torner, J., Bradley, L., & Zhang, Y. (2009). Association between radiographic features of knee osteoarthritis and pain: results from two cohort studies. BMJ (Clinical research ed.), 339, b2844. https://doi.org/10.1136/bmj.b2844
Song, S. J., Park, C. H., Liang, H., & Kim, S. J. (2018). Noise around the knee. Clinics in Orthopedic Surgery, 10, 1 – 8.
Sowers, M., Karvonen-Gutierrez, C. A., Jacobson, J. A., Jiang, Y., & Yosef, M. (2011). Associations of anatomical measures from MRI with radiographically defined knee osteoarthritis score, pain, and physical functioning. The Journal of bone and joint surgery. American volume, 93(3), 241–251. https://doi.org/10.2106/JBJS.I.00667
Knee pain is annoying, and can often impact almost everything in your daily life. Whether that be walking to and from work, squatting down to get or getting in and out of your car. Unfortunately, there isn’t a band-aid solution that can solve your particular knee pain. Knee pain is multifaceted and requires a proper diagnosis of what particular structure might be causing the discomfort or pain.
However, for a specific type of knee pain – or even for any knee pain – taping can be an effective way to get some quick pain relief and help you get through your day. The purpose of this post is an informative guide on a specific taping technique called: “Modified McConnell Taping“. This is not encouraging the use of knee taping without proper rehabilitation advice from your healthcare professional.
Before We Begin: Contact Dermatitis
Before application of tape, you must test if you are allergic or have a reaction to the tape itself. Some individuals may have a reaction to certain components of the tape which may results in symptoms such as:
Tender to touch
Occasionally, specific brands of tape can cause allergic reactions, so you may have to ask your pharmacist on recommendations and to trial different types. This usually involves getting a small piece of tape placed on your hand or wrist, then seeing if there’s a reaction.
Diagnosis of knee pain
The diagnosis of knee pain is quite difficult as there are a multitude of structures that surround the knee. The particular structure this taping works well for is something colloquially coined: “Fat pad impingement“. Unfortunately, with the huge amount of variability within the physiotherapy profession, there is a large amount of variation behind the diagnosis and treatment behind this specific pathology.
The following signs and symptoms may indicate you have “fat pad impingement”. However, many of these symptoms are all common knee pain symptoms for any pathology.
Knee pain signs and symptoms:
Pain directly under the knee cap
Generally achy but sometimes sharp depending on movements
Sometimes may radiate to the sides of the knee cap
Pain with putting weight in a bent position (e.g. up and down stairs, lunging / squatting)
Usually settles with rest and not moving it
Returns after resuming activities, especially high impact exercise such as running or jumping
I must reiterate. Each of these symptoms individually will not mean anything, but collectively when combined with physical tests from a physiotherapist may reveal evidence of “fat pad impingement.”
The Taping Technique
General guidelines after the application of tape are:
Check for any adverse reactions, such as those mentioned in the Before We Begin: Contact Dermatitis section.
Tape can be kept on for 3 – 5 days, so long as you haven’t been sweating excessively
Tape can get wet, and just needs to be pat dried after showering
If the tape begins to come off, it is recommended to reapply as opposed to trying to fix it
Removing the tape: Roll the tape, do not rip the tape off. This can help with reducing skin irritation after taking off tape. (Hint: Don’t just rip it like a band-aid).
Let’s get one thing straight… Taping of the knee is not a long-lasting solution and will not be useful in the prevention of further knee pain. If the underlying reason behind the knee pain is not resolved, then recurrence of knee pain is common. However, this knee taping technique can still be useful in providing some pain relief with general knee pain.
A recommendation would be to follow this knee pain guideline as well as trial the application of this taping technique.
To summarise the knee pain guideline, knee pain can be improved by:
Short-term pain relief strategies, such as massaging, myofascial release and trigger point therapy
Education on pain management and understanding the pain cycle
Long-term management through a structured exercise programme
Have you ever had the weird sensation where your neck pain seemed to cause headaches, but was unable to describe why?
It is theorised that the pathophysiology of cervicogenic headaches involves a specific structure in the neck called the “cervicotrigeminal nucleus.” Essentially, the sensory input from this region coincides with both the head and neck, and the brain can sometimes confuse this input and interpret neck pain as headaches. However, neck pain of any type has been suggested to cause headaches regardless of location, so the exact reason is still unknown.
As with many other pathologies, there are different types of headaches. The one we will focus on today is “cervicogenic headaches” and neck pain. There are unique symptoms that arise with cervicogenic headaches, including:
Headache originates from muscular, articular, osseous (bony), neurologic (nerve) or vascular (artery / veins) structures of the neck
Neck pain should trigger or precede the headache
Travels from the occipital area (see figure below) and spreads towards the front of the face
It is usually unilateral (one-sided)
Aggravated or worsened by neck movement
May have some associated restricted range of motion in the neck or shoulder
Potentially associated shoulder or arm pain
Headaches can also cause:
Photophobia (Light sensitivity)
Phonophobia (Sound sensitivity)
In future posts, we will touch more on the different types of headaches and how each of them can affect you!
Treating the neck pain / headaches
Treatment of the neck can help with headaches and decrease the frequency and severity of symptoms of headache. This includes common treatment procedures such as massage, strengthening of associated muscles and stretching of involved muscles (Gallagher, 2007).
The combination of manual therapy (e.g. massage, trigger point release etc.) and exercise has proven an effective treatment for neck pain compared to many other alternative treatment types (Miller et al., 2010). The combination of these treatments is important, as mobilisation and manipulation only provides short-term relief. Exercise appears to have the added benefit of improving pain and function over long term (Miller et al., 2010). Therefore, the combination of both treatments can combine pain reduction with long-term changes (Miller et al., 2010). The exact type of manual therapy and manipulative treatments is still speculative and varies according to individual practitioners. Similarly, exercise therapy requires further research and the exact type of strengthening is difficult to determine.
Learning new behaviours associated with common tasks, such as sitting down and looking down to read a book or read your phone for long periods of time can also assist with treating your neck pain. As prolonged postures in a specific posture can increase neck pain frequency, and subsequently induce more headaches (Gallagher, 2007).
So what can we do?
Step 1: Postural Adjustments
Posture… Is really not that important. Now before you explode with utter outrage on the blasphemous nature of this statement, hear me out! There seems to be a lack of high quality evidence on the relationship between posture and pain (Mahmoud et al., 2019; Slater et al., 2019). However, what we do seem to know is that prolonged time in one particular posture is detrimental and can lead to increased pain and discomfort (Mahmoud et al., 2019; Slater et al., 2019).
Instead, what we should be focused on is regular postural adjustments. As discussed in my shoulder pain blog post, small postural adjustments in sitting, especially while doing desk work can provide many benefits to your pain and discomfort.
Step 2: Regular Movement
To reiterate the previous point, prolonged postures or positioning in one specific posture can be detrimental and lead to increased pain and discomfort. Therefore, to counteract this, regular movement is encouraged of the neck and shoulders. One particularly important structure that requires movement is the shoulder blade, and ensuring adequate movement of your shoulder blade during various movements.
A particular muscle is of interest when interpreting the link between neck pain and scapula function. This muscle is called the “Levator Scapulae.” This muscle originates from the transverse processes of C1-4 (your upper cervical spine), and attaches to the superior-medial border (top-middle) of the shoulder blade. Its role in shoulder function is the elevation and downward rotation of the shoulder blade.
Without getting too in depth in this post, the reason why this muscle and shoulder blade is important is that many individuals can get neck pain and tightness within this muscle. Which can subsequently lead to headaches to the neck pain nature. Fortunately, the fix for this is generally very simple, and only requires more awareness of the shoulder and shoulder blade region. Simple exercises that can fix this issue include:
Ear to shoulder
Overhead arms stretch
There are not any specific repetition or set ranges for these exercises. Instead, they should just be performed when you remember or feel like you need some movement in your shoulders and neck!
Step 3: Strengthening of upper body and neck
General strengthening exercises of the upper body are extremely beneficial and important in treating neck and shoulder pain. However, what needs to be focused on in these situations is the positioning and the movement of the shoulder blades. This will be further explored within a gym setting in a future blog post.
For now, the general recommendations will be to be aware of shoulder positioning and scapula position during movements. Essentially, the scapula should have freedom of movement when performing any exercise, rather than being stuck onto the ribcage wall.
Neck pain can be the cause of a very specific type of headache called “cervicogenic headaches.” However, despite the complex sounding name, the treatment and prevention of further headaches is quite simple and can be resolved with proper diagnosis and treatment strategies. This includes strategies such as postural adjustments, continuous movement and upper body strengthening practices.
Do you think your neck pain is causing your headache?
Gallagher, R. M. (2007). Cervicogenic Headache. Expert Review of Neurotherapeutics, 7(10), 1279 – 1283.
Mahmoud, N. F., Hassan, K. A., Abdelmajeed, S. F., Moustafa, I. M., & Silva, A. G. (2019). The relationship between forward head posture and neck pain: A systematic review and meta-analysis. Musculoskeletal Medicine, 12, 562 – 577.
Miller, J., Gross, A., D’Sylva, J., Burnie, S. J., Goldsmith, C. H., Graham, N., Haines, T., Brønfort, G., & Hoving, J. L. (2010). Manual therapy and exercise for neck pain: A systematic review. Manual Therapy, 15(4), 334 – 354.
Slater, D., Korakakis, V., O’Sullivan, P., Nolan, D., & O’Sullivan, K. (2019). “Sit up straight”: time to re-evaluate. Journal of Orthopaedic & Sports Physical Therapy, 49(8), 562 – 564
Red flags should be the first point of assessment in any condition. Regardless if it is neck pain, shoulder pain, lower back pain or even foot pain. Red flags are important as they can indicate to the health professional of any serious underlying pathology or anything that would need to be sent to the emergency department for immediate investigations. Across each of the joints, there are some specific red flag signs and symptoms we need to be aware of.
These signs and symptoms should never be interpreted as a direct causation or diagnosis of the conditions that may be associated with them. Instead, a cluster of symptoms are what is commonly used in order to diagnose and correctly identify the condition (Sizer Jr et al., 2007). Therefore, when analysing these red flags, contact with your local doctor is usually the recommended course of action. As in these situations, if an allied health practitioner (e.g. physiotherapist, occupational therapist etc.) identifies any red flags, the usual procedure is to refer onto a doctor for immediate review or referral.
From a clinicians point of view, there are several factors that we need to be aware of (Sizer Jr et al., 2007):
Physical changes (e.g. changes in bowel and bladder function, blood in sputum, bilateral or unilateral radiculopathy pain)
Unresponsive to conservative treatment
Report of present fluctuations in signs and symptoms. Presence of serious pathology is indicated by:
Pain that is worse during rest vs activity
Worsened at night or not relieved in any position
Poor response to conservative care including a lack of pain relief with prescribed bed rest
Poor success with comparable treatment
Physical examination and laboratory findings
E.g. Abnormal reflexes, gait (movement) changes, strength disturbances / differences, changes to sensation (i.e. numbness, tingling)
The Three Category System
A three categorical classification system has been developed and proposed by Sizer Jr et al. (2007). In this paper Medical Screening for Red Flags in the Diagnosis and Management of Musculoskeletal Spine Pain, he outlines this three step categorical system for each part of the spine. Namely, the cervical, thoracic and lumbar.
The classification system that he uses is as follows:
Category 1: Factors that require immediate medical attention
Category 2: Factors that require subjective questioning and precautionary examination and treatment procedures
Category 3: Factors that require further physical testing and differentiation analysis
Blood in sputum Loss of consciousness or altered mental status Neurological deficit not explained by monoradiculopathy Numbness or paresthesia in the perianal region Pathological changes in bowel and bladder Patterns of symptoms not compatible with mechanical pain (on physical examination) Progressive neurological deficit Pulsatile abdominal mass
Age >50 Clonus Fever Elevated sedimentation rate Gait deficits History of a disorder with predilection for infection or hemorrhage History of a metabolic bone disorder History of cancer Impairment precipitated by recent trauma Long-term corticosteroid use Long-term worker’s compensation Nonhealing sores or wounds Recent history of unexplained weight loss Writhing pain
Abnormal reflexes Bilateral or unilateral radiculopathy or paresthesia Unexplained referral pain Unexplained significant upper or lower limb weakness
Sizer Jr et al. (2007)
Category 1 Findings:
These examinations are usually performed as a result of a trip to the emergency department as a result of motor vehicle accident or fall. Major injuries to this area include fracture or dislocation.
National Emergency X-Radiography Utilisation Group (NEXUS)
These two decision-making criteria can be used as a screening device to rule out the need for radiography of the cervical spine.
Category 2 Findings:
Mechanical conditions of the cervical spine that require special attention in category 2 are upper cervical instability (atlantoaxial laxity) and vertebrobasilar insufficiency (VBI).
Suspicion of ligament laxity in the upper cervical spine may be tested through two specific physiotherapy ligament tests – The Sharp Purser test and TLA laxity test. Further radiographic evaluation must be undertaken to confirm any upper cervical instability.
Vertebrobasilar insufficiency (VBI)
VBI circulation is important as it can lead to transient ischemic attacks and cerebrovascular accidents. However, difficulties arise as the signs and symptoms of VBI overlap with more common diagnosis, especially vertigo. The red flags that are relevant to this diagnosis are:
Visual disturbances (diplopia) – Blurry or double vision
Auditory phenomena (sudden sensorineural hearing loss) – Hearing loss
Facial numbness or paresthesias – Numbness, tingling or pins and needles especially around the lips or tongue
Dysphagia – Difficulty swallowing
Dysarthria – Difficulty speaking
Syncope (drop attacks) – Sudden syncope episodes
Category 3 Findings:
Finally, the cervical spine should be screened for radiculopathies (pinched nerves) and myelopathies (compression of the spinal cord).
Radiculopathy can be screened through inspection for muscle atrophy (wastage / loss of muscle), sensory changes (numbness, tingling, pins and needles), tendon reflex testing and a positive Spurlings test.
Cervical spine myelopathies can include symptoms such as: loss of dexterity (e.g. difficulty writing or handling small objects), nonspecific weakness (e.g. unable to grip) and abnormal sensations. Lower cervical myelopathies can also include weakness and stiffness in the legs, as well as changes to their walking. The most common cause for myelopathies is a traumatic injury or incident, usually from a stabbing / gunshot wounds, motor vehicle accident or falls.
Category 1 Findings:
There are numerous category 1 red flags that can be found within the thoracic region. Primarily because the same signals that arise from the organs often coincides with a selected region of the musculoskeletal system. Essentially what this means is that the pain felt in a muscle, bone or general upper back area can be caused by pathology involving the organs.
A common example of this relates to acute myocardial infarction (i.e. heart attack). Pain can often be felt in the left pectoral region (i.e. around the left nipple of the chest) and the upper arms or sternum. This is often associated with pallor (pale color of skin), sweating and nausea.
Tumours, metastatic disease, metabolic diseases and fractures can also create pain signals around the area. These conditions can often be marked by severe thoracic pain, decreased range of movement of the thoracic region and potential intercostal neuralgia (i.e. stabbing, burning pain between the ribs).
Category 2 Findings:
Of particular concerns are osteoporotic changes to the thoracic vertebrae, which can lead to severe changes of postural deviations, vertebral fractures or spinal cord injury. A red flags can be evaluated to identify the potential likelihood, including:
Age over 50
Long-term corticosteroid use
Presence of menopause
Category 3 Findings:
As discussed previously, category symptoms require further physical testing and differential analysis. Within the category 3 classification for thoracic level related pathology, many of these symptoms must be clustered together to provide any meaningful reasoning. These symptoms include:
Referral pain to the front and side of the rib cage
Parathesia or dysthesia (e.g. numbness, tingling, pins and needles, abnormal changes to touch and feeling)
Sensory loss (e.g. absence of feeling)
Bowel and bladder changes
Hyper-reflexia (associated with reflex testing)
Lower back pain is extremely common and these red flags are important, as they can indicate more serious diagnosis such as: malignancy, spinal fracture, infection or cauda equina syndrome (Downie et al., 2013).
Category 1 Findings:
The category 1 symptoms as mentioned in Table 1 outline many of the symptoms that are evaluated in lumbar spine pain for red flags, particularly of which include:
Numbness or paresthesia in the perianal region
Pathological changes in bowel and bladder
Patterns of symptoms not compatible with mechanical pain (on physical examination)
Progressive neurological deficit
Category 2 Findings:
Similar to the thoracic spine, lumbar vertebrae are also at risk of compression fractures. The risk factors relative to the lumbar spine remain the same as the thoracic region. Infections can also arise in the lumbosacral region, which produce symptoms such as:
Potential bowel and bladder symptoms
Severe lower back pain
History of drug use
Prior spinal implementation or surgery
Severe lower back pain radiating into both buttock and thighs
Category 3 Findings:
Lower back pathology can sometimes be associated with altered or changes in sensory, motor and reflexes. These can be tested through physiotherapy sensation tests, muscle tests and reflex testing. Two common tests we also use to assess nerve involvement is the straight leg raise test or slump sitting test.
Other serious pathology
Signs and symptoms unrelated to the spine can also manifest in other serious conditions. These include infections, malignancy (cancer) or a more serious pathology called ankylosing spondylitis.
Chou et al. (2007) briefly outlines some of the symptoms that are associated with a more severe diagnosis:
History of cancer
Unexplained weight loss
Failure to improve after 1 month
Age >50 years old
Previous drug use
Improvements with exercise
Alternating buttock pain
Awakening due to back pain during the second part of the night only
As you can probably tell, there is a lot of overlap between symptoms for each region as well as other pathologies. Many of the findings in category 3 also present in category 1. Which is why a cluster of testing is required in order to rule in or out any certain pathologies.
The world of diagnosis through the use of signs and symptoms is still evolving, and there is certainty more ongoing research require to create established clinical guidelines for clinicians (Chou et al., 2007; Downie et al., 2013; Verhagen et al., 2016).
So if you do have any of these red flags, the important thing to remember is to take a deep breath, relax and go seek a professional opinion from a healthcare professional. Ideally in these situations, a doctor would be first point of call, as they can directly refer or treat many underlying pathologies not related to the musculoskeletal system.
Chou, R., Qaseem, A., Snow, V., Casey, D., Cross, J. T., Jr, Shekelle, P., Owens, D. K., Clinical Efficacy Assessment Subcommittee of the American College of Physicians, American College of Physicians, & American Pain Society Low Back Pain Guidelines Panel (2007). Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Annals of internal medicine, 147(7), 478–491.
Downie, A., Williams, C. M., Henschke, N., Hancock, M. J., Ostelo, R. W., de Vet, H. C., Macaskill, P., Irwig, L., van Tulder, M. W., Koes, B. W., & Maher, C. G. (2013). Red flags to screen for malignancy and fracture in patients with low back pain: systematic review. BMJ (Clinical research ed.), 347, f7095. https://doi.org/10.1136/bmj.f7095
Sizer Jr, P. S., Brismée, J., & Cook, C. (2007). Medical screening for red flags in the diagnosis and management of musculoskeletal spine pain. Pain Practice, 7(1), 53 – 71.
Verhagen, A. P., Downie, A., Maher, C., & Koes, B. W. (2016). Red flags presented in current low back pain guidelines: a review. European Spine Journal, 25, 2788 – 2802