Avin Patel

Red Flags for Lower Back Pain

Red flags are indicators that something needs urgent intervention. We keep an eye out for them in every treatment, but they are also good for you to be aware of as the patient.

Red flags for lower back pain

Lower Back Pain and Osteopathy

Your Lower Back Pain is considered within our remit if it fits the criteria for Non-Specific Lower Back Pain (NSLBP). This rules out infections, tumours, and fractures among other serious causes of lower back pain.

Note that although sciatica does not count as NSLBP, it is still within our remit. We can also help manage the symptoms of rheumatic conditions such as Ankylosing Spondylitis.

Conditions and Their Red Flags

These flags indicate serious pathology and require immediate intervention. At their worst, if they are present in a patient who is attending treatment, they may require an ambulance to hospital.

Cauda Equina Syndrome

Some of the most serious red flags that we see among LBP patients are those that indicate Cauda Equina Syndrome. This condition is caused by the compression of nerves at the bottom of the spinal cord. Compression here can quickly cause irreversible damage, which can cause permanent incontinence and paralysis. Any one of these flags is enough for you to consider urgent medical attention- call 111 if you are unsure.

  • Urinary and or faecal incontinence
  • Urinary retention
  • Saddle-area numbness
  • Severe weakness in both legs

Vertebral Infection

It is possible to develop an infection in the spine or nearby. Osteomyelitis is a bacterial infection of bone, which can occur in the vertebrae. General symptoms of an infection in this area include:

  • fever
  • local redness
  • heat

We take a thorough case history at your first appointment, which is key to spotting flags like these. Red flags for infection are not just about the symptoms, but also underlying conditions and recent medical interventions. Bacteria reaches the spine via the blood, so infections elsewhere are relevant. You are more likely to develop an infection in the spine if you have:

  • Diabetes
  • A history of tuberculosis
  • A recent history of a urinary tract infection (UTI)
  • A tooth infection
  • A history of IV drug use
  • An HIV+ status, or if you are otherwise immunocompromised (including taking medication that supresses your immune system)

Spinal Tumour

Cancer is a very rare cause of lower back pain, and although some flags are relatively common (upper back pain, local tenderness, or pain aggravated by straining) other flags can be quite clear.

  • Slow development of symptoms
  • Pain that is severe and unremitting
  • Night pain (especially that which disturbs sleep)
  • Unexplained weight loss
  • Pain that persists after 4-6 weeks of manual therapy such as osteopathy
  • A history of cancer
  • Being over 50 years old

Spinal Fracture

Spinal fractures can be surprisingly subtle, and should be considered after any trauma. For those with low bone density, such as people with osteoporosis or osteopenia, even minor trauma can lead to a fracture. This may present as seemingly typical lower back pain, and may not be discovered until it shows on a routine MRI or X-Ray years later. However, if you bring a fracture to clinic, we want to identify it before starting treatment and making it worse. We will look for:

  • Traumatic onset of pain, or recent history of trauma
  • Severe spinal pain that started suddenly
  • Severe tenderness over one point of the spine
  • Relief from the pain when lying down
  • Possible “step” between vertebrae

In The Absence of Red Flags

If you are concerned about any of these symptoms for yourself, please call 111, your GP, or go to hospital. If you are confident that your back pain is mechanical, you are welcome to contact us via the link below to make your appointment.

For non-specific lower back pain, you can book an appointment online.


Hypermobility refers to joints that are more flexible than average. Some people are generally quite “bendy”, whereas for others it can be a sign of another condition. The NHS says that about 1/30 people are hypermobile.

Hypermobility signs and symptoms

Managing Hypermobility

Your osteopath needs to be aware of your hypermobile joints, as they can play a role in both your initial problem, and your treatment plan. If your hypermobility is caused by a condition, it may be the case that your ligaments undergo more damage than the average person, and they do not heal as well. This will need to be taken into account by your osteopath.

The image above shows 9 points on the body. These are the points used to measure a person’s hypermobility on the Beighton Scale. Your osteopath can test these quickly, observing you standing with your knees and elbows locked, bending forwards to touch the floor, and bending your thumb and fingers back on both hands. We then have a number to give an idea of roughly how hypermobile you are.

Of course this does not test all joints, and if you have particularly mobile hips, you could still score 0. Your osteopath will take your whole case history into account and assess your body thoroughly at your appointment.

Related Conditions

Some connective tissue disorders cause hypermobile joints. Having one of these conditions may mean that you are more likely to develop joint pain or dislocations.

Ehlers-Danlos Syndrome (EDS)

There are a number of different forms of EDS, but a number of them present with hypermobile joints. Hypermobile EDS is the most common type. Other signs of EDS may be unusually stretchy skin, scoliosis, or a more pronounced kyphosis. Some forms of EDS are genetic, but not all.

Marfan Syndrome

Marfan is less common than EDS, but there are a lot of similarities between the two. The symptoms of Marfan Syndrome begin to develop in late adolescence. As with EDS, hypermobile joints and a scoliosis are common features. In adulthood, there may be early onset osteoarthritis, especially in the hips. Recurrent soft tissue injuries are also common alongside joint pain.

Down’s Syndrome

Joint laxity is considered “almost universal” in children with Down’s Syndrome. This commonly causes flat feet, which is associated with later development of walking. Hips and ankles are often affected, and the bones in the neck may be unstable.

Local Hypermobility

After an injury such as a joint dislocation, the ligaments and capsule of that joint may become lax. Their role is to prevent the joint moving too far, so when they are not in their best condition, the joint is more likely to dislocate again. Repeated dislocations may predispose the joint to developing arthritis. Unfortunately, ligaments take a long time to heal, and often do not return to their original condition. You may have noticed this yourself after a bad sprain.

One way to support a joint with lax ligaments is to help the surrounding muscles support the joint. Your osteopath can give you exercises to strengthen the relevant muscles as part of your treatment plan. We will work with you to find a way that suits you, whether that means using machines at the gym, or a small weight at home.

If you have joint pain alongside hypermobility, you can book an appointment here.


Costochondritis is inflammation of the cartilage in the chest where the ribs meet the sternum (breastbone).


With chest pain, we need to rule out problems with the heart or lungs. Other conditions can also cause chest or rib pain, such as fibromyalgiaanxiety, and shingles.

Symptoms and Causes of Costochondritis

Symptoms themselves can be hard to pin down, as they often come on gradually for no apparent reason, but they can also come and go without explanation. You may find it helpful to keep a pain diary for a few days to see if you can spot any patterns. Coughing, sneezing, and taking deep breaths are likely to aggravate symptoms.

Pain itself is focused around the front of the chest, and could be anything from a dull ache to a sharp pain. Sometimes it is also described as more of a pressure. In some cases, the pain is only felt when the area is touched. More than one rib is often involved, but rib 5 is the most likely to be symptomatic. This is quite high up within the chest, roughly level with the armpit.

The cause of costochondritis can be hard to pin down. Some cases develop after new or repetitive movements like painting a room or moving furniture. There may also be a link with low vitamin D levels.

Slipping Rib Syndrome

A closely related condition is slipping rib syndrome (SRS). The rib doesn’t actually slip, but the connection between the lower ribs becomes lax and irritated. In contrast to costochondritis, SRS affects the lower ribs.

When the tissues become lax, the tip of the rib can move more than it usually would. If it catches a nerve that runs between ribs, it can cause significant pain and may be mistaken for shingles. Alternatively, the hypermobility might cause a strain to the intercostal muscles that run between the ribs. It is also possible for SRS to cause general inflammation in the front of the ribs, which is how it may be mistaken for costochondritis.

Some research suggests that when costochondritis develops alongside Slipping Rib Syndrome, osteopathic manipulation can be beneficial. As hypermobility in one end of the rib will have an effect on the other end (where the rib meets the spine), osteopathic treatment may help the symptoms of SRS.

Mobilisation of the joints at the back of the ribs may also help with the symptoms of costochondritis.

Tietze Syndrome

The same cartilage is affected in Tietze Syndrome as costochondritis. Here there is local swelling over the joint, whereas swelling is more generalised in costochondritis. Tietze Syndrome is poorly understood and considered a rare disease with no clear cause. Occasionally Tietze Syndrome develops after a chest infection. This seems to be due to coughing rather than the infection itself. Your osteopath will work to rule this in or out.

If you have chest pain similar to that described above, you can make an appointment here.

Trigger Points

Everyone has experienced a “knotted” muscle at some point- but what happens if it doesn’t untangle itself? Longer lasting knots can become trigger points (TrPs), and left untreated they can behave in unexpected ways.

Symptoms of Trigger Points

The more common muscle knots can typically be massaged or stretched out, and are gone within a few days. But when they persist, we expect them to develop additional symptoms, such as:

  • Tenderness within a muscle
  • Pain characterised as a deep, dull ache
  • Location easily pinpointed
  • Some relief from heat and massage, but only temporarily
  • Benefit from activity, but aggravated by extreme exercise, or holding a position for too long

Some of these symptoms overlap with more serious pathologies like rheumatoid conditions, so see a professional if they apply to you.

The symptoms change if the TrP is left untreated for too long. We consider anything lasting 3 months or fewer to be “acute”, whereas anything longer becomes “chronic”. Chronic myofascial pain, and chronic TrPs are more likely to be complex.

Chronic Trigger Points

Whereas acute trigger points behave like straight forward “knots”, chronic TrPs are different. The image above illustrates some referral patterns from muscles in the neck and face.

Referred pain is a relatively common occurrence. One of the most recognised patterns is when a heart attack comes with jaw or arm pain instead of chest pain. What happens here is the brain misinterprets the location of a painful stimulus, and causes symptoms in the wrong area. Although that sounds chaotic, it typically follows quite predictable patterns. Your osteopath will be on the lookout for these patterns, as they can often be disguised as something else. Muscles in the buttock, for example, can cause pain down the back of the thigh and be mistaken for sciatica.

Trigger Points within Other Problems

With referred pain in mind, it’s not surprising that TrPs are associated with chronic headaches and migraines, jaw pain, and lower back pain. One study found that the majority of patients sent to an orofacial pain clinic had trigger points at the root of their problem.

The image above shows some patterns associated with three muscles: the masseter, trapezius, and sternocleidomastoid. All three refer pain into the head and face, so all three could be mistaken as headaches or migraines. The masseter muscle (overlying the jaw) could cause pain that is misinterpreted as a problem with the jaw joint, or even toothache.

Causes and Predisposing Factors

TrPs can develop in response to an injury or traumatic event, or more gradually. Poor posture or other causes of persistently overloading a muscle could cause them if given enough time. Similarly, other conditions can allow them to develop, specifically other chronic pain conditions like fibromyalgia.

There are overlapping points between myofascial pain and fibromyalgia. One of these points is subclinical nutrient deficiencies. Myofascial pain syndrome has been associated with slightly low levels of B vitamins, vitamin C, folic acid, calcium, iron, and potassium. As the numbers are only slightly low, they may be disregarded after blood tests despite being significant.

Managing TrPs

TrPs often come with referred pain, which your osteopath is able to identify. This pain will resolve as the trigger point itself is managed. This might mean that your jaw pain is actually nothing to do with the jaw joint itself, but is all down to local trigger points. They might be local to the muscles involved in chewing, or they might be as far away as the top of the shoulder. Your osteopath will work to identify and minimise them.

Traditional acupuncture can be effective in managing TrPs. Dry needling, where the needle is inserted directly into the trigger point, has also shown to be beneficial. Some may also be responsive to direct massage work.

If you suffer from muscle knots or trigger points, book in today to see how we can help.