PT Classroom - Screening Low Back Patients For Serious Conditions in Physical Therapy ׀ by Denny Patel, DPT, CSCS


Denny A. Patel, DPT, CSCS. Dr. Patel graduated from Loma Linda Univeristy with a Masters in 1999 and recently received his Doctorate from Western Univeristy of Health Sciences. He is currently Owner of Santa Ana Tustin Physical Therapy, Inc in Orange County, California. Dr. Patel has been practicing physical therapy for over 10 years now and is also a certified strength and conditioning specialist. He has advised many professional athletes by performing musculosketal evaluations and presenting proper training programs to their personal trainers. He is also a certified clinical instructor by the APTA and takes students/interns on a regular basis. Dr. Patel is also a Part-time instructor for Human Anatomy and Biology at Santa Ana College.

Screening Low Back Patients For Serious Conditions in Physical Therapy


Low back pain is one of the most common complaints that a physical therapist will come across in their practice. According to Koopmeiner (1), “Any good physical therapist will find some biomechanical abnormality on any patient over 20 years of age. The problem is relating it to the patients presenting complaints.” As PT’s transition towards direct access and become more of an integral part of a patient’s care, they must be able to identify red flags that may present as low back pain.

There are many reasons why physical therapists need to screen their patients for potentially serious conditions. One reason may be that a patient was referred without seeing the physician. This can happen in states where they already have direct access or rural areas where the nearest physician may be too far. Another reason may be that the physician had time constraints and did not properly screen the patient themselves. With managed care, physicians may also not order as many diagnostic tests that could potentially catch underlying medical conditions. Patients also forget to tell physicians their true symptoms because of fear, denial or embarrassment. The bottom line is, there is definitely a need for medical screening and here is a short table (2) on what to possibly screen for during a low back evaluation.


Condition Red Flags to look for during Subjective Exam Red Flags to look for during the Physical Exam
Back Related Tumor (3,4) • Over 50 years old
• History of Cancer
• Unexplained weight loss
• No progress with conservative therapy
• Vague, general presentation of symptoms
• Constant pain not affected with position or activity
• Worse with weight bearing
• Worse at night
• Neurological signs in lower extremity
Back Related Infection (Spinal Osteomyelitis) (5) • Recent infection (eg urinary tract or skin infection)
• IV drug user
• Concurrent Immunosuppressive disorder
• Deep constant pain, increases with weight bearing; may radiate
• Fever, malaise, swelling
• Spine rigidity, hypomobile joints
Cauda Equina Syndrome (3,6) • Urine Incontinence or retention
• Fecal Incontinence
• Saddle Anesthesia
• Global or progressive weakness in the lower extremities
• Sensory deficits in the feet (L4-S1)
• Weakness in ankle dorsiflexion and plantar flexion, toe extension
Spinal Fracture (3,7) • History of trauma (including minor falls or heavy lifts)
• Osteoporosis
• Prolonged steroid use
• Over 70 years old
• Loss of function or mobility
• Point tenderness over site of fracture
• Increased pain with weight bearing
• Edema in local area
Abdominal Aneurysm (8,9) • Back, abdominal or groin pain
• History of peripheral vascular disease, coronary artery disease
• Age over 50, HTN, DM
• Symptoms not related to movement
• Abnormal width of aortic or iliac arterial pulses
• Presence of a bruit in the central epigastric area upon auscultation
Kidney Disorders (10) • Unilateral flank or low back pain
• Difficulty with initiating urination, painful urination, blood in the urine
• Recent UTI
• History of Kidney Stones
• Positive Fist percussion test over kidney

This article is just a small piece of a vast amount of information available on medical screening of patients. Physical therapists are advised to continue to research and take continuing education to practice and enhance their screening skills. I feel that the real purpose of medical screening is to evaluate a patient’s complaints and determine whether the patient has signs and symptoms of a systemic disease or medical condition that needs to be further evaluated by a more appropriate health care provider. Therefore, medical screening should not be used to diagnose a disease, but rather safely screen for potential life threatening conditions that are beyond the scope of physical therapy. The take home message: “When in Doubt, Refer Out.”

Last revised: February 4, 2010
by Denny Patel, DPT, CSCS


1)   BoissonnaultW, Koopmeiners M. Medical History Profile: Orhtopaedic Physical Therapy Patients. JOSPT . 1994;20(1):2-10.
2)   Godges, Joe. Kaiser Permanente California Orthopedic residency. 2000.
3)   Bigos S, Bowyer O, Braen G, et al. Acute Low Back Problems in Adults. Clinical Practice Guideline No. 14. AHCPR Publication No. 95-0642. Rockville, MD: Agency for Health Care Policy and Research, Public health Service, U.S. Department of Health and Human Services. December 1994.
4)   Deyo RA, Diehl AK. Cancer as a cause of back pain; frequency, clinical presentation, and diagnostic strategies. J Gen Intern Med 1988; 3: 230-238.
5)   Lew DP, Waldvogel FA. Osteomyelitis. N Engl J Med 1997; 336:999-1007.
6)   Hakelius A, Hindmarsh J. The comparative reliability of preoperative diagnostic methods in lumbar disc surgery. Acta Orthop Scand 1972; 43: 234-238.
7)   Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA 1992; 268; 760-765.
8)   Halperin JL. Evaluation of patients with peripheral vascular disease. Thrombosis Research. 2002; 106: V303-V311.
9)   Krajewski LP, Olin JW. Atherosclerosis of the aorta and lower extremities arteries. In: Youn JR, Olin JW, Bartholomew JR, editors. Peripheral Vascular Diseases. 2nd ed. St Louis: Yearbook Medical Publishing, 1996.
10) Bajwa ZH. Pain patterns in patients with polysystic kidney disease. Kidney Int. 2004; 66: 1561-1569.

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