When Back Pain May Not Be Musculoskeletal

Usually Musculoskeletal — But Not Always

The overwhelming majority of back pain presentations are genuinely musculoskeletal in origin. A small but clinically critical minority, however, reflect visceral, vascular, infective or malignant processes that merely present with back pain as a symptom — which is why a thorough initial assessment always includes active screening for "red flags" before treatment begins.

What These Red Flags Typically Involve

A systematic review of red flags across international low back pain guidelines identified recurring categories: unexplained weight loss, history of cancer, fever, significant trauma, progressive neurological deficit, pain that is constant and unrelated to position or movement, and pain that significantly disturbs sleep (Verhagen et al., 2016). Notably, no single red flag has strong diagnostic accuracy in isolation — their value comes from the overall clinical pattern, not any single finding.

Why This Screening Step Is Non-Negotiable

This is precisely why a responsible manual therapist asks screening questions that may initially seem unrelated to the back itself — ruling out these less common but more serious possibilities is a necessary first step before any musculoskeletal treatment plan can be considered appropriate.