Medical conditions causing back pain – ‘Red Flags’ 

About 95% of back pain is musculoskeletal (MSK) or benign and caused by sprains, degenerative changes in the muscles, joints, disks and connective tissues. However, some serious and life-threatening medical conditions can also present as back pain, and these conditions require medical treatment.

Medical Causes of Back Pain 

The Royal College of General Practitioners (RCGP) separate back pain into three categories: 

  1. Simple backache (non-specific low back pain) 
  2. Nerve root pain – Specialist referral is not generally required initially 
  3. Possible signs of a ‘Red Flag’ or serious spinal pathology – non MSK or mechanical:
  • Possible unwellness, weight loss
  • widespread neurological symptom 
  • signs of structural deformity 
  • Past history of cancer, HIV
  • Reduced resistance to infection such as high dose steroids, anti-rejection, IV drugs or AIDS 
  • Pain that continues to get worse despite treatment or painkillers 
  • Pain that wakes you from sleep at night and keeps you awake 
  • A prompt referral may be required (less than 4 weeks) 

Cauda equina syndrome: immediate referral 

Symptoms may include: 

  1. Sphincter or gait disturbance 
  2. Numbness around the bottom area, known as “saddle anaesthesia” 
  3. Difficulty in going to the toilet (either bowels or bladder) 
  4. Lack of bowel or bladder control 
  5. Severe back pain usually radiating to both legs 

If there are any signs of Cauda Equina Syndrome the Chiropractor will refer you seek medical advice as an emergency. 

See also my article on GP guidelines for Lower Back Pain 

Referral to Doctor or Hospital if signs of ‘Red Flag’

If there is any doubt or suspicion of a ‘Red Flag’ you will be referred to your GP or hospital for further investigation. Chiropractors are highly trained to take a thorough history and physical examination to recognise whether there may be an underlying medical cause for your pain and will refer you to an appropriate consultant or GP if there is any indication, or ‘red flag’, requiring investigation. The character and location of the pain with the associated symptoms are all clues that can help determine the cause. The diagnosis of uncommon medical conditions requires heightened suspicion and it is not always clear-cut.  With many years of experience at treating back problems, sometimes the indication is simply that the symptoms and pain do not match up to being a simple back pain. 

Chiropractic Treatment if ‘Red Flag’ is considered 

Certain conditions require medical intervention or diagnosis and in these instances Chiropractic, Osteopathy, Physiotherapy or other physical treatments may not be indicated initially, other than very gentle treatments to sometimes relieve symptoms and pain. 

As an example, I recently had a client who came in after a trip to New Zealand with back pain and calf pain, which did seem a little suspicious. I referred her to A&E, and she indeed had a DTV (Deep Vein Thrombosis), as it happened. It settled after anticoagulant treatment. 

Spinal Fractures or severe ligament strains or ruptures 

Severe trauma or possible break in one of the bones or tendons may well require a hospital referral for an X-ray or MRI scan. Usually it’s fairly obvious from the injury, but not always in the case of a stress fracture. 

Non-MSK medical causes of back pain 


This is a condition causing “fragile bones”: the thinning and weakening of bones with loss of density, vitamin D and Calcium. There are no symptoms, but a greater risk of fracture.  X-rays and Bone Density Scans can determine whether it is mild, called osteopenia, or significant. Treatment focuses on maintaining or increasing bone density.   

I did recently have a young client who attended the clinic with hip pain, with NO history of trauma. It turned out that she had a hip fracture and osteoporosis, which was highly unusual; in my 32 years of practicing I have never seen this before. It is rare, but can happen.  

A healthy diet and gently active lifestyle with nutritional supplements are important. Dr Paul Clayton has an article about Vitamin K and osteoporosis.

Weight bearing activity, mainly walking regularly, helps strengthen bones. Gentle Chiropractic releasing techniques and massage are quite safe when there is muscle spasm or joint pain.  Please inform us if you have or think you may have osteoporosis and the treatment can be adapted accordingly. In many ways, if you have a joint injury that is preventing you from being active, Chiropractic treatment can be critical to ensure you are back to full health and maintaining that active lifestyle. 

Back pain referred from the abdomen 

  • Aortic aneurysms – distention or enlargement of the Aortic artery supplying blood to the abdomen, pelvis, and legs 
  • Gallstones 
  • Prostate problems
  • Diverticulitis 

Usually cyclical: 

  • Endometriosis; inflammation of uterine tissue in places outside the uterus 
  • Ovarian cysts 
  • Heavy periods 

Chronic Pain and Fatigue Syndromes Causing Back Pain 

  • Fibromyalgia can cause widespread muscle pain and fatigue. 
  • ME or Myalgic Encephalomyelitis 
  • Chronic Fatigue Syndrome (CFS) 

Complex Regional Pain Syndrome (CRPS) 

This is a poorly understood condition with persistent severe and debilitating pain. Often caused by an injury, stroke or heart attack, the resulting pain can be very severe and long-lasting.  It usually only affects one limb, but it can spread to other areas of the body. The skin of the affected area can be so sensitive that a slight touch or knock can cause intense pain. The affected areas can be swollen and stiff with changes in colour or temperature.  CRPS often settles gradually with time, but it can last many years. 

Reflex sympathetic dystrophy syndrome (RSD) is the older name and most common type. The cause is unknown but arises from problems in the sympathetic nervous system that controls the heart rate, blood pressure and internal organs. 

Kidney and Lower Back Pain 

Kidney pain from an infection or stone can give back pain or refer pain into the hips and groin, but usually there are also associated renal symptoms that include pain on urinating, temperature or fever and generally feeling unwell. 


Spinal tumours can be benign or malignant (cancerous) or as a secondary spread from another cancer (metastasis). They are rare, but can be a real concern for clients. I commonly hear “I worry that something is seriously wrong with my back” especially when the back pain is seemingly not improving or keeps recurring. These worries are usually unfounded and if necessary, scans and blood tests can be taken to put the patient’s mind at ease. 

Spinal Infection 

Spinal infection or osteomyelitis is rare but can occur after surgery or without warning, predominantly with these risk factors: weakened immunity, poor nutrition, HIV, Tuberculosis (TB) infection, cancer, diabetes and obesity. Treatment is usually through antibiotics or antifungal medication, with possible surgery. 

Arthritis & inflammatory joint disease affecting the spine 

There are many varying forms, most commonly: 

  • Rheumatoid arthritis (RA). Inflammation and joint erosion in the wrists, hands and feet, mainly. 
  • Ankylosing spondylitis (AS). Progressive stiffness and fusion in the spine and pelvis. 
  • Gout. Uric acid crystals deposit in the joint, causing inflammation, and can be very painful. 

There are autoimmune diseases in which joint lining or articular cartilage is destroyed and the joints fuse. All these conditions can go through ups and downs (exacerbation and remission), and can be mild or severe, ranging from an isolated episode to continued pain. These conditions require medical treatments. 

I discuss Chiropractic care with arthritis in a separate article. There are occasions when care needs to be practiced when treating back pain with arthritis. Chiropractic treatment and massage can sometimes be given to relieve joint pain when there is no inflammation, and to help reduce muscle spasm and improve joint mobility, depending on the severity. Also, Chiropractic treatment can still help joints that are not affected by the disease.