Trokos

Special tests library › Red flags

Neck red flags

What you cannot afford to miss in neck pain, before any special test.

Most neck pain is musculoskeletal. These are the conditions that are not, or that need referral before treatment, with the features that point to each. Every row carries its source, listed at the foot of the page.

Use with your local protocols. Referral pathways, and how urgently to act, differ between health services and countries: where your local protocol or current guideline differs, follow it. Never delay emergency care to check a protocol.

Can’t missWhat points to it
Cervical arterial dysfunction1,2Dizziness, double vision, slurred speech, trouble swallowing, drop attacks, nausea, unsteadiness or facial numbness, particularly when provoked by neck movement; a new drooping eyelid or small pupil on one side (Horner's signs); new neck pain or headache unlike any previously experienced. Assessment stops at this point, with no manual therapy and no further provocative testing. Send the patient to an emergency department now; call an ambulance if neurological symptoms are present now. Dizziness is not classified as cervicogenic until this has been excluded.
Trauma: high-risk neck3Age 65 or over, a dangerous mechanism (fall from height, axial load such as diving, high-speed or rollover crash, ejection, motorised recreational vehicle, bicycle collision), or paraesthesia in the limbs. The neck requires imaging before its range of movement is examined or any treatment is given.
Rigid spine plus any trauma4,5Known ankylosing spondylitis, DISH (diffuse idiopathic skeletal hyperostosis) or a long-fused neck, following any fall or knock, however minor. New pain that differs from the usual stiffness is regarded as a fracture until proven otherwise; these fractures are often unstable and are easily missed on plain radiographs. This is an emergency: send the patient to an emergency department now, by ambulance with the neck protected.
Upper cervical instability6,7Rheumatoid arthritis, Down syndrome or recent trauma, with neck pain, restricted neck movement, or signs of spinal cord compression. Same-day medical assessment is required. Provocative ligament tests should not be performed as a 'check'; their accuracy is unproven.
Acute or rapidly progressive cord compression8Limb weakness that is worsening quickly, new bladder or bowel dysfunction, or deterioration in hand function or walking over days. Send the patient to an emergency department now. Stable, slowly progressive myelopathy differs: it requires prompt referral but is not an emergency.
Degenerative cervical myelopathy9Clumsy hands, loss of fine motor control, unsteady or broad-based gait, symptoms in both arms or in the legs, brisk reflexes. Early myelopathy is often missed: neck stiffness may be the main complaint, and hand symptoms are often attributed to carpal tunnel syndrome.
Malignancy10A history of cancer, age over 50, unexplained weight loss, malaise or rapid fatigue, constant progressive pain, pain at night or at rest, spinal tenderness to percussion, or failure to improve after 4–6 weeks. Urgent medical review and investigation are required before conservative care continues.
Spinal infection11Fever or malaise, injecting drug use, a recent spinal injection or operation, or immunosuppression, with severe neck pain. Same-day medical assessment is required.
Vascular thoracic outlet syndrome12,13A cold, pale or painful hand, a weak or absent pulse at rest, digital emboli, or sudden swelling and blue discolouration of one arm. This is a vascular emergency: send the patient to an emergency department now. It should not be managed as physiotherapy for 'TOS'.

A red flag raises suspicion; it does not make the diagnosis, and its absence does not rule the condition out. The table is not a complete list of every serious condition, and it is not a clinical protocol. When a red flag is present, act on the referral advice in the row, in line with your local protocols. This page is for registered health practitioners and students and is not clinical advice for patients; see the terms of use.

Last checked against the cited sources: 15 October 2026.

Then the tests: Neck special tests, with sensitivity, specificity and likelihood ratios.

Get the book for the neck questions that matter: nerve root or referred pain, which myelopathy signs count, and when a neck after trauma needs imaging

This table opens the chapter ‘The neck’ in Rule It In, Rule It Out. The book then works through the questions that matter in this region, with the published figures for each test and how to read them.

Coming in late 2026 as a PDF and a paperback. Join the list to hear when it's out

Sources

  1. Rushton A, Carlesso LC, Flynn T, et al. International Framework for Examination of the Cervical Region for potential of vascular pathologies of the neck prior to Orthopaedic Manual Therapy (OMT) intervention: International IFOMPT Cervical Framework. J Orthop Sports Phys Ther. 2023;53(1):7–22. Link
  2. Reiley AS, Vickory FM, Funderburg SE, Cesario RA, Clendaniel RA. How to diagnose cervicogenic dizziness. Arch Physiother. 2017;7:12. Link
  3. Stiell IG, Wells GA, Vandemheen KL, et al. The Canadian C-Spine Rule for radiography in alert and stable trauma patients. JAMA. 2001;286(15):1841–1848. Link
  4. Westerveld LA, Verlaan JJ, Oner FC. Spinal fractures in patients with ankylosing spinal disorders: a systematic review of the literature on treatment, neurological status and complications. Eur Spine J. 2009;18(2):145–156. Link
  5. Reinhold M, Knop C, Kneitz C, Disch A. Spine Fractures in Ankylosing Diseases: Recommendations of the Spine Section of the German Society for Orthopaedics and Trauma (DGOU). Global Spine J. 2018;8(2 Suppl):56S–68S. Link
  6. Lacy J, Bajaj J, Gillis CC. Atlantoaxial Instability. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; updated 2023 Jun 12. Bookshelf ID NBK519563. Link
  7. Cattrysse E, Swinkels RA, Oostendorp RA, Duquet W. Upper cervical instability: are clinical tests reliable? Man Ther. 1997;2(2):91–97. Link
  8. Fehlings MG, Tetreault LA, Riew KD, et al. A Clinical Practice Guideline for the Management of Patients With Degenerative Cervical Myelopathy: Recommendations for Patients With Mild, Moderate, and Severe Disease and Nonmyelopathic Patients With Evidence of Cord Compression. Global Spine J. 2017;7(3 Suppl):70S–83S. Link
  9. Davies BM, Mowforth OD, Smith EK, Kotter MRN. Degenerative cervical myelopathy. BMJ. 2018;360:k186. Link
  10. Storari L, Piai J, Zitti M, et al. Standardized Definition of Red Flags in Musculoskeletal Care: A Comprehensive Review of Clinical Practice Guidelines. Medicina. 2025;61(6):1002. Link
  11. Darouiche RO. Spinal epidural abscess. N Engl J Med. 2006;355(19):2012–2020. Link
  12. Illig KA, Donahue D, Duncan A, et al. Reporting standards of the Society for Vascular Surgery for thoracic outlet syndrome. J Vasc Surg. 2016;64(3):e23–e35. Link
  13. Nord KM, Kapoor P, Fisher J, et al. False positive rate of thoracic outlet syndrome diagnostic maneuvers. Electromyogr Clin Neurophysiol. 2008;48(2):67–74. Link

Red flags for other regions: Shoulder · Elbow · Wrist and hand · Thoracic spine and chest wall · Low back and pelvis · Hip and groin · Knee · Ankle and foot

One study, one test, once a month

Rule It In is a free evidence letter for musculoskeletal clinicians: one recent study explained, one examination test with its real numbers. From Trokos, publisher of Rule It In, Rule It Out.

Free when you confirm your email: a one-page PDF of the strongest special tests to rule in and rule out, with tests that carry a caution flagged separately.