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Thoracic spine and chest wall red flags

What you cannot afford to miss in thoracic and chest wall pain, before any special test.

Most thoracic and chest wall 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
Cardiac referred pain1,2Chest pain or tightness, pain spreading to the jaw or to either arm, symptoms brought on by exertion, cardiac risk factors, and no mechanical trigger. The presentation should be managed as a possible cardiac event rather than a musculoskeletal one: call an ambulance if symptoms are present now. If symptoms have settled, medical assessment should still be arranged the same day, and an ambulance called if there is any doubt; the examination should not continue.
Aortic dissection3Sudden, severe, tearing or ripping pain between the shoulder blades or in the chest, especially with unequal arm pulses or blood pressures, fainting, or a known aneurysm or connective tissue disorder. This is an emergency: call an ambulance. Delay is fatal.
Pulmonary embolism4Sudden pleuritic chest pain with breathlessness, especially after immobilisation, surgery or long-haul travel, with calf swelling, coughing blood, or a known clotting risk. Chest wall tenderness or a recent strain should not deter the examiner from considering this diagnosis. Emergency assessment is required immediately.
Thoracic cord compression5,6Progressive weakness or sensory change in both legs, a deteriorating or broad-based gait, or new bladder or bowel dysfunction. Send the patient to an emergency department now.
Malignancy6,7A history of cancer, unexplained weight loss or fatigue, constant progressive pain, pain at night or at rest, or spinal tenderness to percussion. The thoracic spine is the most common site of spinal metastasis. Refer for urgent medical assessment and imaging before conservative care continues. Any new weakness or numbness in the legs, or change in bladder or bowel function, is an emergency: send the patient to an emergency department now (see Thoracic cord compression, above).
Spinal infection5Fever or malaise, injecting drug use, a recent spinal injection or operation, or immunosuppression, together with severe or constant back pain. Same-day medical assessment is required.
Osteoporotic vertebral fracture8,9Sudden mid-back pain after little or no trauma in an older person, or in a person with osteoporosis or long-term corticosteroid use. Most of these fractures cause few or no symptoms and are found only incidentally on imaging. Refer for medical assessment and imaging.
Fracture through a rigid spine10,11,12Known ankylosing spondylitis or DISH (diffuse idiopathic skeletal hyperostosis), with new pain or a new change in a previously rigid spine after any fall or knock, however minor. These fractures are often unstable and are easily missed on plain films. This is an emergency: send the patient to an emergency department now, by ambulance with the spine protected.
Shingles before the rash13One-sided, band-like, burning pain in a dermatomal distribution around the chest, with no rash yet. The rash usually follows within days. The skin should be re-examined at the next visit, and the patient advised to see a doctor the same or next day if a rash appears.
Visceral referral6Flank pain or tenderness at the angle between the lowest rib and the spine (kidney), or pain that is not affected by movement or position (for example, not eased by lying down). Refer for medical assessment.

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: Thoracic spine and chest wall special tests, with sensitivity, specificity and likelihood ratios.

Get the book for sorting chest-wall pain from the heart, lungs and aorta, and spotting the osteoporotic fracture

This table opens the chapter ‘The thoracic spine and chest wall’ 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. Swap CJ, Nagurney JT. Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes. JAMA. 2005;294(20):2623–2629. Link
  2. Storari L, Barbari V, Brindisino F, Testa M, Maselli F. An unusual presentation of acute myocardial infarction in physiotherapy direct access: findings from a case report. Arch Physiother. 2021;11:5. Link
  3. Nienaber CA, Clough RE. Management of acute aortic dissection. Lancet. 2015;385(9970):800–811. Link
  4. Konstantinides SV, Meyer G, Becattini C, et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J. 2020;41(4):543–603. Link
  5. Finucane LM, Downie A, Mercer C, et al. International Framework for Red Flags for Potential Serious Spinal Pathologies. J Orthop Sports Phys Ther. 2020;50(7):350–372. Link
  6. 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
  7. Ziu E, Viswanathan VK, Mesfin FB. Spinal Metastasis. StatPearls Publishing; updated August 14, 2023. Link
  8. Han CS, Hancock MJ, Downie A, et al. Red flags to screen for vertebral fracture in people presenting with low back pain. Cochrane Database Syst Rev. 2023;(8):CD014461. Link
  9. McCarthy J, Davis A. Diagnosis and management of vertebral compression fractures. Am Fam Physician. 2016;94(1):44–50. Link
  10. 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
  11. Caron T, Bransford R, Nguyen Q, Agel J, Chapman J, Bellabarba C. Spine fractures in patients with ankylosing spinal disorders. Spine (Phila Pa 1976). 2010;35(11):E458-E464. Link
  12. 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
  13. Cohen JI. Herpes Zoster. N Engl J Med. 2013;369(3):255–263. Link

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

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