Pink Flags and Tendons

Original Editor - Mandy Roscher Top Contributors - Kim Jackson

Introduction[edit | edit source]

In life, flags are used to help us provide us with information or give an indication of something. A flag of a country identifies it. A flag in a sporting event lets you know if you are on a final lap or disqualified.

In the medical field, the flag system identifies various aspects of the person or problem and defines them according to certain subcategories.[1]

In physiotherapy, red and yellow flags are commonly used.

  • Red flags are clinical factors and label any signs of serious pathology[2][3]
  • Yellow flags are psychosocial factors, thoughts, feelings and behaviours.[4] A yellow flag is not a diagnosis but rather identifies any potential psychological or social factors that may cause someone to recover slower or differently as one would expect[2]

There are also orange (psychiatric and mental illness), blue (personal factors affecting the workplace), and black (restrictions for returning to work) flags.[4][5]

A pink flag is an unofficial flag developed by Louis Gifford. Where yellow flags focus on the psychosocial barriers to recovery, pink flags rather focus on the positive aspects.[1] Gifford felt that in medicine the focus is more commonly on the negative such factors that aggravate a condition or delay healing.[1] A yellow flag is a psychosocial predictor of a poor or bad outcome whereas a pink flag is a psychosocial predictor of a good or positive outcome.[6] Tendinopathy can be difficult to manage and recovery can be slow. It can be helpful to focus on and promote pink flags to promote good outcome.

The ABCDEFW of Yellow and Pink Flags[edit | edit source]

There are many psychosocial factors that can be a barrier or an aid to recovery. An acronym of ABCDEFW was developed to help remember the various aspects[1]

  • A = Attitudes and beliefs
  • B = Behaviours
  • C = Compensation and financial
  • D = Diagnostic and treatment
  • E = Emotions
  • F = Family
  • W = Work

A yellow flag may be catastrophising or fear avoidance behaviours whereas a pink flag would be believing they will definitely get better and having a low fear of the pain[6]

Example of Louis Gifford Pink Flags[6]

Pink flag ‘A’: Attitudes and Beliefs

  • Low fear, low concern about pain
  • The belief that to keep going at work and normal activities help recovery
  • An expectation that being active will eventually lead to quicker recovery even though exacerbations may occur
  • Believing that you’re going to get better and that you will get back to all previous activities.
  • The belief that pain is quite manageable and controllable.
  • Desire to be involved in one’s own recovery and not reliant on medical management – that one’s own biology will do the job far better in the end and that there is no such thing as a magic fix.
  • The belief that pain does not mean harm.

While there has not been any formal research conducted into pink flags there has been substantial research into yellow flags. Identifying and dealing with yellow flags has shown to improve treatment outcomes.[1] Dealing with yellow flags is synonymous with turning yellow flags into pink flags. It can thus be assumed that focusing on and working to increase and enhance pink flags will improve treatment outcomes. We should be just as interested in the positives of a patient as we are in the negatives.[6]

In treatment, a therapist should identify the yellow flags and pink flags. They should work to enhance and encourage the pink flags and work to change the yellow flags into pink flags.[2] This can be done through communication, education, careful choice of words and improving confidence.[2]

Use of Terminology in Tendinopathy[edit | edit source]

Research shows that the diagnosis given affects the person’s decision making regarding investigations and treatment.[7] Nickel et al conducted a systematic review in 2017 looking at how using different terminology for the same condition affect decision making. They found that patients expected more invasive treatment (eg a cast or surgery) when the more medicalised term fracture was used versus those that opted for a sling or “it will heal on its own” approach when the term “a crack in the bone” was used.[7]

In tendons, there has been much debate on the terminology used. The term tendinitis and tendinosis have historical popularity and are still being used by certain health care practitioners.

The international scientific tendinopathy symposium consensus on clinical terminology “recommend that clinicians and patients use the term tendinopathy to refer to persistent tendon pain related to mechanical loading.” They also did not support the use of tendinosis when a loss of microstructure was seen on imaging as there is no evidence that there is any clinical relevance of this diagnosis.[8] They separate tendon tears from the diagnosis of tendinopathy as this represents a “macroscopic discontinuity” and will require different clinical management (eg Achilles rupture).[8]

A patient who is given the diagnosis of tendonitis may be led to believe there is an inflammatory component to the condition.[9] An inflammatory condition implies that rest is required to allow the inflammation to settle. We know that rest is not indicated for tendinopathy and the best evidence for treatment is an active management approach of progressive loading.[10] A patient who believes their tendon is inflamed may be reluctant to embrace exercise as a treatment approach. It is important to change this belief and use the correct terminology of tendinopathy.[9]

Imaging and Tendinoapthy[edit | edit source]

Imaging and tendinopathy have been researched over the years. Imaging can create both yellow and pink flags.  If an ultrasound or MRI finds that the tendon is structurally intact with no pathoanatomical changes it may reassure someone and make them feel more confident to exercise (pink flag). If it finds that there is degeneration in the tendon it may produce fear and anxiety (yellow flag). It can be much harder to undo a negative belief. It is agreed that changes found on imaging (MRI or Ultrasound) of tendons do not correlate to clinical symptoms.[11] While imaging may be helpful to exclude pathology the patient’s clinical presentation should be the primary factor driving treatment goals and progressions.

Encouraging Self-Efficacy in Tendinopathy[edit | edit source]

Research continually shows that exercise is the gold standard treatment for tendinopathy.

  • Physiotherapists and any other health care practitioners involved in the management of tendinopathy patients must make sure that they are communicating with their patients effectively.
  • Using words that heal rather than words that harm. Encouraging an active rehabilitation approach and empower the patients with education on the condition so they can understand why the active management approach is the best for tendinopathy.
  • It is important, however, to ensure that the diagnosis of tendinopathy is correct.
  • If it is a paratendonitis rather than tendinopathy where the paratendon is irritated from repetitive movement a low load exercise programme may worsen the condition.
  • There is no recipe for treatment and it should be individually tailored to each patient.

References[edit | edit source]

  1. 1.0 1.1 1.2 1.3 1.4 Gifford L. Red and Yellow Flags and improving treatment outcomes: or" top down before bottom up". Summer 2006 In Touch.
  2. 2.0 2.1 2.2 2.3 Occupational Health and Wellbeing. Psychosocial Flag System. Available from: (accessed 707/05/2020)
  3. Finucane LM, Downie A, Mercer C, Greenhalgh SM, Boissonnault WG, Pool-Goudzwaard AL et al. International Framework for Red Flags for Potential Serious Spinal Pathologies. J Orthop Sports Phys Ther. 2020;50(7):350-372.
  4. 4.0 4.1 Winkelmann C, Schreiber T. Using ’White Flags’ to categorize socio-cultural aspects in chronic pain. European Journal of Public Health. 2019;29:10.
  5. Post Sennehed C, Gard G, Holmberg S, Stigmar K, Forsbrand M, Grahn B. "Blue flags", development of a short clinical questionnaire on work-related psychosocial risk factors - a validation study in primary care. BMC Musculoskelet Disord. 2017;18(1):318.
  6. 6.0 6.1 6.2 6.3 Gifford L. Now for pink flags. PPA News. 2005;20:3-4.
  7. 7.0 7.1 Nickel B, Barratt A, Copp T, Moynihan R, McCaffery K. Words do matter: a systematic review on how different terminology for the same condition influences management preferences. BMJ open. 2017 Jul 1;7(7):e014129.
  8. 8.0 8.1 Scott A, Squier K, Alfredson H, Bahr R, Cook JL, Coombes B, de Vos RJ, Fu SN, Grimaldi A, Lewis JS, Maffulli N. Icon 2019: international scientific tendinopathy symposium consensus: clinical terminology. British Journal of Sports Medicine. 2020 Mar 1;54(5):260-2.
  9. 9.0 9.1 Khan KM, Cook JL, Kannus P, Maffulli N, Bonar SF. Time to abandon the “tendinitis” myth: painful, overuse tendon conditions have a non-inflammatory pathology. ([HTML]
  10. Cook JL, Purdam CR. The challenge of managing tendinopathy in competing athletes. Br J Sports Med. 2014 Apr 1;48(7):506-9.
  11. Docking SI, Ooi CC, Connell D. Tendinopathy: is imaging telling us the entire story?. journal of orthopaedic & sports physical therapy. 2015 Nov;45(11):842-52.