Pink Flags and Tendons

Original Editor - Mandy Roscher Top Contributors - Mandy Roscher, Kim Jackson, Jess Bell, Lucinda hampton, Tarina van der Stockt and Robin Tacchetti

Introduction

In life, flags are used to help 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. In physiotherapy, red and yellow flags are commonly used.

Red flags "are signs and symptoms related to the screening of serious underlying pathologies mimicking a musculoskeletal pain."

Red flags are specific attributes derived from a patient's medical history and the clinical examination that are usually linked with a high risk of having a serious disorder like an infection, cancer, or a fracture. Red flags are not diagnostic tests, and they don't necessarily predict diagnosis or prognosis. Rather, they are clinical prediction guides. Their main function is to raise the therapist's suspicion when they are combined. Examples of red flags include:

• aged over 50 years
• progressive symptoms
• thoracic pain
• past history of cancer
• weight loss
• drug abuse
• night pain
• systemically unwell (fever)
• night sweats

For more information on Red Flags and a clinical framework to help guide practice, please see: An Introduction to Red Flags in Serious Pathology.

Yellow flags are psychosocial factors, thoughts, feelings and behaviours. A yellow flag is not a diagnosis. Rather, it identifies any potential psychological or social factors that may cause someone to recover slower or differently than might be expected.

Yellow flags have been found to predict poorer outcomes. Common examples of yellow flags are:

• catastrophising (i.e. thinking the worst)
• finding painful experiences unbearable, reporting extreme pain disproportionate to the condition
• having unhelpful beliefs about pain and work (e.g. "if I go back to work my pain will get worse")
• becoming preoccupied with health, over-anxious, distressed and low in mood
• fear of movement and of re-injury
• uncertainty about what the future holds
• changes in behaviour or recurring behaviours
• expecting other people or interventions to solve the problems (being passive in the process) and repeated / serial visits to various practitioners for help but having no improvement

There are different ways to assess for yellow flags, including the following screening tools:

• Optimal Screening for Prediction of Referral and Outcome (OSPRO)
• Functional Pain Management Society’s Intake Questionnaire

There are also orange (psychiatric and mental illness), blue (personal factors affecting the workplace), and black (restrictions for returning to work) flags. Please see Table 1 for examples of different types of flags.

Table 1. Types of Flags

Flag	Nature	Examples
Red	Signs of serious pathology	Examples of serious pathology are cauda equina syndrome, fracture, tumour Red flag signs include: unremitting night pain, sudden weight loss of 10 pounds over three months, bladder and bowel incontinence, previous history of cancer, saddle anaesthesia, etc
Orange	Psychiatric symptoms	Clinical depression Personality disorder
Yellow	Beliefs, appraisals and judgements	Unhelpful beliefs about pain Belief that an injury is uncontrollable or likely to worsen Expectations of poor treatment outcomes or a delayed return to work
	Emotional Responses	Distress that does not meet the criteria for diagnosis of a mental disorder Worry, fear, anxiety
	Pain behaviour (including pain and coping strategies)	Avoidance of activities due to expectations of pain and possible reinjury Over-reliance on passive treatments
Blue	Perceptions about the relationship between work and health	The belief that work is too hard and is likely to cause further injury The belief that workplace supervisors and workmates are unsupportive
Black	System or contextual obstacles	Legislation restricting options for return to work Conflict with insurance staff over injury claim Overly solicitous family and healthcare providers Heavy work, with little opportunity to modify duties

A pink flag is an unofficial flag developed by Louis Gifford. While yellow flags focus on the psychosocial barriers to recovery, pink flags focus on the positive aspects.

• Gifford felt that in medicine, the focus is more commonly on negative factors that aggravate a condition or delay healing.
• 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.
• Tendinopathy can be difficult to manage, and recovery can be slow - it can, therefore, be helpful to focus on and promote pink flags to promote good outcome.

"It’s easy, take the yellow flags and paint them PINK....If they come in yellow with the patient – work out how to make them shift to pink. Good rehabilitation, good management, good explanation, reaching targets, helping the pain, better pain management, keeping going etc" -- Louis Gifford

The ABCDEFW of Yellow and Pink Flags

Many psychosocial factors can be a barrier or an aid to recovery. Louis Gifford introduced the "PINK FLAGS – ABCDEFW initiative" - these are the "positive" flags that suggest that an individual will do well with their treatment or rehabilitation.

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

In essence, a yellow flag would be catastrophising or fear avoidance behaviours, whereas a pink flag would be when a patient believes they will definitely get better and they have a low fear of pain.

Louis Gifford provides the following example for Pink flag ‘A’: Attitudes and Beliefs

• The individual has low fear / low concern about pain
• They have the belief that continuing to go to work and engaging in their usual activities will help recovery
• There is an expectation that being active will result in a faster recovery even if they may experience exacerbations
• They believe that they will get better and return to all their usual activities
• They believe that their pain is manageable and can be controlled
• They want to be involved in their recovery - they do not need to rely on medical management (i.e. their biology will aid healing and they know there is no "magic fix")
• They understand that pain does not mean harm

While there has not been any formal research on pink flags, there has been substantial research on yellow flags. Identifying and dealing with yellow flags has been shown to improve treatment outcomes. Dealing with yellow flags is synonymous with turning yellow flags into pink flags. Thus, it can be assumed that focusing on and working to increase and enhance pink flags will improve treatment outcomes. As Louis Gifford notes, we should be just as interested in the positives of a patient as we are in the negatives.

When assessing and treating patients, the therapist should aim to identify any relevant flag, including yellow and pink flags. They should work to enhance and encourage the pink flags and work to change the yellow flags into pink flags. This can be achieved through communication, education, careful choice of words and improving confidence.

Use of Terminology in Healthcare Settings

Research has highlighted that a given diagnosis will affect an individual's decision-making regarding investigations and treatment. In 2017, Nickel et al. conducted a systematic review which explored how using different terminology for the same condition can affect a patient's decision-making. For example:

• When medicalised terms like broken bone, fracture, greenstick fracture or hairline fracture were used, patients expected more invasive treatments, such as surgery or casting. However, if a less medicalised term was used such as "crack in the bone", patients expected a less invasive treatment like a sling.
• Women given a diagnosis of polycystic ovary syndrome (PCOS) had a "significantly higher intention to have an ultrasound compared with women who were given the term ‘hormonal imbalance’". They were also more likely to have lower self-esteem.

If you would like to learn more, you can read the full systematic review here: Words do matter: a systematic review on how different terminology for the same condition influences management preferences.

Use of Terminology Specific to Tendinopathy

There has been much debate on the terminology used to describe tendinopathy or tendon-related pain. The terms tendinitis and tendinosis were previously popular and are still being used by some healthcare practitioners.

• Tendinopathy: a complex, multifaceted condition that is associated with persistent tendon pain related to mechanical loading
• Tendinitis: has been defined as "is the inflammation of the tendon and results from micro-tears that happen when the musculotendinous unit is acutely overloaded with a tensile force that is too heavy and/or too sudden"
• Tendinosis: has been defined as "a degeneration of the tendon’s collagen in response to chronic overuse; when overuse is continued without giving the tendon time to heal and rest, such as with repetitive strain injury, tendinosis results"

The International Scientific Tendinopathy Symposium Consensus on Clinical Terminology offers the following recommendations:

• “We recommend that clinicians and patients use the term tendinopathy to refer to persistent tendon pain related to mechanical loading.”
• They 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.
• They recommend separating tendon tears from the diagnosis of tendinopathy as this represents a “macroscopic discontinuity” and will require different clinical management (eg Achilles rupture)

Why does this matter?

Because the term tendinitis refers to an inflammatory process, an individual who is given this diagnosis may focus on the idea that there is an inflammatory component to their tendon pain. They may, therefore, believe that rest is an appropriate management strategy as it will allow time for the inflammation to settle. However, we know that rest is not indicated for tendinopathy, and the best evidence for treatment is an active management approach of progressive loading. But a patient who believes their tendon is inflamed may be reluctant to embrace exercise as a treatment approach. It is, therefore, essential that we challenge this belief and use the correct terminology of tendinopathy.

"We want to use words that promote exercise and actually really empower them to get moving." -- Ebonie Rio

Imaging and Tendinoapthy

There has been much research on imaging and tendinopathy over the years. Imaging can create both yellow and pink flags. If on imaging, an ultrasound or MRI finds that a tendon is structurally intact and there are no pathoanatomical changes, a patient may feel reassured and more confident to exercise - which are pink flags. Conversely, if imaging shows that there is degeneration in the tendon, a patient may feel fear and anxiety - which are yellow flags. It is much harder to undo a negative belief!

However, the presence of tendon pathology on imaging does NOT implicate the tendon as the source of a patient's symptoms as changes found on tendon imaging (MRI or ultrasound) do NOT correlate to clinical symptoms. 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

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.
• We need to use words that heal rather than words that harm.
• We must encourage an active rehabilitation approach and empower our patients with education on their 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 paratenonitis rather than a tendinopathy, a low-load exercise programme may worsen the condition.
  • NB: paratenonitis is when the paratenon is irritated from repetitive movement - a paratenon is "a sheath-like connective tissue that allows the tendon to move with minimal friction".
• There is no recipe to manage a tendinopathy - treatment must always be individually tailored to each patient.

Summary

• There are many flags to look out for when assessing a patient, including red, yellow, orange, blue and black flags
• Louis Gifford proposed the term pink flags, which are essentially the opposite of yellow flags
• While yellow flags predict poorer outcomes, pink flags are features that are associated with a positive outcome
• When working with individuals with tendinopathy, we need to do more than simply recognise pink flags (and other flags) in their history - we must also work to ensure that all our language is biopsychosocial (because the words and terminology we use really matter)