Why I’m not a fan of the term “clearing XYZ” and ”ruling out red flags”

A mini blog

For a long time I have had concerns about the loose terms we use in MSK examination such as ”I cleared the spine” or ”first I would rule out red flags”, these terms seem to suggest that a) this is actually possible & b) once done the clinician is confident and will rarely. if ever return to these things as possible contributors or concerns in the persons current presentation.

I propose this is an error in clinical reasoning, we should replace these terms with ”lowering the probability of XYZ” and in the case of red flags switch to trying to identify them rather than ”ruling them out” ,which is a nonsense term, adapted from utilizing sensitive tests to ”rule out condition”.

It can be seen that ”ruling out red flags” is not a great term when the sensitivity of most ”red flag indicators have awful sensitivity (even though this is not the intent of the term). ref link here https://cor-kinetic.com/wp-content/uploads/2018/07/red-flags-for-low-back-pain-are-not-always-really-red.pdf

Reference here https://bjsm.bmj.com/content/bjsports/52/8/493.full.pdf

I propose that clinicians should reverse their paradigm and be trying to identify relevant red flags that increase the suspicion of a serious condition, rather than “ruling out” anything.

As for the term “I cleared XYZ” I propose we again utilize the same reasoning and propose, ”we lowered the probability of involvement” ie “after a thorough history and exam it was apparent that the probability of the shoulder pain originating from the neck was minimal” as opposed to ”I cleared the neck from the picture”

As always, thanks for reading this mini blog.

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