The Pharmacology of Recovery – How Anticoagulants Change Rehabilitation (Part 7 of 10)

Written by Rehab Mechanics

The prescription of therapeutic anticoagulation following deep vein thrombosis ($\text{DVT}$) and bilateral pulmonary embolism ($\text{PE}$) fundamentally alters the rules of physical therapy and athletic performance. Physiotherapy in Toronto at Queen West Rehab Mechanics assists in bridging medical hematology with orthopedic safety by establishing strict clinical guidelines for anticoagulated patients. Contrary to common belief, blood thinners do not chemically "dissolve" an established thrombus; direct oral anticoagulants ($\text{DOACs}$) and low-molecular-weight heparin ($\text{LMWH}$) selectively inhibit clotting factors ($\text{Factor Xa}$ or thrombin) to prevent clot propagation while endogenous plasmin slowly lyses the fibrin scaffold over a mandatory 3- to 6-month biological window. During this phase, all contact sports, collision drills, and high-velocity eccentric loading are strictly prohibited due to fatal internal hemorrhage and intracranial bleeding risks. By pairing clinical concussion rehabilitation and vestibular retraining with cardiovascular monitoring, specialized physical therapy establishes rigorous screening protocols to identify vascular red flags across Toronto.

The Patient’s Story / Toronto Context

Toronto’s active professionals, corporate executives, and high-performance endurance athletes pride themselves on pushing through physical adversity. Whether managing complex cross-border transactions in the Financial District, coding software in Liberty Village, or maintaining intense focus during high-cadence training sessions along the Martin Goodman Trail, physical resilience is treated as a non-negotiable asset.

However, following a blunt sports impact, a minor motor vehicle collision along the Gardiner Expressway, or an awkward twist during a recreational soccer match at Lamport Stadium, a heavy, frustrating lower-extremity symptom frequently settles in: The Unresolving Calf Ache.

Consider a 39-year-old corporate director from King West who sustained a direct cleat impact to the gastrocnemius during a weekend soccer match, or a 44-year-old competitive runner from Trinity Bellwoods navigating stubborn post-running calf tightness.

On paper, their physical rehabilitation is progressing. Their ankle range of motion is restored, and their balance tests are stabilizing.

Yet, inside our treatment rooms at Rehab Mechanics inside the Prime Medical Centre at 68 Abell Street in Queen West, they report a subtle, ominous anomaly:

"My physical therapist stretched my calf and released the trigger points, but the muscle feels weirdly hot, heavy, and swollen, and no amount of elevation or foam rolling relieves the deep, throbbing pressure behind my shin."

When they present this persistent vascular congestion to standard medical channels, Medicine 2.0 offers its routine compartmentalized brush-off: "You just have a Grade 1 muscle strain or a stubborn charley horse. Ice it, take an anti-inflammatory pill, and wait for it to pass."

At Rehab Mechanics, we reject the notion that post-traumatic calf pain should be brushed off as a simple muscle cramp. When a localized soft-tissue contusion fails to resolve within standard physiological healing windows, clinicians must rigorously screen for provoked venous thromboembolism before applying aggressive massage or deep pressure.

To manage vascular complications, you cannot rely on passive rest or guesswork. You must evaluate the vascular superhighway at the cellular and hydrodynamic level.

Welcome to Part 7 of our clinical series on The Jalen Hurts Case Study – The Pharmacology of Recovery – How Anticoagulants Change Rehabilitation. By conducting a comprehensive biomechanical assessment at our Queen West physio clinic, specialized physical therapy assists in decoding how physical trauma, endothelial injury, and venous stasis interact across high-performance athletes in Toronto.

Structural / Biomechanical Analysis

To understand why an elite quarterback like Jalen Hurts is sidelined for months despite possessing normal muscle strength, we must examine the molecular pharmacology of anticoagulants, the mechanism of endogenous fibrinolysis, and the mechanical biomechanics of hemorrhagic risk.

+---------------------------------------------------------------------------------------------------+
|               THE PHARMACOLOGICAL PARADIGM & ENDOGENOUS FIBRINOLYTIC WINDOW                        |
+---------------------------------------------------------------------------------------------------+
|   [CLINICAL DIAGNOSIS: PROVOKED DVT & BILATERAL PULMONARY EMBOLI]                                 |
|   Immediate Initiation of Therapeutic Anticoagulation (DOAC: Rivaroxaban / Apixaban)             |
|         │                                                                                         |
|         ├─────────────────────────────────────────┐                                               |
|         ▼                                         ▼                                               |
|   [1. WHAT ANTICOAGULANTS DO]             [2. WHAT ANTICOAGULANTS DO NOT DO]                      |
|   • Direct Factor Xa / IIa Inhibition     • Do NOT dissolve the existing physical clot           |
|   • Halts Thrombin Generation             • Do NOT break covalent fibrin mesh cross-links         |
|   • Eliminates Secondary Thrombus Growth  • Do NOT instantly clear pulmonary arterial branches   |
|         │                                         │                                               |
|         └─────────────────────────────────────────┼───────────────────────────────────────┘       |
|                                                   ▼                                               |
|   [THE BIOLOGICAL DRIVER: ENDOGENOUS FIBRINOLYSIS]                                                |
|   Tissue Plasminogen Activator (tPA) Cleaves Plasminogen ──► Plasmin Degrades Fibrin Scaffold     |
|   Gradual Enzymatic Dissolution Requires Mandatory 3 to 6-Month Remodeling Window                 |
|         │                                                                                         |
|         ▼                                                                                         |
|   [THE CLINICAL REHABILITATION RE-CALIBRATION]                                                    |
|   ABSOLUTE CONTRAINDICATION: Contact Sports + Collision Drills + Blunt Impact Trauma              |
|   PERMITTED: Graded Closed-Chain Non-Contact Loading + Low-Resistance Stationary Ergometer        |
|         │                                                                                         |
|         ▼                                                                                         |
|   [PERMANENT VASCULAR AUTONOMY & THE QUEEN WEST NEUROLOGICAL BASELINE]                            |
|   • Vascular Safety: Eliminates missed DVT red flags and prevents catastrophic PEs                |
|   • Vagal Coherence: Parasympathetic stabilization melts suboccipital and cervical guarding       |
|   • Peak Kinetic Readiness: Restores unshakeable athletic resilience across Toronto pavement      |
+---------------------------------------------------------------------------------------------------+

1. The Dissolution Fallacy: Anticoagulation vs. Fibrinolysis

The most common misconception among athletes, coaches, and clinicians is that "blood thinners" dissolve blood clots:

  • The Anticoagulant Mechanism: Modern therapeutic anticoagulants—specifically Direct Oral Anticoagulants ($\text{DOACs}$) such as Apixaban ($\text{Eliquis}$) and Rivaroxaban ($\text{Xarelto}$), or Low-Molecular-Weight Heparin ($\text{LMWH}$)—function by selectively inhibiting specific serine proteases in the coagulation cascade. $\text{Factor Xa}$ inhibitors block the conversion of prothrombin to thrombin, preventing the polymerization of fibrinogen into fibrin.

  • Halting Propagation, Not Dissolving: Anticoagulants act as a chemical shield that halts the growth of the existing thrombus and prevents new embolic fragments from forming. They do not dissolve the clot already lodged in the leg or lung.

  • The Endogenous Cleaning Crew: True clot dissolution relies entirely on the body's natural fibrinolytic system. Endothelial cells synthesize and secrete Tissue Plasminogen Activator ($\text{tPA}$), which converts inactive plasminogen bound within the thrombus into the active enzyme plasmin. Plasmin slowly cuts the cross-linked fibrin mesh into soluble fibrin degradation products (such as $\text{D-dimer}$).

  • The Mandatory Time Horizon: This endogenous biological enzymatic breakdown is a slow, cellular process. It requires a minimum of $3\text{ to }6\text{ months}$ of sustained therapeutic anticoagulation for the pulmonary arterial tree and deep popliteal veins to recanalize and restore vascular patency.

2. The Bleeding Hazard: Why Contact Sports Are Strictly Banned

Why is Jalen Hurts completely ruled out from playing football even if his shortness of breath resolves and his calf feels completely normal?

  • Impaired Hemostasis: By chemically blunting the coagulation cascade, anticoagulants intentionally disable the body's primary mechanical defense against hemorrhage. If a blood vessel ruptures, the normal microvascular platelet-fibrin plug cannot form effectively.

  • Intramuscular Hematoma & Acute Compartment Syndrome: If an athlete taking $\text{DOACs}$ absorbs a routine blunt tackle or cleat blow to the quadriceps or calf, microvascular bleeding does not self-seal. Blood continues to pour into the unyielding fascial compartment, causing an expanding intramuscular hematoma that spikes interstitial pressures and can precipitate acute limb-threatening compartment syndrome.

  • Catastrophic Intracranial Hemorrhage: The primary concern in contact sports is head trauma. A routine helmet-to-helmet impact or violent whiplash collision—which might normally cause a mild concussion—can trigger catastrophic, fatal subarachnoid or subdural intracranial bleeding in an anticoagulated athlete. Contact sports are an absolute, non-negotiable medical contraindication while on blood thinners.

3. Re-Calibrating Physical Therapy: The Non-Contact Loading Window

How do physical therapists manage an athlete on therapeutic anticoagulants?

  • Eliminating Mechanical Shearing: While the thrombus is organizing, aggressive deep tissue massage, instrument-assisted soft-tissue mobilization ($\text{IASTM}$), dry needling, and aggressive end-range passive stretching are strictly prohibited over the affected limb. Manual pressure can mechanically shear a fragile, un-recanalized thrombus or cause extensive subcutaneous bruising.

  • Controlled Closed-Chain Mechanotransduction: Once acute medical stabilization is achieved ($7\text{ to }14\text{ days}$ post-diagnosis), absolute bed rest is avoided. As we will explore in Part 8, gentle, non-contact closed-chain loading (such as stationary cycling and isometric postural stability) stimulates safe venous return without exposing the athlete to blunt impact or falling risks.

+----------------------------------------------------------------------------------------------------+
| PHARMACOLOGICAL CLASS   | MOLECULAR TARGET & MECHANISM    | REHABILITATION SAFETY PROFILE          |
+-------------------------+---------------------------------+----------------------------------------+
| Direct Oral             | Direct Factor Xa Inhibition     | Rapid onset (2-4 hrs); predictable     |
| Anticoagulants (DOACs)  | (Apixaban, Rivaroxaban)         | pharmacokinetics; strict no-contact rule|
+-------------------------+---------------------------------+----------------------------------------+
| Direct Thrombin         | Direct Factor IIa Inhibition    | Oral administration; no routine blood  |
| Inhibitors (DTIs)       | (Dabigatran)                    | monitoring; high bleeding risk on fall |
+-------------------------+---------------------------------+----------------------------------------+
| Vitamin K Antagonists   | Inhibits Factors II, VII,       | Narrow therapeutic window; requires    |
| (Warfarin / Coumadin)   | IX, X, & Proteins C & S         | weekly INR monitoring; dietary clashes |
+-------------------------+---------------------------------+----------------------------------------+
| Low-Molecular-Weight    | Potentiates Antithrombin III    | Subcutaneous injection; used in acute  |
| Heparin (LMWH)          | against Factor Xa > IIa         | hospital triage and surgical bridging  |
+-------------------------+---------------------------------+----------------------------------------+
| Thrombolytic Therapy    | Recombinant tPA (Alteplase)     | Emergency critical care only; actively |
| (The Clot Busters)      | converts plasminogen to plasmin | dissolves clots in massive unstable PE |
+----------------------------------------------------------------------------------------------------+

Clinical Red Flags

While physical therapy plays a vital role in safe vascular reconditioning, clinicians treating patients on therapeutic anticoagulation must screen for acute hemorrhagic and recurrent thrombotic emergencies:

  • Spontaneous Internal Hemorrhage / Acute Bleeding: Any spontaneous, unexplained epistaxis (nosebleeds) lasting $>15\text{ minutes}$, frank hematuria (blood in the urine), hematochezia or melena (black, tarry stools), or hematemesis (coffee-ground emesis), demanding immediate emergency medical evaluation.

  • Intracranial Hemorrhage Warning: Sudden, severe "thunderclap" headaches, acute confusion, pupillary asymmetry, or focal neurological deficits following any minor head bump, requiring immediate emergency neuro-imaging.

  • Rapidly Expanding Intramuscular Hematoma: A muscle belly (e.g., quadriceps or calf) that becomes tense, wooden, visibly ecchymotic, and exquisitely painful following light exertion, carrying a critical risk of acute compartment syndrome.

  • Recurrent Venous Thromboembolism: Sudden return of unilateral leg swelling or acute shortness of breath despite anticoagulant therapy, signaling treatment failure, sub-therapeutic dosing, or heparin-induced thrombocytopenia ($\text{HIT}$).

Primary Source Proof (PubMed / NIH)

Extensive peer-reviewed hematology, sports medicine, and vascular surgery literature confirm that anticoagulants prevent thrombus propagation while endogenous fibrinolysis resolves clots, that direct oral anticoagulants deliver superior safety profiles in active populations, and that contact sports present an unacceptable risk of catastrophic hemorrhage during active anticoagulation.

The Rehab Mechanics Corrective Protocol

We do not treat sports injuries in isolation from the vascular environment surrounding the musculoskeletal system. Inside our Queen West clinic at 68 Abell Street, our clinical protocols integrate rigorous vascular screening with spine and lower-limb mechanics.

+----------------------------------------------------------------------------------------------------+
| PHASE                   | CLINICAL STRATEGY               | VASCULAR & BIOMECHANICAL GOAL          |
+-------------------------+---------------------------------+----------------------------------------+
| Phase 1: Vascular &     | • Comprehensive Wells' DVT screen| • Quantifies unresolving swelling risk |
| Soft-Tissue Triage      | • Limb circumference telemetry  | • Screens for deep venous occlusion    |
| (Week 1)                | • Palpation temperature check   | • Establishes emergency medical referral|
+-------------------------+---------------------------------+----------------------------------------+
| Phase 2: Medical        | • Immediate duplex ultrasound   | • Confirms or rules out deep thrombus  |
| Escalation & Triage     | • Physician hematology liaison  | • Initiates anticoagulation therapy   |
| (Weeks 1–3)             | • Absolute cessation of massage | • Eliminates mechanical dislodgement risk|
+-------------------------+---------------------------------+----------------------------------------+
| Phase 3: Non-Contact    | • Safe closed-chain conditioning| • Preserves baseline cardiovascular VO2|
| Vascular Conditioning   | • Low-impact stationary cycling | • Protects internal hematoma risk      |
| (Weeks 3–8)             | • Graded venous return pacing   | • Stimulates safe lymphatic flow       |
+-------------------------+---------------------------------+----------------------------------------+
| Phase 4: Structural     | • Full athletic re-integration  | • Sustained vascular homeostasis       |
| Durability & Autonomy   | • Transition to Part 8 Protocol | • Unshakeable neurological resilience  |
| (Weeks 8–12+)           | • Lifelong hydrodynamic health  |   across dynamic Toronto pavement      |
+----------------------------------------------------------------------------------------------------+

Actionable Takeaway: The Rehab Mechanics 4-Point Anticoagulated Athlete Protocol

If an athlete or patient in your clinic is prescribed therapeutic blood thinners following a diagnosed blood clot across Toronto, execute these four tactical rules:

  1. Strictly Prohibit All Contact and Collision Activities: Immediately suspend all participation in contact sports (football, hockey, rugby, soccer, martial arts) and high-velocity activities with fall risks (skiing, outdoor road cycling).

  2. Halt Aggressive Manual Modalities Over the Limb: Cease all deep tissue massage, instrument-assisted soft-tissue mobilization ($\text{IASTM}$), dry needling, and forceful stretching on the affected limb to prevent traumatic intramuscular hematomas.

  3. Verify Stable Dosing Before Progressing Loading: Never advance exercise intensity until the patient's primary care physician, hematologist, or sports medicine specialist confirms therapeutic, stable anticoagulation adherence ($>14\text{ days}$).

  4. Monitor Spontaneous Bleeding Biomarkers Daily: Educate the patient to inspect daily for unexplained subcutaneous hematomas (bruising), gingival bleeding during tooth brushing, or dark stools, escalating any abnormalities to emergency care immediately.

Phase 1 — Vascular & Soft-Tissue Triage (Week 1)

Before prescribing advanced physical loading during your Full-Body Biomechanical Assessment:

  • Vascular Risk Screening: Auditing injury mechanism, swelling asymmetry, localized skin temperature, and Wells' Criteria for DVT.

  • Mobility & Tendon Assessment: Evaluating lower extremity range of motion to establish a safe baseline for rehabilitation.

Phase 2 — Medical Escalation & Triage (Weeks 1 to 3)

We eliminate mechanical intervention risks when vascular occlusion is suspected:

  • Urgent Doppler Ultrasound Referral: Coordinating immediately with local emergency departments or vascular imaging centers to perform definitive duplex ultrasound scans.

  • Physician Collaboration: Partnering directly with hematologists and vascular surgeons to oversee safe anticoagulation management.

Phase 3 — Non-Contact Vascular Conditioning (Weeks 3 to 8)

With medical clearance established and anticoagulation stabilized, we maintain baseline conditioning:

  • Low-Impact Ergometer Cycling: Prescribing controlled, non-contact stationary cycling at low resistance to maintain cardiovascular fitness without exposing the limb to blunt impact.

  • Venous Return Pacing: Integrating gentle, non-resistive ankle pumps to stimulate natural venous return without mechanical shear stress.

Phase 4 — Structural Durability & Transition to Part 8 (Weeks 8 to 12+)

We lock in permanent vascular and physical resilience across Toronto:

  • Objective Functional Re-Audit: Re-evaluating lower extremity range of motion, strength symmetry, and cardiovascular output.

  • Transition to Part 8 (Safe Conditioning While Anticoagulated): Blood thinners keep the athlete safe from clot propagation, but how do you maintain elite cardiovascular output and muscle volume without exposing the body to impact trauma? In Part 8 of this series, Safe Conditioning While Anticoagulated – The "No-Contact" Blueprint, we will explore safe exercise programming, stationary cycling, and zero-impact loading protocols across Toronto.

Related Conditions We Treat

  • Post-Traumatic Deep Vein Thrombosis ($\text{DVT}$)

  • Superficial Vein Thrombosis ($\text{SVT}$) Management

  • Post-Thrombotic Syndrome ($\text{PTS}$) Prevention

  • Post-Surgical Lower Extremity Edema

  • Athletic Soft-Tissue Contusions & Strain Differentiation

  • Chronic Venous Insufficiency & Circulatory Support

Related Blogs

Services Used in Treatment

FAQ Section

  • Do blood thinners (anticoagulants) dissolve blood clots? No. Anticoagulants do not dissolve existing blood clots. They stop the clotting cascade so the clot cannot grow or send off new pieces, allowing your body's natural enzymes (plasmin) to slowly break down the clot over several months.

  • Why is Jalen Hurts not allowed to play football while taking blood thinners? Taking anticoagulants significantly reduces your blood's ability to clot. If an athlete takes a high-impact hit or suffers head trauma while on blood thinners, it can trigger uncontrollable internal bleeding, large muscle hematomas, or fatal brain hemorrhages.

  • What is the difference between DOACs and Warfarin? Direct Oral Anticoagulants ($\text{DOACs}$) directly target specific clotting factors ($\text{Factor Xa}$ or thrombin), work quickly, and do not require frequent blood monitoring. Warfarin blocks Vitamin K recycling and requires regular blood tests ($\text{INR}$) to verify safe dosing.

  • Can I receive deep tissue massage while on blood thinners? No. Deep tissue massage, instrument-assisted scraping ($\text{IASTM}$), and aggressive foam rolling are strictly prohibited over an affected limb because they can cause severe subcutaneous bleeding or dislodge residual clot fragments.

  • How long does an athlete typically have to stay on blood thinners after a DVT or PE? Medical guidelines generally mandate a minimum course of $3\text{ to }6\text{ months}$ of therapeutic anticoagulation for provoked venous thromboembolism to allow complete vascular remodeling and prevent recurrence.

  • Can I lift weights while taking blood thinners? You can perform controlled, low-to-moderate resistance exercises once medically cleared, but heavy lifting with intense breath holding (Valsalva) or high-risk movements with fall hazards must be avoided.

  • What are the warning signs of internal bleeding from anticoagulants? Sudden severe headaches, vision changes, coughing up blood, blood in the urine, black or tarry stools, or large, unprovoked bruises that swell and throb.

  • When can an athlete return to contact sports after a blood clot? Contact sports are strictly off-limits until the full course of anticoagulation is completed, repeat ultrasound or CT imaging confirms clot stabilization or resolution, and medical specialists grant formal clearance.

How Physiotherapy Helps

  • Protecting vascular safety by rigorously screening every lower-extremity soft-tissue injury for deep vein thrombosis red flags

  • Collaborating with vascular surgeons and hematologists to coordinate safe, non-contact rehabilitation protocols

  • Preserving cardiovascular fitness through low-impact ergometer conditioning that avoids blunt-force trauma

  • Guiding safe lymphatic return and venous circulation pacing once medical clearance is established

  • Reducing mechanical overload on recovering tissues by maintaining strict non-contact loading parameters during anticoagulation

  • Improving whole-body kinetic chain transfer by eliminating movement compensations safely across Toronto pavement

CTA — Contact Us Today

Contact Us Today — All you have to lose is the pain. Don't let unresolving sports injuries or hidden vascular risks derail your physical recovery. Book a comprehensive biomechanical and vascular screening assessment with our clinical team today to build your safe recovery blueprint from the inside out. Located inside the Prime Medical Centre at 68 Abell Street, Queen West (Explore our Services or browse our Physiotherapy Topics Index). Email: info@rehabmechanics.com | Phone: (416) 533-3900

About the Author

Mr. Sanjay Attwala (B.Sc., M.Sc., RPT) is a Registered Physiotherapist, clinical director, and the founder of Rehab Mechanics in Toronto. With over 15 years of registered clinical practice and a deep specialization in complex musculoskeletal rehabilitation, Sanjay synthesizes rigorous international academic training with advanced evidence-based therapeutics to guide his clinical practice and patient education initiatives.

Academic Background & Credentials

Clinical Expertise & Philosophy                                 

Sanjay’s clinical approach rejects passive symptom management in favor of identifying underlying biomechanical root causes. His diverse expertise spans advanced manual therapies, personalized corrective exercise prescription, and modern physical modalities. At the Rehab Mechanics Toronto Queen West clinic, a routinely diagnoses and treats complex conditions including:

  • Spinal & Discogenic Pathology – Cervical, thoracic, and lumbar disc injuries, sciatica, and sacroiliac joint (SIJ) dysfunction.

  • Upper & Lower Extremity Injuries – Rotator cuff tears, frozen shoulder, tennis/golfer’s elbow, carpal tunnel syndrome, and complex ankle/foot pathologies.

  • Perinatal & Pelvic Health Rehabilitation – Specialized assessment and rehabilitation protocols tailored specifically for women during pregnancy and the post-partum period, addressing pelvic girdle pain, diastasis recti, and core stabilization.

  • Specialized Rehabilitation – Pelvic health therapy, TMJ dysfunction, post-surgical rehabilitation (including Total Hip and Total Knee Replacements), and custom orthotics dispensing.

  • Shockwave Therapy: with advanced cutting edge technological devices to suit your needs.

Interdisciplinary Practice & Patient Care

Sanjay practices an integrated model of healthcare, working closely alongside medical doctors inside the Prime Medical Centre on Abell Street to streamline patient recovery pathways. He maintains a human-centric, communication-first clinical framework, ensuring that care remains fully customized rather than automated. His clinical caseload encompasses a broad operational spectrum under Ontario's regulatory frameworks, including:

  • Motor Vehicle Accident (MVA) Claims – Rehabilitation navigating Ontario’s statutory accident benefits schedule.

  • Workplace Safety and Insurance Board (WSIB) – Occupational injury management and return-to-work screening.

  • Extended Health Care (EHC) & Private Practice – Multi-tier insurance coordination and long-term athletic development plans.

Commitment to Research & Community

Outside of his clinical caseload at Rehab Mechanics and his additional practice affiliations in Etobicoke, Sanjay is an active health writer and community educator. He translates contemporary peer-reviewed medical research into accessible, actionable guidance on his professional blog. As a dedicated father and husband, he mirrors his professional advice in his personal life, focusing on structural mobility, cross-training, and longevity to help his family and his community thrive. Naturally he takes he a keen interest in rehabilitation for women who are pregnant and post-partum.

Disclaimer:

The information provided on this blog is intended for educational and informational purposes only. It does not constitute medical advice, diagnosis, or a treatment plan. Always seek the direct advice of a Registered Physiotherapist, physician, or other qualified health provider regarding any medical condition or physical rehabilitation routine.

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Safe Conditioning While Anticoagulated – The "No-Contact" Blueprint (Part 8 of 10)
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When the Clot Travels – Recognizing Pulmonary Embolism Red Flags (Part 6 of 10)