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Physical Therapist Case Study: Inappropriate use of a multi-hip machine and improper manual therapy technique resulting in a labral tear.

Medical Malpractice Case Study with Risk Management Strategies
Presented by HPSO and CNA
Medical malpractice claims may be asserted against any healthcare provider, including physical therapists. This case study involves a physical therapy business owner who managed an outpatient physical therapy office, an employed physical therapist (PT) and a physical therapy assistant (PTA).


The insured physical therapist (“primary PT”) and physical therapy business owner (“PT owner”) had both been practicing for more than 25 years. The physical therapy assistant (PTA) was newly licensed and had only been employed at the physical therapy outpatient office for three months. The primary PT involved in the patient’s care was also a new employee of the practice.
This case involves a 35-year-old male patient who presented for physical therapy due to an ongoing history of lower back pain. Following the initial evaluation, a diagnosis of sciatica and decreased core stabilization was noted. The patient was initially progressing well, engaging in therapeutic exercises and utilizing the “multi-hip” machine for muscle strengthening. On the fifth day of treatment, the patient complained of pain during hip flexion while using the “multi-hip” machine. The primary PT instructed the patient to discontinue using the machine and provided alternative exercises. During his deposition, the primary PT testified that this recommendation was documented in a notebook that the physical therapy practice staff used to informally communicate patient care information. However, this information was not documented in the patient’s plan of care in the healthcare information record, nor was it verbally communicated to the PTA on the treatment team. The notebook was no longer available at the time the lawsuit was filed. 
After missing several appointments, two weeks later, the patient returned for therapy and reported to the PTA that she was unable to attend the previously scheduled sessions due to worsening back pain and new onset of hip and leg pain. The PTA acknowledged the patient’s complaints but did not consult with the primary PT about the patient’s increased pain level. The PTA initiated the session with the “multi-hip” machine and increased the weight on the machine. Within minutes, the patient complained of severe pain and was directed by the PTA to rest and prepare for an alternative mode of exercise. However, the patient was unable to continue due to the pain and was observed limping out of the building.
Two weeks later, at the next scheduled appointment, the patient continued to complain of severe back pain. The same PTA assessed the patient and performed muscle energy techniques to relax the patient’s muscles and mobilize and realign the hip. The patient immediately complained of excruciating pain and severe muscle spasms.
The primary PT conducted a brief assessment and performed therapeutic ultrasound and soft tissue mobilization treatments. The PT business owner also came to assist and performed a long axis distraction technique to mobilize the hip joint. Neither of these treatments were documented in the healthcare information record. The patient’s severe pain persisted throughout the treatment session. The PT business owner notified the patient’s physician, who advised that  physical therapy should be discontinued. Subsequently the patient underwent numerous orthopedic evaluations and was diagnosed with femoral acetabular impingement (FAI), CAM lesion and an anterior hip labral tear requiring surgical repair. The patient’s underlying conditions (FAI and CAM lesion) were discovered during the subsequent diagnostic evaluations and were not known at the time of treatment by the insured PT/PTA.
The patient filed a lawsuit against the primary PT, the PTA and the PT business owner asserting a failure to take adequate precautions to prevent hip injury. The patient asserted that the PTA was negligent in using the multi-hip machine, and that using this machine caused a labral tear injury. The plaintiff’s physical therapy expert opined that the PTA should have reported the patient’s new onset of severe pain to the primary PT. A secondary allegation was asserted claiming that the muscle mobilization techniques performed by the PTA in the subsequent visit exacerbated the injury. Allegations against the PT were related to the lack of communication about the change in the treatment plan, failure to appropriately supervise the PTA and a lack of documentation.  The plaintiff asserted that the PT business owner failed to provide adequate training to ensure competency of the employed staff.

Risk Management Comments

The plaintiff’s/patient’s treating orthopedic surgeon, who served as an expert witness, testified that the mechanical force applied during the use of the multi-hip machine was the direct cause of the labral tear. When the patient was being evaluated for surgical repair of the labral tear, it was discovered that the patient had an unknown, pre-existing femoral head CAM lesion. While orthopedic surgery experts for the defense opined that the CAM lesion would have predisposed the patient to developing a labral tear, the experts also admitted that the labral tear was most likely sustained during physical therapy.
The physical therapy expert for the defense was critical of the gaps in documentation regarding the patient’s pain levels, treatment plans and post-injury care, as well as the overall lack of communication among the physical therapy team members. The use of an informal notebook to communicate clinical patient information was considered as a contributing factor to the lapses in communication in this case. Using informal methods to document patient information also may create defense challenges in litigation when the patient information is no longer available.
The expert noted that the PTA should have reported the patient’s new onset of severe pain to the primary PT, and that the primary PT should have communicated the updated plan of care to the PTA.
The patient had subsequent surgeries on the opposite hip and knee. The plaintiff’s expert witness linked all of the patient’s surgeries to the original labral tear, testifying that compensatory overuse on the opposite hip exacerbated a pre-existing CAM lesion. The plaintiff’s expert acknowledged that, while the PTA and the primary PT would not have known about the CAM lesion when treating, the PTA and primary PT should nevertheless have been more responsive to the patient’s complaints of pain during treatment.


Based upon the negative expert reviews and the lack of documentation, defense counsel did not believe that the lawsuit could be successfully defended. The parties agreed to mediation, and the claim was resolved on behalf of the primary PT, the PT business owner, and the PTA.
Total Incurred:  Greater than $1,000,0000
(Monetary amounts represent the payments made on behalf of the employed PT, the PT business owner of a private outpatient office and the insured PTA, as an employee of the PT practice.)

Risk Management Recommendations pertaining to Physical Therapy Assistants:
  • Refer all patients with a change in condition or increased pain to the supervising physical therapist for assessment prior to initiating or continuing therapy.
  • Document any new patient complaints of pain or change in condition in the healthcare information record.

Risk Management Recommendations pertaining to Physical Therapists:
  • Document all discussions with the patient and changes in treatment plans in the patient healthcare information record. Recognize patients’ medical conditions, subjective complaints, co-morbidities, and any additional risk factors that may affect therapy.
  • Communicate, coordinate, and document all aspects of patient care with the patient care team, including the results of the initial examination and evaluation, diagnosis, prognosis, plan of care, intervention, responses to intervention, changes in patient or client status relative to the intervention, reexamination, and episode of care summary.
  • Contact the referring provider for any new patient complaints, such as pain or swelling.

Risk Management Recommendations pertaining to PT Business Owners:
  • Adhere to the APTA Standards of Practice, including but not limited to, the following:​
    • Develop and implement a written plan for continuous performance improvement and quality of care relating to physical therapy services.
    • Develop and implement written policies and procedures that align with the APTA Standards of Practice, that are reviewed regularly and revised as necessary and that reflect the operation, mission, purposes, goals, objectives, and scope of the Standards of Practice for Physical Therapy.
  • Perform, at a minimum, annual performance reviews for each employee, including a review of errors, “near misses,” documentation, as well as directly observed competencies. Provide physical therapy staff with coaching and mentoring, as needed.
  • Ensure that clinical practices comply with standards endorsed by physical therapy professional associations, state practice acts and facility protocols.
  • Provide ongoing education for physical therapy assistants, upon hire and ongoing thereafter.
  • Ensure that appropriate job descriptions are in place, including supervisory expectations for all staff members.
  • Be knowledgeable about the levels of supervisory responsibility of a PT and know when it is acceptable for a PT to have general, direct or direct personal supervision of physical therapy assistants, physical therapy aides, physical therapy students and any other clinical providers working at your place of business.
These are illustrations of actual claims that were managed by the CNA insurance companies.  However, every claim arises out of its own unique set of facts which must be considered within the context of applicable state and federal laws and regulations, as well as the specific terms, conditions and exclusions of each insurance policy, their forms, and optional coverages. The information contained herein is not intended to establish any standard of care, serve as professional advice or address the circumstances of any specific entity. These statements do not constitute a risk management directive from CNA. No organization or individual should act upon this information without appropriate professional advice, including advice of legal counsel, given after a thorough examination of the individual situation, encompassing a review of relevant facts, laws and regulations. CNA assumes no responsibility for the consequences of the use or nonuse of this information.
This publication is intended to inform Affinity Insurance Services, Inc., customers of potential liability in their practice. This information is provided for general informational purposes only and is not intended to provide individualized guidance. All descriptions, summaries or highlights of coverage are for general informational purposes only and do not amend, alter or modify the actual terms or conditions of any insurance policy. Coverage is governed only by the terms and conditions of the relevant policy. Any references to non-Aon, AIS, NSO, HPSO websites are provided solely for convenience, and Aon, AIS, NSO and HPSO disclaims any responsibility with respect to such websites. This information is not intended to offer legal advice or to establish appropriate or acceptable standards of professional conduct. Readers should consult with a lawyer if they have specific concerns. Neither Affinity Insurance Services, Inc., HPSO, nor CNA assumes any liability for how this information is applied in practice or for the accuracy of this information.

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