Physical Therapy Case Study: Failure To Identify Complications Associated With Dry Needling

Summary

The patient was a 40-year-old male who presented to the insured PT with complaints of chronic neck and shoulder pain related to musculoskeletal injuries sustained in a motor vehicle accident three years earlier. Following the accident, he completed a course of physical therapy at another facility, which included dry needling, and he reported that this intervention was effective in improving pain management.

Approximately six months after discharge from that treatment, the patient self-referred to a new practice for continued management of persistent symptoms and was assigned to the insured PT.  An initial evaluation was performed, which identified a thin body habitus, marked cervical hypomobility in all planes, and tightness in the cervical parascapular musculature, upper trapezius, and levator scapulae. A treatment plan was established consisting of biweekly physical therapy sessions, including cervical joint mobilization, myofascial release targeting the upper trapezius, levator scapulae, and rhomboids, and therapeutic exercises designed to improve strength, function, range of motion, and overall flexibility. Over the following months, the professional relationship between the therapist and patient gradually became more personal, evolving into a friendship. The therapist began sharing personal information and engaging in frequent communication with the patient via text messaging, email, and social media. They also socialized outside of the clinical setting with friends.

On the date of the incident, the patient had been treated for approximately six months, with moderate improvement. While his shoulder pain had decreased, he continued to report intermittent muscle spasms and chronic neck discomfort. Based on his previous positive response, the therapist recommended dry needling-- a modality for which he had received appropriate training and demonstrated competency. Based upon their developing friendship, the PT offered to perform the dry needling as a “curbside” treatment and did not bill for or document a note in the healthcare information record. The procedure was explained verbally to the patient, including needle placement, what to expect in terms of pain relief and positioning. However, the PT did not discuss associated risks, assuming prior familiarity, and did not obtain written informed consent for the intervention. The patient verbally consented.

The PT performed dry needling to the cervical parascapular musculature using three 15 mm needles. Two needles were placed near the region of the glenohumeral joint, and one was inserted posteriorly in the subscapular area. No immediate complications were observed during or at the conclusion of the treatment session.

Approximately 30 minutes after the appointment, the patient contacted the clinic by phone and spoke directly to the PT.  He reported severe upper thoracic pain, rated 9/10, accompanied by shortness of breath. He noted that the pain was most pronounced with deep inspiration. Given the acute onset of symptoms, the PT advised that the presentation was likely attributable to muscle irritation resulting from compensatory overuse of adjacent musculature following relaxation of the upper trapezius and levator scapulae during dry needling. The PT informed the patient that the symptoms were unlikely to represent a serious complication and stated that, in the event of the rare occurrence of pneumothorax, symptom onset would not typically be expected until several hours after the procedure. The patient was advised to rest and apply heat to the affected area to alleviate presumed muscular irritation. He was also instructed to call and/or return to the clinic for further evaluation if symptoms persisted. Notably, this communication occurred late on a Friday afternoon, approximately one hour prior to the clinic closing. Approximately 30 minutes later, the patient made a second call to the clinic and spoke to the receptionist reporting that he continued to have ongoing pain and shortness of breath. The receptionist indicated that she would relay the message to the PT and informed the patient that the clinic was about to close. However, she was not aware that the PT had already left for the day, so not perceiving this as an emergency, instead conveyed the patient’s call to the PT the following Monday. Upon receiving the message, the PT attempted to return the call and was informed by a family member that the patient had been hospitalized for treatment of a pneumothorax. The patient required chest tube placement, and after seven days was discharged home in stable condition without residual injury related to the incident.
 

Risk Management Comments

Six months following discharge from the hospital, the patient (plaintiff) filed a lawsuit against the PT and the practice owner, alleging that the dry needling procedure was performed improperly and that the post-procedural management deviated from the applicable standard of care. The plaintiff’s PT expert opined that the therapist failed to recognize classic signs and symptoms of pneumothorax, resulting in a delay in appropriate medical intervention. The plaintiff claimed damages including pain and suffering, medical expenses, and lost wages.

The defense PT expert was unable to support the care rendered. The expert noted that the rapid onset of symptoms, combined with the patient’s thin body habitus—an identified risk factor—should have raised concern for a potential pneumothorax. The expert further opined that the PT should have directed the patient to seek immediate emergency medical care upon reporting chest pain and shortness of breath. Given the close temporal relationship between the procedure, symptom onset, and subsequent imaging confirmation of pneumothorax, the defense expert was unable to offer a favorable opinion on either liability or causation.
 
The PT acknowledged that the dry needling treatment was performed as a “curbside” favor for the patient, with whom he had developed a personal relationship. The absence of documentation in the healthcare information record, lack of written informed consent, and failure to generate billing or treatment notes for the date of service were identified as significant weaknesses in the defense of the claim.
 

Resolution

Defense counsel believed that the plaintiff’s expert’s criticisms could be compelling to a jury and that it would be plausible for jurors to conclude that the treatment did not align with the standard of care. Based upon this, as well as the lack of expert support for the defense, defense counsel believed that there was a limited chance for a successful jury verdict. The parties agreed to mediation, and the claim was settled on behalf of the PT.
 
Total Incurred: More than $195,000.
(Monetary amounts represent the payments made on behalf of the insured PT)
 

Risk Management Recommendations

• Conduct thorough informed consent discussions prior to engaging in treatment or performing procedures and document the discussion in the healthcare information record. At a minimum, informed consent discussions should include the following:
  • Known risks and benefits of the treatment/procedure, alternative options and the consequences of declining the suggested therapy.
  • An opportunity to ask questions and documentation of questions asked and answered.
  • Use of the “teach-back” method to ensure that the patient has a full understanding of what the treatment/procedure entails, and
  • Written confirmation that the patient agrees to the proposed treatment/procedure.
• Document all pertinent patient information in the healthcare information record in an objective, concise manner. Maintaining consistent, comprehensive, and timely documentation of treatment plans and other PT services provided is one of the physical therapist’s primary professional responsibilities, as noted in Principle 7E of the American Physical Therapy Association Code of Ethics for the Physical Therapist. Consider the following recommendations, among others, when documenting physical therapy notes:
  • Document patient assessments, equipment settings and operator of equipment, observations, communications, treatments, patient education.
  • Prior to initiating treatment, evaluate and document the patient’s skin integrity, neurological status, sensory status, as well as their ability to perceive pain and communicate with staff. 
  • Include the results of objective tests and any evaluation of the patient’s sensory, and cognitive status, if applicable.
  • Document reexaminations and revisions to goals/treatment plans, including data from repeated or new examination elements, to provide useful context for evaluating progress and modifying treatment plans.
  • Refrain from altering the healthcare information record and enter late entries only when pertinent to patient care.
• Seek opportunities for continuing education regarding dry needling and managing patient complications. See APTA Standards of Practice number IV. The Federation of State Boards of Physical Therapy (FSBPT) updated its dry needling competency framework in a 2024 report, reaffirming dry needling as an intervention within the physical therapy scope of practice and outlining recommended competency and training requirements. Chest pain and/or tightness, shortness of breath, and cough during or after thoracic/periscapular dry needling are key indicators of a potential pneumothorax.  A pneumothorax may be the result of improper needle placement or depth of insertion. It is critical for PTs performing dry needling to possess the knowledge and skills to not only perform the intervention safely, but also to promptly recognize and respond to potential complications.
• Avoid extending the professional boundaries. PTs must exercise professional judgment in all patient interactions outside of a professional setting, to avoid ambiguity in what is supposed to be a therapeutic, patient-centered relationship. Additionally, keep all treatment delivery within the clinic or office setting and during regular business hours to maintain a professional relationship to make it less likely that documentation, informed consent, patient education, follow-up care and information, and other crucial care steps are inadvertently omitted.
• Conduct clinical and operational practices that comply with state and federal standards and those endorsed by physical therapy professional associations, such as the American Physical Therapy Association (APTA) Standards of Practice.

 
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The information, examples and suggestions presented in this material have been developed from sources believed to be reliable as of the date they are cited, but they should not be construed as legal or other professional advice. CNA, Aon, Affinity Insurance Services, Inc., NSO, or HPSO accepts no responsibility for the accuracy or completeness of this material and recommends the consultation with competent legal counsel and/or other professional advisors before applying this material in any particular factual situations. This material is for illustrative purposes and is not intended to constitute a contract. Please remember that only the relevant insurance policy can provide the actual terms, coverages, amounts, conditions and exclusions for an insured. All products and services may not be available in all states and may be subject to change without notice.  Certain coverages may be provided by a surplus lines insurer. Surplus lines insurers do not generally participate in state guaranty funds, and insureds are therefore not protected by such funds.  The claims examples are hypothetical situations based on actual matters.  Settlement amounts are approximations. Certain facts and identifying characteristics were changed to protect confidentiality and privacy. Any references to non-CNA, non-Aon, AIS, NSO, and HPSO websites are provided solely for convenience, and CNA, Aon, AIS, NSO and HPSO disclaim any responsibility with respect to such websites. “CNA” is a registered trademark of CNA Financial Corporation. Certain CNA Financial Corporation subsidiaries use the “CNA” trademark in connection with insurance underwriting and claims activities.  This material is not for further distribution without the express consent of CNA.   Copyright © 2026 CNA. All rights reserved.
 
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