Treatment by physiotherapist of farmer's shoulder injury requiring surgery

Names have been removed to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person's actual name.

Parties involved

Mr A    Consumer / Complainant
Mrs A    Consumer's wife
Ms B    Provider / Physiotherapist
Dr C    Consumer's general practitioner
Dr D    Orthopaedic Surgeon
Ms E    Expert Advisor
Mr F    Physiotherapist at the physiotherapy clinic
Ms G    Physiotherapist specialising in orthopaedics and sports medicine
Dr H    Occupational Physician
Ms I    Barrister

Complaint

On 23 May 2002 Accident Compensation Corporation (ACC) forwarded to the Commissioner a complaint made to them by Mr A. His complaint concerned the standard of service Mr A received from Ms B, a physiotherapist at a physiotherapy clinic. On 5 July Mr A was referred to Advocacy Services South Island Trust for the purpose of resolving the matter by agreement between the parties. On 8 October, Advocacy Services advised the Commissioner that Mr A declined to meet with Ms B. The Commissioner decided that the matter warranted investigation.

Mr A's complaint was summarised as follows:

During the period 1 October to 19 November 2001 Ms B, physiotherapist, did not provide services of an appropriate standard to Mr A. In particular, Ms B did not refer Mr A for diagnostic investigations when the physiotherapy treatment he was receiving for a shoulder injury was proving to be ineffective.

An investigation was commenced on 28 November 2002.

Information reviewed

• Relevant clinical records from the physiotherapy clinic, Dr C and Dr D
• Copy of the policy for 'Reassessment/Review of Treatment' from the physiotherapy clinic's Treatment Guidelines, dated May 2001 and May 2002
• Independent expert physiotherapy advice from Ms E

Information gathered during investigation

Background

On 29 September 2001, Mr A, aged 59 years, slipped and fell heavily while sorting sheep in the yards on his farm. Mrs A informed me that they were at the end of a winter drought at the time, and the ground "was as hard as concrete". She said that her husband fell on to his shoulder and lay stunned. She advised him to lie where he was as she thought that he had broken his arm or leg. After a few minutes, Mr A said that he was all right and got up.

Dr C, Mr A's general practitioner, was unavailable on 29 September, so Mr A sought advice from a physiotherapist friend who recommended that he contact the physiotherapy clinic.

1 October 2001

Mr A saw Ms B, a physiotherapist employed at the physiotherapy clinic, on 1 October. Ms B is a registered physiotherapist who holds postgraduate qualifications.

Mr A reported moderate to severe shoulder pain and reproducible referred left arm pain when he turned his head to the left. Ms B tested Mr A for rupture of his rotator cuff tendon and concluded that he had suffered a rotator cuff sprain, rather than a rupture, with cervical spine involvement. Ms B noted that Mr A had a previous history of cervical and lumbar spine problems for which he had received osteopathic treatment.

Ms B's first treatment of Mr A's shoulder consisted of ultrasound therapy, soft tissue massage, manual traction, ice pack and electrical nerve stimulation. Tape was applied to his shoulder and advice given about position and exercise. She noted that the short-term goal was for Mr A to gain 90o of shoulder abduction in one week. The long-term goal was for Mr A to return to normal activities in six weeks. Ms B estimated that Mr A would require up to 12 treatments to reach the expected goals.

Ms B informed me that Mr A simply told her that he had fallen on to his shoulder. She said that if she had known that Mr A had "[Mr A] stunned on the ground, which was hard as concrete" (as reported to me by Mrs A), she would have been alerted to the greater possibility of a more severe injury.

Ms B informed me that the physiotherapy clinic does not have a formalised treatment plan for their patients, and Mr F, Ms B's employer, advised that "[the physiotherapy clinic] does have a formalised plan which is individualised to the patient and their problems". Ms B stated that the first time Mr A came into the clinic she discussed the sort of thing she would do for his shoulder and the investigations that would be done, if needed. She said that this is the standard information she gives to all patients. Ms B said that "treatment plans are recorded at the left margin on the flip side of the first treatment card". They note with symbols in the clinical records the various discussions and treatments. On the second page of the patient's clinical notes there is a 'TE' above a 'CG', which when ticked indicates that the proposed treatment has been explained (TE) and consent has been given (CG).

4 October 2001

Mr A next saw Ms B on 4 October. When Ms B tested his cervical spine and shoulder as part of her objective assessment (physiotherapist's assessment of patient's symptoms) plan, she found that he had tenderness on palpation and a click-like sensation deep in the shoulder. Ms B considered that these factors, combined with Mr A reporting a 50% improvement in function, "confirmed confidence in my initial diagnosis and that there was no need for further investigations".

Next six weeks

Over the next six weeks Mr A had nine treatments from Ms B. Her treatment plan changed from acute soft tissue management to one designed to strengthen and mobilise Mr A's shoulder. At the fourth visit on 10 October, Mr A developed full range of movement in the shoulder but experienced considerable pain when performing these movements. Mr A was instructed to follow the treatment plan at home. Ms B stated that Mr A reported "subjective and functional improvement" and that her objective assessments of his condition, which are noted in the section of the clinical record marked 'Clinical Tests', confirmed this.

Ms B informed me that each time a patient attends for an appointment, she commences the session with a subjective examination (patient's report of symptoms), which is followed by her objective examination. She said that her initials, and the subjective examination, are recorded on the title page of the patient record card.

Mr A informed me that during the time that he was being treated by Ms B he was concerned about his lack of progress and asked three times to be referred for diagnostic examination of his shoulder. He was of the opinion that if he had not "pushed" Ms B to refer him for a diagnostic X-ray and/or ultrasound scan, she was "quite prepared to leave [it] until after Xmas".

Ms B said that she remembers discussing with Mr A whether there was a need for referral, but does not remember exactly at what point in his treatment this occurred. Ms B said that Mr A did not specifically ask for an X-ray, an MRI or a referral to a surgeon, and his comments about this were more in line with a general enquiry. She said that all along Mr A was showing such good improvement, she did not think referral was warranted. She said that she felt at the time that he was happy with her explanations.

Ms B stated that Mr A continued to report improvement in the movement and function of his shoulder throughout the seven weeks that she treated him, but in his two appointments on 15 and 18 October he was bothered by the "symptoms coming from the cervical spine".

Mr A informed me that he did his exercises "religiously". He said it was his ambition to "get plenty of movement".

On 19 November Ms B noted that although Mr A was reporting an 80% improvement in his condition, he still had an intermittent ache in his left elbow and was not confident about his ability to resume heavy farm work. She noted that the long head of his left bicep tendon was thickened and painful on palpation and that the shoulder was painful when externally rotated. As these symptoms had been present for two weeks and his functional improvement had reached a plateau, Ms B decided that it was appropriate to refer Mr A for an X-ray and ultrasound scan.

Subsequent treatment

On 28 November Mr A had an X-ray and ultrasound scan of his left shoulder. The radiology department reported that the ultrasound and X-ray were "consistent with an avulsion of the subscapularis from its normal site". (The subscapularis is one of the muscles that forms part of the rotator cuff.) As a result of this report Ms B referred Mr A to his general practitioner for further assessment. A locum for Mr A's general practitioner, Dr C, referred Mr A to Dr D, an orthopaedic surgeon.

Dr D assessed Mr A on 6 December and ordered an MRI scan of his shoulder. In a letter to the locum dated 7 January 2002, Dr D stated that if the MRI confirmed a subscapularis full thickness tear, he would recommend surgical repair.

An MRI performed on 28 December 2001 confirmed that two-thirds of Mr A's subscapularis was torn and the long head of the bicep was displaced. Mr A stated that when he was given the result of the ultrasound examination on 29 November he told Ms B that there was fluid on the scapularis tendon. She replied that she could not believe that he had ruptured the tendon as he had too much movement.

Dr D arranged for Mr A to be admitted for surgery on 28 January 2002. However, the surgery was delayed until 7 February 2002, because Mr A had infected skin wounds on his forearms.

Additional information

Ms B advised me that over the course of Mr A's treatment he was informed that he would be referred for further investigation if it appeared necessary. Ms B stated that physiotherapists and general practitioners do not routinely request X-rays and ultrasound scans for patients presenting with shoulder problems, and that diagnoses and clinical decisions are reached by evaluating the physical findings and the information relayed by the patient.

Mr A saw Ms B on 5 and 19 November. Ms B informed me that when there was no further improvement in Mr A's condition at that time, she made a "fair clinical judgement", and referred him for X-ray and ultrasound investigation.

Review of practice

Mr F, senior physiotherapist at the physiotherapy clinic, informed me: "[A]t [Mr A's] age pre-existing partial tears are not uncommon. Partial tears do progress, and this is what I feel occurred in this instance." He stated that during the time that Mr A was receiving treatment he continued to actively work on his farm.

Mr A responded to Mr F's statement that he did not stop working during his treatment. Mr A agreed that he continued to work on his farm while he was attending the physiotherapy clinic. He did as much as he could with one arm, but employed people to do the heavy work and relied a lot on his wife.

Mr F said that as a result of Mr A's complaint, an internal review was carried out and an opinion on his treatment was sought from a musculoskeletal medicine specialist. The review "took the form of a presentation of an anonymous case history, examination findings, progress and changes". The specialist was asked to comment on the likelihood of a partial tear progressing through to a full tear in such an individual. Following a review of the information, the reviewer found that Mr A received a high standard of care from Ms B, and that his treatment was based on sound clinical reasoning, which was competently carried out. The reviewer concluded that there was no basis for Mr A's complaint, but did not provide a written report of his opinion.

The physiotherapy clinic's treatment guidelines

The physiotherapy clinic provided the following guidelines on reassessment/review of treatment which were in use at the time Mr A was treated.

"Reassessment/Review of Treatment - May 2001

1. Any patient whose condition reaches a plateau, and shows no improvement should be reassessed, to ensure that their treatment is still appropriate.

2. The patient should be informed that their treatment session for that day may consist primarily for a reassessment, rather than a full treatment session.

3. If the treating physiotherapist is unable to find a probable cause for the plateau in progress, or if they feel they need a second opinion due to the nature of the condition, then this reassessment should be done by another physiotherapist. In this instance, an appointment is made with the other physiotherapist for a full review. This treatment is documented on treatment card and then the physiotherapists will discuss the outcome of this assessment. The patient will then stay under the care of the initial physiotherapist, with a revised treatment plan if necessary.

4. Any patient who continues to fail to make progress, and who has been reassessed by a second physiotherapist, with no further recommendations resulting from this, should be referred back to their Doctor for review of their condition. In this instance the physiotherapist should contact the Doctor in writing or verbally to inform them of outcome to date, and the reason for concerns with progress. (Ref: Treatment Manual: Referrals and Outgoing Correspondence About Clients.)"

The policy was updated in May 2002, as set out below:

"Reassessment/Review of Treatment - May 2002

All patient treatments at the physiotherapy clinic are subject to continual review of progress. Patients who indicate that insufficient progress is being made in the status of their condition, should be reassessed, to ensure that the treatment provided is appropriate.

Procedure:

1. Patient may be reviewed for following reasons.

• Failure to improve after 7-10 treatments (plateau).
• Atypical presentation.
• Changes in presentation.
• Rate of change is less than expected.

2. The review may consist of :

• Internal informal discussion about the treatment with another physiotherapist.
• An internal 2nd opinion consisting of an examination by the other physiotherapist.
• An external 2nd opinion consisting of an examination by another physiotherapist, Doctor or for diagnostic evaluation (imaging).

Treatment reviews, assessments and recommendations are documented on the patient's treatment card.

3. Any patient who continues to fail to make progress, and who has been reassessed by a second physiotherapist, with no further recommendations resulting from this, should be referred back to their Doctor for review of their condition. In this instance the physiotherapist should contact the Doctor in writing or verbally to inform them of outcome to date, and the reason for concerns with progress. (Ref: Treatment Manual: Referrals and Outgoing Correspondence About Clients.)"

Independent advice to Commissioner

The following expert advice was obtained from Ms E, an independent physiotherapist:

"Re: Complaint File 02HDC07420/ ...

Thank you for inviting me to review the above file and provide the following report. The following documents were forwarded to me with your covering letter dated 14 February 2003:

A. [Mr A's] complaint forwarded to the HDC by ACC on 4 June 2002 (6 pages).

B. Notes taken during a telephone conversation with [Mrs A] on 27 November 2002 (1 page).

C. Clinical records for [Mr A] received from [Dr C], general practitioner (23 pages).

D. Clinical records for [Mr A] received from [Dr D], orthopaedic surgeon (6 pages).

E. Letter of response and accompanying documents from [Ms B], dated 23 December 2002 (11 pages).

Complaint

The complaint was that:

During the period of October to 19 November 2001 [Ms B], physiotherapist, did not provide services of an appropriate standards to [Mr A]. In particular [Ms B]:

• Did not refer [Mr A] for diagnostic investigations when the physiotherapy treatment he was receiving for a shoulder injury was proving to be ineffective.

Physiotherapy Treatment Provided by [Ms B]

• [Ms B] first assessed and treated [Mr A] on 1 October 2001, two days after [Mr A's] accident (29 September 2001). [Ms B] treated [Mr A] on ten occasions for the next approximate two months. Her final treatment was on 6 December 2001. Thereafter, [Ms B] was no longer involved in [Mr A's] physiotherapy treatment or management.
• The initial diagnosis made by [Ms B] was: rotator cuff strain, with cervical spine involvement. The subscapularis muscle is one of the muscles that are collectively known as the 'rotator cuff'. The subscapularis muscle's primary function is as an internal rotator of the shoulder joint. A diagram showing the subscapularis muscle is attached with this report.
• The physiotherapy treatment provided was to [Mr A's] left shoulder and neck, and included the following:
  • An initial assessment of [Mr A's] range of movement and pain, with subsequent assessments of this throughout the treatment period.
    
    
  • Shoulder and neck joint mobilisations (clinically known as manual therapy).
  • Icepack and TENS (transcutaneous nerve stimulation).
  • Ultrasound.
  • Exercises to increase ranges of movement in the shoulder and neck.
  • Exercises to increase the shoulder muscle strength.
  
  
  
• There is no documented evidence in [Ms B's] physiotherapy treatment notes that a 'lift off' test was performed at the initial treatment. A positive 'lift off' test is a Red Flag for shoulder injuries.

The 'lift off' test is positive if the patient is unable to push their hand away from their lumbar spine. A positive test indicates a major tear to the rotator cuff. The evidence I sighted does not, however, nominate this test as being a specific one for subscapularis tears. Despite this, the 'lift off' test should have been performed at the initial treatment. If positive, it would have been a clear indicator for early onwards referral.

• From [Ms B's] physiotherapy treatment notes, there was limited evidence of specific testing for an increase in the range of shoulder external rotation, or of a weakness in shoulder internal rotation, both of which could have raised the possibility of a subscapularis tear.
• [Ms B] recorded [Mr A's] reports of improvement (as a percentage) throughout the treatment period. The 19 November 2001 treatment record recording was: generally 80% better.

NB: [Mr A's] report to [Ms B] of improvement was in contrast to that reported by [Mrs A] (as per the telephone call in document B): [Mrs A] advised that ... the physiotherapy he received did no good.

• Although [Mrs A] (document B) reported that ... her husband asked [Ms B] three times to be referred for further examination ... these comments were not recorded in [Ms B's] treatment notes.
• On 19 November 2001 [Ms B's] treatment notes recorded her plan to refer [Mr A] for an x-ray and an ultrasound scan. The referral letter was dated 29 November 2001. [Mr A] duly had these investigations, and a subsequent MRI scan. [Dr D], orthopaedic surgeon, recommended the latter. The MRI finding was a subscapularis tear and a medial subluxation of the long head of biceps. [Mr A] went on to have a surgical repair on 7 February 2002. The surgical repair date was over two months after [Ms B's] onwards referral letter.

Summary of Physiotherapy Treatment Provided

• The treatment provided by [Ms B] did not evaluate or detect adequate history or clinical signs that may have led her to conclude that the subscapularis muscle was torn. There was, therefore, an unnecessary delay in her onwards referral for diagnostic investigations. Had the 'lift off' test been performed, and had the two critical points below received greater consideration, there would have been clear indication for an earlier onward referral. The two critical points were as follows:
  • A history of significant trauma, ie a fall onto hard ground, apparently leaving [Mr A] 'stunned'.
    
    
  • [Mr A's] age ie over 40 years. With age, there is a gradual deterioration in the integrity of the rotator cuff.

Physiotherapy Treatment Notes that may have indicated a possible Subscapularis Tear (in conjunction with a Subluxing Long Head of Biceps):

• 1/10/01: slipped and landed onto left shoulder
• 1/10/01: resisted biceps testing produced pain++
• 1/10/01: HBB (hand behind back) to hip produced pain++
• 4/10/01: palpable click ? deep in shoulder
• 6/10/01: act ( active) flex ( flexion) painful arc, with hitching at 90 degrees
• 30/10/01: thickening Hd (head) biceps
• 5/11/01: initial clicking still (present).

Typical Clinical Presentations for Subscapularis Tears and Related Comments

• A number of key points in the history are relevant for the early detection of subscapularis tears. These are as follows:
  • A history of significant trauma. As per document B, [Mrs A] advised that ... her husband ... slipped ... and fell onto the ground ... the ground was as hard as concrete. ... Her husband fell onto his shoulder, and lay there stunned. She said that she told him to stay where he was as he was unsure whether he had broken his arm or leg. The aforementioned indicates significant trauma.
  • The typical age for such tears is greater than 40 years. [Mr A] was 59 years of age at the time of his accident.
  • There is reduced range of shoulder movement and, in particular, a loss of internal rotation strength.
  • The 'lift off' test cannot be performed.
• Referral to a specialist should ideally be within the first ten days, although initial treatment should include rest, anti-inflammatory medication and physiotherapy.
• Optimally, surgery should be performed within the first three weeks post-injury. In [Mr A's] case, surgery was performed over four months post-injury.
• There is a consensus in the literature that the best treatment for subscapularis tears is surgery, but results are variable.
• The subscapularis muscle is not accessible to observation or palpation, so the clinician needs to gauge other muscles' action to produce internal rotation. Internal rotation is the subscapularis muscle's primary action. Pectoralis major is the primary internal rotator muscle of the shoulder.
• Subscapularis tears are less frequent, compared with other specific muscles within the rotator cuff. [Dr D] also recorded this in his letter to the HDC (3 December 2002) ... subscapularis tears are uncommon.
• Some sources state that the prognosis for subscapularis tears is less favourable compared with supraspinatus and infraspinatus tears. The latter two are the more commonly torn in the rotator cuff.
• Clinically, subscapularis tears can be poorly able to be recognised and, as such, there is often a frequent delay in presentation to surgery.
• An isolated subscapularis tear is considered to be rare, and it is usually in conjunction with a subluxed biceps tendon. [Mr A] had the latter too.
• In a non-surgical, conservative-treatment study cited, the patients were treated conservatively and 'improved so substantially' that it was felt surgical treatment was not required. These patients had a number of similar features to those of [Mr A], and were as follows:
  • A delayed presentation (average 31/2 months).
  • Significant night pain.
  • Older age group (mean of 61 years).
  • History of trauma.
  • Had full thickness tears. They did not, however, have subluxed biceps tendons.
  • Their physiotherapy treatment included accessory joint mobilisations and strengthening exercises.
  • At three months post-treatment review, all patients were asymptomatic, apart from a decrease of internal rotation and a decrease in 'lift off' strength. This indicated a sound functional outcome, with some returning to full tennis play (including serving).

Other Relevant Details

• Although it has been concluded (retrospectively) that the physiotherapy treatment [Mr A] received for his shoulder injury was not of an appropriate standard, the following points should be noted:
  • Pain is a subjective emotion, and its reports vary greatly from patient to patient.
  • [Ms B's] onward referral letter (to [Mr A's] GP) was dated 29 November 2001. Although this was two months post-injury, it was not until over one month later that [Dr D] made his decision to undertake a surgical repair (as per his letter to [the locum], dated 7 January 2002). And, it was a further one month before the surgery was actually performed. I note a 'last moment' delay of a few days in surgery due to an unrelated skin infection (as per [Dr D's] letter to [Dr C] dated 28 January 2002). This two-month delay is noteworthy in terms of soft tissue healing time frames.
  • Although the optimal three weeks post-injury for surgery did not occur, the additional two months post-diagnostic investigations (ultrasound scan, etc) is unlikely to have assisted achieve a satisfactory outcome. The additional two-month period was obviously well outside of [Ms B's] control, treatment provision or patient management. I am of the opinion that this factor is a relevant one to consider in the overall complaint against [Ms B].
  • It appears [Mr A] sought to register his formal complaint (initially to ACC) when he became ... frustrated by his slow progress 12 weeks after his subscapularis repair (as per letter to [Dr C], [Dr D], dated 1 May 2002). [Mr A] did express some dissatisfaction earlier though. This was evident in [Ms B's] letter to [Dr D] (dated 8 March 2002), where she wrote ... [Mr A] has intimated to me that earlier detection of the subscapularis tear would have improved the outcome of his surgery (document E).
  • [Ms B] went on to comment that ... I would like to take this opportunity to explain to you that the rationale for the timing of [Mr A's] x-ray and ultrasound. There had been a steady functional improvement from clinical and occupational perspectives up until mid November but at this point his improvement plateaued. I therefore did not hesitate to initiate further investigations.
  • It is not possible to comment on whether the slow progress was due to the delay in the surgical repair, [Mr A's] personal tolerance of his shoulder pain and dysfunction, or other factors.
• [Ms B's] treatment notes record that [Mr A] did achieve a full range of shoulder forward flexion. Achieving this may be a deceptive and confounding factor/clinical sign with regard to a subscapularis tear.
• With the involvement of [Mr A's] neck in the initial injury, a moderate amount of [Ms B's] treatment was applied to [Mr A's] neck. As [Ms B's] initial assessment that there was 'cervical spine involvement' too, it was clinically appropriate that her treatment was also to the neck. There may have been treatment days when [Mr A's] neck may have warranted more clinical attention than his shoulder. There is often an overlap between shoulder and neck pathology signs and symptoms. Clearly differentiating between them can be a clinical challenge.

Commendations on [Ms B's] Physiotherapy Treatment

• [Ms B's] clinical notes were clear, well documented, and signed.
• [Ms B's] notes followed her initial treatment plan, and each treatment was documented (as appropriate), under Subjective, Objective, Treatment and Plan headings. Reviews of shoulder function were also recorded.
• [Ms B] appeared to follow recognised procedures for clinical reasoning in that, once no further improvement was evident, her clinical decision was to refer [Mr A] for further diagnostic investigations (documented in [Ms B's] notes on 19 November 2001).
• [Ms B] has completed a recognised post-graduate qualification in musculoskeletal physiotherapy, namely a Diploma of Manual Therapy.

Summary Response

• From the documentation provided by the HDC, my clinical experience and professional opinion, and the references cited, I conclude that [Ms B's] physiotherapy services were not of an appropriate standard. In particular, [Ms B] did not refer [Mr A] for further diagnostic investigations (eg an ultrasound scan) within ten days of his injury, nor did she make a referral to an orthopaedic specialist during that ten-day period. Had she performed the 'lift off' test, in conjunction with the two critical points of [Mr A's] initial presentation, namely his history of significant trauma and his age, the need for diagnostic investigations and onwards referral should have been apparent.
• Despite the above conclusion, [Ms B] physiotherapy treatment appeared to be professional and thorough. It is my opinion that [Ms B's] failure to detect a subscapularis tear (and hence the need for diagnostic investigations) was an unfortunate clinical oversight on her part. It may be all too 'easy' to see this oversight retrospectively. It was not a major departure from recognised standards of care. [Ms B's] conduct is likely to incur mild disapproval by her peers. She did not overtly indicate a lack of responsibility to the consumer (her patient, [Mr A]) or demonstrate a breach of ethical standards.

References Cited

ACC GP Treatment Profiles 2001.

Gerber CJ. Complex and Revision Problems in Shoulder Surgery. Lippincott-Raven, Philadelphia. Chapter 2: 9-18, 1991.

Kapandji IA. The Physiology of the Joints, Volume One, Upper Limb, 5th Edition.

Rosen's Emergency Medicine Concepts and Clinical Practice, 5th Edition, Editor-in-Chief J.A. Marx, 2002.

Watson L. Australian Clinical Educators. Advanced Shoulder Course Manual, 2001."

Responses to Provisional Opinion

Ms B's response

In response to my provisional opinion, Ms B stated:

"I wish to comment in particular on:

1. The lift off test

2. The degree of trauma involved

3. The 10 day threshold

4. The perceived effectiveness of my treatment.

(1) The lift off test

The lift off test is not considered a stand alone test. It is not taught in the musculo-skeletal component of the Degree of Physiotherapy, University of Otago (refer to G Sole University of Otago 24 July 2003). It is also not included on the recommended text 'Neuromusculoskeletal Examination and Assessment' by N Petty and A Moore. Validation of this test has not been established (pers comm. Tony Schneiders Lecturer University of Otago) and it has low specificity (Leroux J L et al).

To perform the lift-off test the patient must place the hand behind the back against the lumbar spine and then be able to push his hand away against resistance (Silliman J and Hawkins R). [Mr A] could not place his hand against his lumbar spine due to pain and high irritability (refer to [Ms G] University of Otago 24 July 2003). Internal rotation as in this test, drives the humeral head up against the acromion, coraco-acromial ligament and coracoid process producing compression on the structures that lie below. In clinical practice performing this test can be painful, weak or unachievable for patients with conditions such as rotator cuff strains, acute tendonitis, calcific tendonitis, and bursitis, all conditions that are seen in any musculo-skeletal physiotherapy clinic.

Diagnosis and clinical decisions are very rarely made by relying on one test. They are established by evaluating the subjective examination, the objective examination and applying clinical reasoning.

(2) The degree of trauma involved

On reading the report it is clear that on his first appointment [Mr A] significantly understated the degree of trauma involved. ... From my notes and recollection [Mr A] simply told me he fell to the ground, landing on his shoulder.

(3) The 10 day threshold

I was surprised to see [Ms E] place so much weight on referral within ten days and I would like to know what this is based on and its validity. In your opinion you accept this view that in not referring [Mr A] within 10 days, I did not provide physiotherapy services of an appropriate standard. Referral in these circumstances within an arbitrary 10 days is simply not realistic or practicable. Warner JJ et al in their paper 'Diagnosis and treatment of anterosuperior rotator cuff tears', studied 19 patients who had subscapularis tears. The outcome of surgery was variable and they reported repair before 6 months of symptoms is associated with better functional outcome.

I agree with [Ms E] that subscapularis tears are rare (Smith K L et al and Warner JJ et al) are poorly recognized and consequently there is often a delay in presentation to surgery (page [10] HDC report). In this case [Mr A's] diagnosis was further complicated by his cervical spine involvement.

(4) The perceived effectiveness of my treatment

Another very significant factor which I believe may have led me to initially not diagnose [Mr A's] partial tear, was what he told me at his second and third treatments and I suggest that this has not been given sufficient weight. [Mr A] reported at his second treatment that he was 50% better with improved shoulder function. At his third treatment 8 days after his fall he reported further improvement. This is not the sort of result I would have expected of a patient with a tear as severe as [Mr A's] was subsequently proven to be.

Your report includes a reference to [Mrs A] saying that the physiotherapy treatment 'did no good'. However I never spoke to [Mrs A] and could only go by what my patient reported and my subjective findings. I cannot understand why [Mr A] would report such significant improvement to me while indicating the opposite to his wife. On more than one occasion [Mr A] happily and voluntarily reported his improvement to the clinic receptionist [ ... ].

When I referred [Mr A] for investigations he was reporting an 80% overall improvement but his improvement had plateaued and specifically external rotation of the shoulder remained limited and painful and there was thickening and tenderness over the long head of biceps. Had the treatment been ineffective, especially from [Mr A's] viewpoint I definitely would have referred him earlier.

With reference to my comments above and the supporting information I do not accept that I have breached Standard Fourteen of The New Zealand Society of Physiotherapists, Standards of Practice."

Ms B also provided a short statement from Ms G, a physiotherapist who specialises in orthopaedics and sports medicine. Ms G stated, in support of Ms B, that "subscapularis muscle tears are not common and are easily missed, even by the experienced clinician". She said:

"The lift-off test is not included in the book by N Petty and A Moore, 'Neuromusculo- skeletal Examination and Assessment' ... We teach the test at post-graduate level, but not as a routine test. If the history indicates that there may be a subscapularis lesion and if the severity and irritability of the pain allows, the test may be included in the physical examination."

Mr F's response

In his response to my provisional opinion, Mr F stated that Mr A's complaint that Ms B did not refer him for diagnostic investigations when the physiotherapy treatment he was receiving for a shoulder injury was proving to be ineffective is "not founded in fact". Mr F stated:

"[Mr A] showed strong positive gains from treatment which he acknowledged to [Ms B] and clinic staff. It is also recorded on his clinical notes. At the point where no further gains were resulting, he was referred for the appropriate investigations. It is my assertion that Standard fourteen: Standards of Clinical Practice of the New Zealand Society of Physiotherapists' Standards of Practice July 2002 have not been breached."

Mr F disputed Ms E's statement, "A positive lift-off test is a red flag for shoulder injuries". Mr F stated: "No evidence of any controlled trials or any evidence of any description that the lift-off/Gerber test has been clinically validated was found." He said that there is "a paucity of any supporting research ... that supports [Ms E's] assertion that the lift-off test is a valid and reliable test for subscapularis injury".

In support of his submission, Mr F provided a statement from Dr H, occupational physician. Dr H stated:

"My own experience as an Occupational Physician with 26 years of experience is that the Gerber lift-off test is unreliable and poorly reproducible for diagnosing subscapularis pathology. Whilst there is no specific literature on this particular test, my own view is that the test would attract a kappa score of slight to poor.

In conclusion I do not believe that the omission of the Gerber's lift-off test is a significant issue particularly as other tests for the medial rotators were carried out. Since this test is not diagnostically reliable the lack of provision of the test cannot be seen as failure to provide appropriate care. In my opinion there is no evidence-based literature to support this test as a gold standard. I agree that whilst EMG work does indicate that subscapularis is active in this test, but clinically the test lacks reliability and validity and can be confounded by a number of factors both physical and psychological."

Mr F said that Ms B's "assessment [of Mr A] was appropriate and referral was made once improvement had plateaued".

Mr F questioned Ms E taking account of Mrs A's statements about her husband's condition throughout the physiotherapy treatment and that he had asked three times to be referred for further examination. Mr F stated: "[Mrs A] was not present at the clinic at the initial or any other treatment session."

Mr F pointed out that there was a variance in Mr A's report of circumstances of the injury and that of his wife. Mr F commented that Mr A's description of the events to Ms B took place two days following the event, but Mrs A's report was made a year later.

In relation to Ms E's comments about Ms B's recording in her physiotherapy treatment clinical notes "limited evidence of specific testing", Mr F stated:

"Clinical notes are clinical notes and record deviations from the expected norm and/or from the comparisons of the opposite side. When a difference is found, it is noted. It is not standard practice to record everything about a person that is normal. If there were a difference at the time of the examination of the complainant's joint range and/or muscle power, it would have been so noted."

Mr F disputed Ms E's comment that there were points notes in Ms B's treatment record "that may have indicated a possible subscapularis tear". Ms E listed those points in her advice. He stated: "The points [Ms E] sees as indicative, are neither unique nor definitive of a subscapularis tear."

Ms I, barrister, also responded on behalf of Mr F in response to the provisional opinion. Ms I stated:

"All references to [Mrs A's] view of the injury and of what happened at the consultations should be deleted from the report. As a matter of natural justice it is simply too dangerous to rely on the opinions of [Mrs A]. That is because:

• The account is very delayed;
• [Mrs A] did not attend any of the consultations;
• [Mrs A] has no clinical expertise so as to be able to assess the adequacy of the care;
• She may be biased."

Ms I stated that Ms E appeared to have been led into error by Mrs A's account of the circumstances of the injury as a "significant trauma". She stated: "There is no good evidence that can defeat [Ms B's] assertion that [Mr A] did not present as having suffered a significant trauma."

Ms I submitted that the physiotherapy clinic is not vicariously liable for Ms B's failure to refer Mr A within ten days of the injury.

Ms I noted that Mr A declined to meet with Ms B and Mr F when this matter was referred to Advocacy Services South Island Trust for resolution. She stated: "It appears that the lack of involvement of [Mr A] has caused problems in the investigation of this matter."

Mr A's response

In his response to the provisional opinion Mr A stated that he was asked by an advocate if he wanted to meet with Ms B. He told the advocate that if he did meet Ms B, he was not prepared to go down to her and would prefer her to come to his home. He said the invitation to meet was never formalised.

Further independent advice to Commissioner

The following further independent physiotherapy advice was obtained from Ms E:

"Thank you for your letter dated 10 September 2003, inviting me to respond to aspects of my March 2003 report.

Enclosed with your letter were the following documents:

• Health and Disability Commissioner's provisional opinion dated 15 July 2003 (15 pages).
• Letter from [Mr F] dated 23 July 2003 (7 pages).
• Letter from [Ms B] dated 4 August 2003 (9 pages, including supporting documents).
• Letter from [Ms I], Barrister dated 29 August 2003 (5 pages).
• Letter from [Dr H] dated 16 August 2003 (3 pages).

I am returning the above documents with this report.

You have asked if there are any aspects of [Ms B's] and [Mr F's] responses that have caused me to review my earlier advice. In particular, you have asked that I comment on three areas.

1. The significance of the 'lift-off' test and, was this case a situation where the 'lift- off' test could not be undertaken;

2. The standard of the clinical records in relation to accurately recording the clinical picture; and

3. The clinical guidelines that recommend referral for imaging and/or orthopaedic assessment within ten days of injury.

Although not specifically requested, I have also provided comment on two further points.

4. My reference to [Mrs A's] comments; and

5. My qualifications to review physiotherapists' clinical care and notes.

In preparation for this report I undertook further literature searches, consulted with two further experienced musculoskeletal physiotherapists (whose post-graduate qualifications include Diploma of Manipulative Therapy, Diploma of Mechanical Diagnosis & Therapy, Diploma of Ergonomics, and who have accredited physiotherapy practices), and an orthopaedic surgeon with extensive shoulder injury expertise (the surgeon has been in practice for 35 years). The physiotherapists I consulted were in addition to those I consulted as part of preparation of my March 2003 report.

1. 'Lift-off' Test

Diagnostic issues

I fully agree with [Dr H's] statement (16 August 2003) that ... the truth in musculoskeletal medicine diagnosis is that many of the tests that doctors and physiotherapists commonly use do not have reliability. This applies to the 'lift-off' test. As the orthopaedic surgeon I consulted advised, even with an ultrasound scan, only 70% of subscapularis muscle tears are identified; 30% are missed. Furthermore, he advised that 5-10% are missed with MRI.

These opinions confirm my earlier advice that subscapularis muscle tears are often not clinically recognised. They are considered not to be common; this probably contributes to the fact that frequently there is delayed presentation to a surgeon.

Literature references and clinical experience

While I accept the evidence (including references) provided by [Mr F], [Ms B] and [Dr H], I wish to add the following information and references relating to the importance of the 'lift-off' test:

• Ambacher & Holz (2002) studied subscapularis tendon ruptures. They wrote that ... typical clinical signs for a subscapularis lesion are the 'lift-off' test. They also commented that ... subscapularis tendon ruptures are rare injuries and are often missed initially.
  
  
• Clark et al. (2003) studied traumatic rupture of subscapularis tendons. They concluded ... the 'lift-off' test can isolate a subscapularis injury ... increased vigilance during the history and physical examination is necessary to detect these injuries.
  
  
• Gerber & Krushell (1991) found that ... a simple clinical manoeuvre called the 'lift-off test' reliably diagnosed or excluded clinically relevant rupture of the subscapularis tendon ... clinical diagnosis was best achieved by ultrasonography or MRI.
  
  
• Greis et al. (1996) studied validation of the 'lift-off' test and analysed subscapularis activity during maximal internal rotation. They concluded ... this study demonstrates the importance of the subscapularis during the 'lift-off' test and suggests that other potential internal rotators of the humerus have a limited role in maintaining internal rotation when the arm is placed behind the back.
  
  
• Picard et al. (1998) studied a particular surgical procedure for shoulder and stability, and commented ... internal rotation was assessed by the 'lift-off' test.
  
  
• Travis et al. (2001) studied subscapularis tendon repairs. Their diagnostic measures included a positive 'lift-off' test, combined with appropriate imaging. They commented that using these methods ... will lead to an early diagnosis.

Further studies indicate that there are situations where the 'lift-off' test cannot be reliably performed.

• Burkhart & Tehrany (2002) reported on arthroscopic subscapularis tendon repairs, commenting that ... the 'lift-off' test could not be performed reliably due to pain or restricted movement in 19 of the 25 patients.
  
  
• Hertel et al. (1996) studied what they termed 'lag' signs in the diagnosis of rotator cuff rupture, and found that ... the internal rotation lag sign (IRLS) was compared with the Jobe (a rotator cuff test) and the lift-off signs for the subscapularis tendon ... the IRLS was as specific but more sensitive than the lift-off sign. Partial ruptures of the subscapularis tendon could be missed by the lift-off sign but were detected by the IRLS.
  
  
• Vidil & Augereau (2000) studied surgery relating to irreparable subscapularis muscle tears, and found that ... the 'lift-off' test was positive for those patients for whom it could be performed. The study concluded that there were circumstances that precluded their patients being able to perform the 'lift-off' test.

The findings of the above three studies are in line with my clinical experience and with my communication with the orthopaedic surgeon. When certain musculoskeletal injuries first present, acute inhibition of soft tissues may hamper a clinician's ability to carry out the 'lift-off' test. When acute, there may be a painful block to attempted active movement testing and, even if the 'lift-off' test were carried out, its results may not be able to be accurately interpreted due to generalised shoulder pain and weakness. Accordingly, I concur that there are situations where the 'lift-off' test cannot be reliably undertaken. In these situations, the patient's history and mechanism of injury and other assessment and evaluation tools are used by the clinician to form a diagnosis.

'Lift-off' test training

I understand (letter to [Ms B] from [Ms G], School of Physiotherapy, University of Otago dated 24 July 2003) that the 'lift-off' test is now not taught at undergraduate physiotherapy level at the University of Otago. [Ms G] added that it is taught at post-graduate level, but not as a routine test. It may not have been taught when [Ms B] studied for her post-graduate Diploma of Manual Therapy. By contrast, the principal lecturer at the School of Physiotherapy, Auckland University of Technology advised me that the 'lift-off' test is currently taught at both under and post-graduate levels at the Auckland University of Technology, and that the article by Greis et al. (1996) is used to support its validity.

Evidence-based medicine

Although there is no evidence-based medicine supporting the 'lift-off' test in the Cochrane Collaboration (as [Mr F] correctly pointed out), in a clinical role physiotherapists often have to rely on the best available consensus literature. The GP Treatment Profiles are an example of this. Cormack's (2002) article on evidence-based practice states that many questions related to physiotherapy practice have not been asked and/or answered in the Cochrane databases. Furthermore, Cormack (2002) states that while many clinicians may be under the misconception that evidence-based practice is based solely on data obtained from research, it also includes clinical expertise and patient values. Evidence derived from research is the crucial component however.

Both musculoskeletal physiotherapists I consulted advised that they routinely use the 'lift-off' test at some stage of their early clinical management, but they also acknowledged that when the patient first presents it may not be possible to carry out the test. My view is that it seems possible that it would have been feasible to carry out the test during subsequent treatment(s).

Initial presentation and degree of trauma

[Ms B's] letter dated 4 August 2003 states that ... [Mr A] could not place his hand against his lumbar spine (as is required as part of the 'lift-off' test) due to pain and high irritability. This indicates that this is a situation where the 'lift-off' test could not be undertaken, that is, not at the first treatment.

I am unclear, however, as to the degree of trauma of [Mr A's] initial presentation. In her letter of 4 August 2003, [Ms B] comments on the high irritability of [Mr A's] initial presentation. [Mrs A] had also reported that [Mr A's] fall was severe (apparently leaving [Mr A] 'stunned'). By contrast, on the second page of her 4 August 2003 letter (under heading (2) 'The degree of trauma involved'), [Ms B] states that had she known the degree of trauma she would ... have been alerted to the greater possibility of a more severe injury.

I agree with [Mr F] that there appears to be a disparity between what has been recorded about the degree of the initial injury. Unfortunately, at this stage of the investigation, it is unlikely that accurate information on the severity of [Mr A's] fall can be obtained. From the information I have been provided with, the injury appears to be one that could have pointed towards a muscle tear or rupture.

Summary and conclusion relating to 'lift-off' test

There is clearly mixed opinion among clinicians and in the literature with regard to the application of the 'lift-off' test, and its validity has not been widely demonstrated. The consensus appears to be that it is a recognised and valuable test for subscapularis muscle tears. Each patient is an individual case, however, and physiotherapists use clinical reasoning to develop a treatment programme.

Without accurate knowledge of the degree of trauma at the initial presentation, I cannot comment as to whether this was a situation where the test could not have been undertaken. I take the view though that if the initial presentation was one of high irritability as [Ms B] commented, and as severe as reported by [Mrs A], acute soft tissue inhibition is likely to have precluded [Ms B's] ability to carry out the 'lift-off' test. If the test could not have been carried out at the first treatment, it may however have been possible to carry it out at a subsequent treatment.

2. Clinical Records

I wish to repeat that [Ms B's] treatment notes were clear, well documented and signed. They appear to have accurately recorded the clinical picture.

I have two additional comments to make.

• The notes stated that there was steady improvement functional movements (15 October 2001). There is no objective qualification as to what functional movements had improved, e.g. those related to every day or farm activity (the latter would be a more objective measure of the extent of [Mr A's] improvement).

  The clinical notes of 19 November 2001 record that [Mr A] was ... generally 80% better. This does not indicate whether [Mr A] was 80% pain free, or whether his ability to carry out his usual farm work was 80% improved.

  It is my clinical experience that patients may report they are 'x %' better, but this is often interpreted as being 'x %' pain free. It is important to objectively record functional recovery.

• There is no record in the notes that [Ms B] had discussed [Mr A's] treatment with [Mr F]. [Ms B] states in her letter to [Mr A], dated 24 January 2002 ... I had discussed your care during the course of your treatment with my colleague [Mr F] who agreed with my course of action.

  I note that the physiotherapy clinic's 'Reassessment/Review of Treatment - May 2002' policy states Treatment reviews, assessments and recommendations are documented on the patient's treatment card. The policy also states that this applies to informal reviews. I could find no record of an internal clinical review in [Ms B's] notes, although the review may have occurred after [Mr A] was referred on to the specialist.

3. Clinical Guidelines Recommending Imaging and/or Orthopaedic Assessment within Ten Days

Evidence-based practice and treatment profiles

Evidence-based practice is certainly the desired clinical approach in physiotherapy, as it is in the wider medical field. It is unfortunate that we do not yet have recognised evidence-based guidelines in New Zealand for all conditions that medical and paramedical professions treat. In a number of cases, therefore, we have to rely on current, consensus-based ones.

The ACC GP Treatment Profiles (2001) denote a Red Flag for rotator cuff (R/C) tears. The subscapularis muscle is one of the rotator cuff muscles. The treatment profiles state:

If patient cannot push hand away from lumbar spine region, this indicates a major tear of R/C.

Under Key Points in the same section, the following is included:

• patients > 40 with a significant shoulder injury are more likely to have a tear of their R/C
• referral to a specialist should be made early if a significant R/C tear is suspected
• the ability to repair surgically an R/C tear diminishes with time (window of opportunity to surgically repair is optimally in the first 3 weeks).

A medical advisor at ACC Healthwise informed me that the section of the treatment profiles relating to rotator cuff injuries was largely developed by the New Zealand Orthopaedic Association. I contacted their executive director, but unfortunately he did not have copies of the relevant supportive literature, and I have not been successful in contacting the key contributors. This could be done if required.

Further to this, the May 2003 issue of ACC News (distributed to all treatment providers by ACC Healthwise) included a brief section on rotator cuff injury management. I quote:

Rotator cuff and ultrasound. Ultrasound is ACC's preferred technique for investigating potential rotator cuff injuries. Please use it wherever possible for patients presenting with this condition.

I am cognisant that the GP Treatment Profiles are not rigid prescriptions, and that they include choice in clinical judgement according to patients' individual circumstances. That aside, if a Red Flag is included, this warrants immediate clinical attention.

The ACC Physiotherapy Treatment Profiles (2000, Sections 3.0-3.12) do not cover all the conditions that physiotherapists treat, only the more common ones. As subscapularis muscle tears are not common, they are not mentioned in these profiles. The ACC Physiotherapy Treatment Profiles (2000) do not include the 'lift-off' test. Rotator cuff sprain is included (Section 3.7), but there is no specific guidance included that would have assisted [Ms B] in this case. It is unfortunate that there is not consistent information, e.g. relating to Red Flags, in the GP and in the Physiotherapy Treatment Profiles. I can only presume that this is due to the general assumption that physiotherapists' training and experience in musculoskeletal diagnosis and treatment is greater than that of GPs.

Onwards referral and surgical timing

According to Watson (1999), a surgical dilemma exists relating to rotator cuff tears. Watson (1999) noted that, in recognition of the potential diagnosis of a tendon rupture (rather than a tendonitis), the diagnosis should be clarified as soon as possible so that surgical intervention may be implemented if necessary. One of the main reasons for this is that the torn tendon portion relatively quickly retracts with resulting loss of tendon extensibility. This can render the surgical repair less than ideal, in particular as the rotator cuff has a tenuous blood supply. Watson (1999) continues by saying that if good clinical gains are made, then the patient can continue to be managed conservatively, i.e. without surgical intervention.

Gerber et al.'s (1996) research findings commented that the diagnosis was made for each patient on the basis of the clinical examination, and was confirmed by imaging studies and operative exploration. The results were less successful when there was an increased delay from the time of the injury to the time of the operative repair.

Zanetti et al. (1999) commented that subscapularis tears should be looked for specifically in patients older than 40 years. In my March 2003 report I mentioned the importance of [Mr A's] age as a factor that may have indicated a muscle tear; that was, in conjunction with the reported history of significant trauma, i.e. a fall onto hard ground, apparently leaving [Mr A] 'stunned'. Watson (2001) cautioned that in such situations (as I understand [Mr A's] appeared to be), a decision on further clinical management should be made only in the hands of an experienced surgeon, so that unacceptable delays of tears that require surgical repair do not occur.

Pfirrmann et al. (1999) wrote that magnetic resonance arthrography is accurate in the detection and grading of subscapularis tendon lesions.

[Dr K's] letter dated 7 January 2003 to [the locum] (for [Mr A's] GP) stated … subscapularis injuries have a poor prognosis in the majority of cases treated non-operatively and it is best to get on and repair these structures sooner rather than later. I note that this letter was written after [Mr A] had completed his physiotherapy treatment.

Practically, there is often a time lag between when a muscle tear is suspected, e.g. by a physiotherapist, until the patient sees a specialist. This is influenced by the time it takes for a referral and appointment to be made with the GP, for an appointment to become available with the specialist, for an imaging procedure appointment to be made and, in a number of situations, for funding to be approved (e.g. by ACC). In the light of the aforementioned comments, I agree with [Ms B] (4 August 2003, second page (3) 'The 10 day threshold') that onwards referral is not realistic or practical, i.e. even if imaging and/or orthopaedic referral is made within 10 days. The actual time before a patient can have imaging and/or see an orthopaedic specialist is usually a number of further days (or indeed can be weeks).

Neck involvement

[Ms B] found [Mr A's] shoulder condition was compounded by his neck (cervical spine) involvement and symptoms. This is not an unusual clinical scenario. As a result, a portion of the treatments given included those to the neck. The only comment I have in relation to this is that with the limited time available at each treatment session, the physiotherapist usually focuses the treatment on the key area that presents on that day; the key area may vary for each treatment. From what I read in [Ms B's] treatment notes, the neck received similar amounts of attention to that which the shoulder received. Her clinical reasoning for this appears to be sound. This may have impacted on the timing for referring [Mr A] onto a specialist.

Onwards referral within ten days

Unfortunately I have been unable to find the reference from which I drew the comment in my March 2003 report that … referral to a specialist should ideally be within the first ten days.The research I have carried out in preparation for this report indicates that onwards referral should be within three weeks. References supporting this include the ACC GP Treatment Profiles, Watson (1999), Watson (2001), and Rosen (2002). Early onwards referral is best practice. I am forced to conclude that I may have made a documentation error, and I apologise for the concern that has arisen in relation to this. This discrepancy does not significantly alter the tenor of my overall opinion though.

4.   Reference to [Mrs A's] Comments

[Mr F] made mention of my reference to [Mrs A's] comment on her husband's injury and its management. My report was written on the information I was given by the Health and Disability Commissioner.

5.   Qualifications & Clinical Experience

[Mr F] expressed concern at my qualifications and capability to advise the Health and Disability Commissioner on the current complaint.

…

[Mr F] is correct in that my current area of work is in occupational health.

In addition to citing various literature sources as part of my preparation of my original report, I consulted with two experienced musculoskeletal physiotherapists, i.e. not those whom I consulted in relation to this report's preparation. Their relevant qualifications included MSc Physiotherapy, Post-Graduation Diploma of Rehabilitation, and 'Member' New Zealand College of Physiotherapy. One of the physiotherapists also has an accredited practice.

Summary and Conclusion

In response to your request that I review my earlier advice, I have re-examined my previous report, sought additional material, and have further consulted with experienced musculoskeletal clinicians.

My view has been amended to read as follows:

It is unclear whether [Mr A's] case was one where the 'lift-off' test could have been undertaken. If the initial presentation was one of high irritability, and as severe as reported by [Mrs A], acute soft tissue inhibition is likely to have precluded [Ms B's] ability to carry out the 'lift-off' test. If the test could not have been carried out at the first treatment, it may however have been possible to carry it out during a subsequent treatment.

[Ms B's] failure to refer [Mr A] on earlier was an unfortunate clinical oversight, in view of his age and the apparent severity of his fall. But, given the rare nature of subscapularis tears, and the compounding feature of [Mr A's] neck symptoms, it was a minor departure from recognised standards of care. I also repeat my apology that the ten day onwards referral period should have been within three weeks. [Ms B] did not overtly indicate a lack of responsibility to the consumer (her patient, [Mr A]) or demonstrate a breach of ethical standards.

…

References

ACC GP Treatment Profiles (2001).

ACC News 56, May 2003.

ACC Physiotherapy Treatment Profiles (2000).

Ambacher, T. & Holz, U. (2002). Ruptures of the subscapular tendon. A diagnostic problem? Unfallchirurg, l05(5), 486-91.

Burkhard, S.S. & Tehrany, A.M. (2002). Arthroscopic subscapularis tendon repair: Technical and preliminary results. Arthroscopy, 18(5), 454-63.

Clark, R.J., Marchessault, J., Sizer, P.S. Jr., Slauterbeck, J. (2002). Isolated traumatic rupture of the subscapularis tendon. Journal of the American Board of Family Practice, l5(4), 304-8.

Cormack, J.C. (2002). Evidence-based practice … what is it and how do I do it? Journal of Orthopaedic & Sports Physical Therapy, 32(10), 484-487.

Gerber, C., Herche, O., Farron, A. (1996). Isolated rupture of the subscapularis tendon. Journal of Bone & Joint Surgery - American Volume, 78(7), 1015-23.

Gerber, C., Krushell, R.J. (1991). Isolated rupture of the tendon of the subscapularis muscle. Clinical features in 16 cases. Journal of Bone & Joint Surgery - British Volume, 73(3), 389-94.

Gerber CJ. Observations on the Classification of Instability. In: Complex and Revision Problems in Shoulder Surgery. Warner, J.J.P., Iannotti, J.P., Gerber, C.J. Lippincott-Raven, Philadelphia. Chapter 2: 9-18, 1997.

Greis, P.E., Kuhn, J.E., Schultheis, J., Hintermeister, R., Hawkins, R. (1996). Validation of the lift-off test and analysis of subscapularis activity during maximal internal rotation. American Journal of Sports Medicine, 24(5), 589-93.

Hertel, R., Ballmer, F.T., Lombert, S.M., Gerber, C. (1996). Lag signs in the diagnosis of rotator cuff rupture. Journal of Shoulder & Elbow Surgery, 5(4), 307-13.

Pfirrmann, C.W., Zanetti, M., Weishaput, D., Gerber, C., Hodler, J. (1999). Subscapularis tendon tears: detection and grading at MR arthrography. Radiology, 213(3), 709-14.

Picard, F., Saragaglia, D., Montbarbon, E., Tourne, Y., Thony, F., Charbel, A. (1998). Anatomo-clinical consequences of the vertical sectioning of the subscapular muscle in Latarjet intervention. Revue de Chirurgie Orthopedique et Reparatrice de l Appareil Moteur, 84(3), 217-23.

Rosen's Emergency Medicine Concepts and Clinical Practice, 5^thEdition, Volume One, Part Two. Editor-in-Chief J.A. Marx, 2002.

Travis, R.D., Burkhead, W.Z. Jr., Doane, R. (2001). Technique for repair of the subscapularis tendon. Orthopaedic Clinics of North America, 32(3), 495-500.

Vidil, A. & Augereau, B. (2000). Transfer of the clavicular portion of the pectoralis major muscle in the treatment of irreparable tears of the subscapularis muscle. Revue de Chirurgie Orthopedique et Reparatrice de l Appareil Moteur, 86(8), 835-43.

Zanetti, M., Weishaupt, D., Jost, B., Gerber, C. (1999). MR imaging for traumatic tears of the rotator cuff: high prevalence of greater tuberosity fractures and subscapularis tendon tears. American Journal of Roentgenology, 172(2), 463-7.

Watson, L. (1999). The Shoulder. Australian Clinical Educators.

Watson, L. (2001). Advanced Shoulder Course - Level 2 Manual.Australian Clinical Educators."

Code of Health and Disability Services Consumers' Rights

The following Right in the Code of Health and Disability Services Consumers' Rights is applicable to this complaint:

RIGHT 4

Right to Services of an Appropriate Standard

2)  Every consumer has the right to have services provided that comply with legal, professional, ethical, and other relevant standards.

Professional Standards

The New Zealand Society of Physiotherapists' Standards of Practice, July 2002, state:

"Standard Fourteen: Standards of Clinical Practice

The physiotherapist manages the patient in accordance with current physiotherapy practice to achieve optimal and timely outcomes.

Criteria

…

14.8  The physiotherapist ceases intervention if the physiotherapy clinical practice does not achieve identified goals within a time frame appropriate to the condition or injury, or does not enable the patient to maintain health or lifestyle."

Opinion: No breach - Ms B

Failure to refer when treatment proved ineffective

During the period 1 October to 19 November 2001 Mr A attended the physiotherapy clinic for treatment of a shoulder injury sustained on his farm on 29 September.  Ms B assessed that Mr A had sprained the rotator cuff in his left shoulder and, over a six-week period, her treatment plan was initially for soft tissue management, progressing to strengthening and mobilisation exercises which he continued at home.  Ms B recorded on 10 October that Mr A had some resolution of his symptoms. 

On 19 November it was apparent that there had been no further change in the condition of Mr A's shoulder and Ms B referred him for an X-ray and ultrasound scan.  These examinations found that he had an avulsion of the subscapularis muscle from its normal site.  A later MRI ordered by Dr D, an orthopaedic surgeon to whom Mr A had been referred by his general practitioner, found that there was a two-thirds tear to the subscapularis and the long head of the bicep was displaced.  Mr A required surgery to correct the injury.

Mr A was concerned about his lack of progress and believes that if he had not "pushed" Ms B to refer him for a diagnostic X-ray and/or ultrasound scan, she would not have done so. 

There is a discrepancy between Mr A's and Ms B's accounts about his request for diagnostic examination.  Ms B recalled that Mr A did not specifically ask for a referral for X-ray or ultrasound examination - the discussion about referral was more general and, because she was initially satisfied with his rate of progress, she told him that referral was not warranted.  Ms B thought at the time that Mr A was satisfied with her explanation.

My expert advisor stated that the subscapularis muscle is not accessible to observation or palpation, so the clinician needs to gauge other muscles' action to produce internal rotation.  Internal rotation is the subscapularis muscle's primary action.  My expert stated:

"Had [Ms B] performed the 'lift off' test, in conjunction with the two critical points of Mr A's initial presentation, namely his history of significant trauma and his age, the need for diagnostic interventions and onward referral should have been apparent."

In her response to the provisional opinion, Ms B stated that the lift-off test is not considered a stand alone test and its validation has not been established.  To perform a lift-off test, the patient must place a hand behind the back against the lumbar spine and then be able to push his hand away against resistance.  Mr A could not place his hand against his lumbar spine due to pain and high irritability in his shoulder and was therefore unable to perform the test.  Ms B was also unaware of the degree of trauma suffered by Mr A when he injured his shoulder, which was later described to one of my staff.  Mr A simply told her that he had fallen on to his shoulder.  If she had known he had fallen on to concrete hard ground and been stunned by the impact, she would have been alerted to the greater possibility of more severe injury. (Mrs A informed me that Mr A had been stunned by the impact but there is no evidence that Mr A informed Ms B.)

My expert stated that a positive lift-off test is a 'red flag' for shoulder injuries and is used routinely at some stage in early clinical management by the musculoskeletal physiotherapists canvassed.  It is acknowledged that when a patient first presents it may not be possible to carry out the test, but it should be considered and/or performed during subsequent treatments.

Ms B stated:

"Diagnosis and clinical decisions are very rarely made by relying on one test.  They are established by evaluating the subjective examination, the objective examination and applying clinical reasoning."

Ms B stated that another significant factor that led her initially not to diagnose Mr A's partial tear was that Mr A reported at his second treatment that he had 50% improved shoulder function, and further improvement at his next appointment.  She never spoke with Mrs A and could only evaluate Mr A's progress by what he reported to her and her subjective findings.  Ms B could not understand why Mr A would report such significant improvement to her while indicating the opposite to his wife.

Ms B stated that when she referred Mr A for investigation on 19 November he was reporting 80% overall improvement.  However, Ms B acknowledged that Mr A's progress had reached a plateau at that time and external rotation of the shoulder remained limited and painful.  If the treatment had been ineffective, especially from Mr A's viewpoint, she would definitely have referred him earlier.

My expert stated that optimally surgery should be performed in the first three weeks post- injury, but in Mr A's case the surgery was performed over four months post-injury.  The main reason that the diagnosis should be clarified as soon as possible is because the torn tendon retracts relatively quickly, resulting in loss of tendon extensibility, which makes surgical repair less than ideal.  My expert acknowledged that there is often a time lag between when a muscle tear is suspected by the physiotherapist until the patient is seen by a specialist, because of the time it takes to arrange diagnostic examinations and specialist appointments and the time frames for onward referral, which can extend past the optimal time.

The New Zealand Society of Physiotherapists' Standards of Practice state that if physiotherapy clinical practice does not achieve identified goals within a time frame appropriate to the condition or injury, or does not enable the patient to maintain health or lifestyle, the physiotherapist must cease treatment. 

My expert's research into this case found that subscapularis tears should be specifically looked for in patients older than 40 years (such as Mr A) and, when combined with a repeated history of significant trauma, a decision on further clinical management should be made only in the hands of an experienced surgeon so that unacceptable delays do not occur in relation to tears that require surgical repair.  My expert considered that Ms B's failure to consider a subscapularis tear and further assessment of Mr A's progress was an "unfortunate clinical oversight". 

Although I am left with the impression that Ms B was a little tardy in not referring Mr A for further investigations at an earlier point, the matter is not clear-cut, particularly given the incomplete history of the circumstance of the injury.  Accordingly, I accept that Ms B complied with professional physiotherapy standards and therefore did not breach Right 4(2) of the Code.

Opinion: No breach - the physiotherapy clinic

Vicarious liability

Under section 72(2) of the Health and Disability Commissioner Act 1994, employers are vicariously liable for ensuring that employees comply with the Code.  Under section 72(5) it is a defence for an employing authority to prove that it took such steps as were reasonably practicable to prevent the employee from doing or omitting to do the things that breached the Code.

As Ms B did not breach the Code in relation to the service she provided to Mr A, no question of vicarious liability on the part of the physiotherapy clinic arises.

Follow-up actions

• A copy of this report will be sent to the Physiotherapy Board of New Zealand.
• A copy of this report, with personal identifying details removed, will be sent to the New Zealand College of Physiotherapy and the New Zealand Society of Physiotherapists Inc, and placed on the Health and Disability Commissioner website, www.hdc.org.nz, for educational purposes.