The Post-Op Client Who Wants More Than the Note Allows
Renata is a licensed massage therapist with nine years of experience working in a chiropractor's office in Lubbock. A new client, age 64, is four days out of a total knee replacement, takes warfarin daily, and has a right calf that is warm, swollen, and tender to the touch. She hands Renata a note from her surgeon reading "massage to low back and hips as tolerated" and then asks Renata to (a) work deep on the calf "to break up the fluid," (b) "adjust" her right hip because it feels out of place, and (c) tell her whether the leg pain is sciatica or a disc problem so she can skip her follow-up appointment. Renata's employer wants the $95 session to proceed and tells her to "just avoid the knee."
1. Evaluate each of the client's three requests. Which may Renata perform, which must she decline, and on what legal basis?
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None of the three may be performed as asked.
- (a) Deep work on the calf - decline. Massage therapy is the manipulation of soft tissue for therapeutic purposes, but the license does not authorize treatment that the therapist knows or should know is contraindicated. A warm, swollen, tender calf four days post-op in an anticoagulated client is a classic picture of possible deep vein thrombosis. Working it could dislodge a clot. The surgeon's note authorizes low back and hips only; it does not authorize the calf. Scope of license is not the same as scope of safety - both must be satisfied.
- (b) "Adjusting" the hip - decline. Correcting joint alignment by manipulation is chiropractic practice, a separately licensed profession. Massage therapy is soft tissue work; representing that she can put a joint "back in place" exceeds the massage license even if the technique feels similar to what she does on soft tissue.
- (c) Diagnosing sciatica versus a disc - decline. Diagnosis is outside the massage therapy scope. Renata may describe what she observes, may share general information, and must refer, but she may not render a diagnosis or advise the client to skip medical follow-up.
The employer's instruction is not a defense. The licensee holds the license and is personally accountable for what she does with her hands, regardless of what the business owner wants.
2. What may Renata lawfully and appropriately do in this session, and what should she say and document?
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Lawful session plan:
- Limit work to the areas the surgeon cleared - low back, hips, and surrounding soft tissue - at conservative pressure, with positioning that protects the surgical knee.
- Obtain informed consent for that specific plan; explain what she will not do and why.
- Tell the client plainly that the calf findings (warmth, swelling, tenderness) need same-day medical evaluation and that she should call her surgeon's office before her follow-up. Referral is not optional politeness; it is the compliant response to a red-flag presentation.
- Stop the session if the client reports chest pain, shortness of breath, or worsening leg symptoms.
Documentation: a note stating the date, the surgeon's written restriction, the areas treated, pressure used, the calf findings observed, the fact that the calf was not treated, the referral made and the client's response, and that the client requested a hip adjustment and a diagnosis, both declined. Objective language only. If the client later claims she was injured, that note is the therapist's best evidence.
3. Suppose Renata follows her employer's pressure, works the calf, and the client is hospitalized that night with a clot. Analyze her regulatory exposure and the weight of the employer's instruction.
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- Grounds for discipline exist independently of whether the client sues. The Act permits discipline for practicing in a manner that endangers a client and for conduct outside the scope of the license. Treating a suspected clot with deep pressure, against a written restriction and outside the cleared area, fits both.
- A complaint can be filed by anyone - the client, a family member, a physician, or a coworker - and TDLR may investigate without the client's cooperation.
- "My boss told me to" is mitigation at most, not a defense. The license is individual. The employer may also face exposure, but that does not reduce the therapist's own liability.
- Parallel exposure: civil negligence and, depending on facts, potential criminal liability. Regulatory and civil tracks run separately.
- The compliant alternative was available and cheap: a fifteen-minute session on the cleared areas plus a documented referral. Choosing that would have satisfied the client's therapeutic need, the surgeon's restriction, and the statute simultaneously.