Musculoskeletal SOAP Notes (with Examples)

Musculoskeletal problems are extremely common in everyday clinical practice. Many patients visit clinics for pain in their muscles, joints, ligaments, or bones. Because these conditions affect movement, strength, and daily function, it is important for clinicians to document the case clearly.

SOAP notes make this process easy. They help you write patient information in a simple, organized, and professional way. A musculoskeletal focused SOAP note includes what the patient says, what the clinician observes, the assessment of the condition, and the treatment plan.

In this blog, you will learn how musculoskeletal SOAP notes work, why they are important, and how to write them with confidence. You will also see excellent musculoskeletal SOAP note examples that you can use in real settings.

What Is a Musculoskeletal SOAP Note?

A musculoskeletal SOAP note is a structured medical record that focuses on bones, joints, muscles, tendons, ligaments, and movement problems. It helps clinicians describe pain type, triggers, physical findings, functional limits, and possible causes.

Using SOAP format brings clarity. It reduces confusion in follow-up visits and helps other healthcare professionals understand the case quickly. It also protects the clinician legally, improves communication, and supports better care.

How to Write a Musculoskeletal SOAP Note

A musculoskeletal SOAP note follows the standard four sections:

S — Subjective

This is everything the patient reports.

For musculoskeletal issues, include:

• Location of pain
• Onset and duration
• Type of pain (sharp, dull, burning, throbbing)
• Factors that worsen it (lifting, running, bending)
• Factors that reduce it (rest, heat, medication)
• Movement limitations
• Past injuries
• Relevant lifestyle habits

Short, simple language works best.

O — Objective

This includes measurable findings:

• Range of motion
• Swelling, bruising, redness
• Tenderness on palpation
• Strength level
• Gait changes
• Imaging results (X-ray, MRI, etc.)
• Vital signs (if needed)

Always write exact numbers if available.

A — Assessment

Here you write what you think is happening:

• Likely diagnosis
• Possible differential diagnoses
• Severity
• Functional impact
• Risks or complications

The assessment is based on the S + O findings.

P — Plan

Here you describe what will be done next:

• Medications
• Physical therapy or exercises
• Hot/cold therapy
• Imaging orders
• Follow-up visit
• Activity modifications
• Referrals

Make it clear and actionable.

Musculoskeletal SOAP Note Examples

Below are five SOAP notes for common conditions. You can copy and adapt them for your own clinical use.

Lower Back Pain (Acute Strain)

Subjective

Patient is a 32-year-old male who reports lower back pain for the past 3 days. Pain started after lifting a heavy box at work. Patient felt a sudden pull in the lower back at the time of injury. Describes current pain as sharp during movement and dull at rest. Rates pain 6/10.

Pain is worse with bending forward, twisting, and getting out of bed in the morning. Sitting for long periods also increases discomfort. Walking gives mild relief. Denies numbness, tingling, or weakness in legs. No bowel or bladder changes. No fever, no weight loss.

No history of back surgery. Has had mild back pain in the past but never this strong. Patient took ibuprofen 400 mg which provided some relief.

Sleep is disturbed due to pain when turning in bed.

Objective

Patient walks with a stiff, guarded gait. Appears uncomfortable while sitting and standing.

Inspection:

No visible deformity or bruising. Mild muscle tightness noted in lumbar region.

Palpation:

Tenderness over lumbar paraspinal muscles (L3–L5). No midline vertebral tenderness.

Range of Motion:
• Flexion: Limited to 40° due to pain
• Extension: Mild discomfort
• Lateral bending: Slightly limited
• Rotation: Painful on right side

Neurological exam:

Strength 5/5 in both legs. Sensation intact. Reflexes normal. Negative straight leg raise bilaterally.

Other:
No red-flag signs. Vitals stable.

Assessment

Primary Diagnosis:

Acute lumbar muscle strain related to improper lifting at work.

Secondary Considerations (low suspicion):
• Lumbar disc herniation (unlikely due to no radicular symptoms)
• Facet irritation
• Muscle spasm secondary to strain

Pain appears mechanical and muscular. No evidence of nerve compression.

Plan

1. Medication:
   • Ibuprofen 400–600 mg every 6–8 hours as needed (avoid if stomach issues).
   • Optional: Muscle relaxant at bedtime for severe spasm.
2. Therapies:
   • Apply heat to lower back 15–20 minutes twice daily.
   • Begin gentle stretching after 48 hours.
   • Recommend physical therapy in 3–5 days if pain persists.
3. Activity Guidance:
   • Avoid heavy lifting, twisting, or bending for 1 week.
   • Encourage short walks to reduce stiffness.
   • Educate on proper lifting technique for future prevention.
4. Follow-Up:
   • Recheck in 7 days or sooner if symptoms worsen.
   • Return immediately for numbness, bowel/bladder problems, or severe weakness.
5. Patient Education:
   • Strains usually improve in 1–2 weeks.
   • Continue mild movement; avoid prolonged bed rest.

Knee Pain (Possible Meniscus Irritation)

Subjective

Patient is a 27-year-old male who reports right knee pain for the past 10 days. Pain began after twisting his knee while playing football. He did not fall but felt a sudden sharp discomfort during the twist.

Describes pain as deep, aching, and sometimes sharp. Reports a catching and clicking feeling inside the knee. Pain worsens when squatting, climbing stairs, and walking long distances. Rates pain 5/10 at rest and 7/10 during activity.

Denies numbness, tingling, or instability. No redness or fever. Swelling appeared within a few hours after injury and has improved slightly but still present.

Patient has not taken any medication except occasional ice application. No history of previous knee injuries or surgeries.

Objective

Inspection:

Mild swelling noted around the right knee joint. No redness. No obvious deformity.

Palpation:

Tenderness along the medial joint line. Mild pain with palpation of medial meniscus area.

Range of Motion:
Flexion slightly limited due to pain. Extension full but uncomfortable at the end range.

Special Tests:
• McMurray test: Painful with medial rotation.
• Joint line tenderness: Positive.
• Lachman test: Negative (no ACL injury).
• Varus/Valgus stress: Stable (no ligament instability).

Gait:

Mild limp due to discomfort.

Neurovascular:

Pulses normal. Sensation intact.

Assessment

Primary Diagnosis:

Suspected medial meniscus irritation or mild meniscus tear.

Differential Diagnoses:
• Medial collateral ligament (MCL) strain (less likely due to stable valgus test)
• Patellofemoral pain syndrome
• Knee sprain
• Synovitis from overuse

Mechanism of injury and test results strongly suggest meniscus involvement. No signs of ligament tear or fracture.

Plan

1. Medication:
   • NSAIDs such as ibuprofen 400 mg every 6–8 hours with food for 5–7 days.
2. Therapy / Self-Care:
   • RICE: Rest, Ice, Compression, Elevation for first 48–72 hours.
   • Avoid squatting, running, and twisting movements.
   • Use knee brace during walking if needed.
3. Rehabilitation:
   • Begin gentle strengthening and stretching exercises once acute pain decreases.
   • Referral to physical therapy for quadriceps and hamstring strengthening.
4. Imaging:
   • If symptoms do not improve in 10–14 days, order MRI to confirm meniscus condition.
5. Activity Guidance:
   • Limit high-impact activities.
   • Encourage light walking as tolerated.
   • Avoid any sport until fully pain-free.
6. Follow-Up:
   • Reevaluate in 1–2 weeks.
   • Return sooner if swelling worsens, locking occurs, or knee becomes unstable.

Shoulder Pain (Rotator Cuff Tendinitis)

Subjective

Patient is a 35-year-old female who reports left shoulder pain for the past 2 weeks. Pain began gradually after repeated overhead lifting during gym workouts. She did not experience a specific injury but noticed soreness that slowly became worse.

Describes the pain as aching, with sharp pain when lifting the arm above shoulder height. Reports difficulty reaching overhead cabinets and discomfort when lying on the left side at night. Rates pain 7/10 during activity and 4/10 at rest.

Pain increases with reaching, lifting, and overhead movements. Rest provides some relief. No numbness, tingling, or neck pain. Denies shoulder instability. No history of shoulder surgery.

Tried over-the-counter ibuprofen with mild improvement.

Objective

Inspection:

No visible deformity or swelling. Normal shoulder alignment.

Palpation:

Tenderness over the supraspinatus tendon and anterior shoulder. No warmth or crepitus.

Range of Motion:
• Active abduction limited due to pain.
• Painful arc noted between 70°–110°.
• Passive range of motion full.

Strength Testing:
• Supraspinatus: 4/5 due to pain
• External rotation: mild pain
• Internal rotation: normal

Special Tests:
• Hawkins-Kennedy test: Positive
• Neer sign: Positive
• Drop arm test: Negative

Neurovascular:

Normal sensation and pulses in the arm.

Assessment

Primary Diagnosis:

Rotator cuff tendinitis (supraspinatus tendinopathy) due to repetitive overhead activity.

Differential Diagnoses:
• Subacromial bursitis
• Impingement syndrome
• Rotator cuff partial tear (less likely due to preserved strength)
• Biceps tendinitis

Clinical signs strongly support rotator cuff inflammation without major structural tear.

Plan

1. Medication:
   • NSAIDs such as ibuprofen 400–600 mg every 6–8 hours for 5–7 days.
   • Consider topical anti-inflammatory gel.
2. Therapies:
   • Ice shoulder 15 minutes, twice daily.
   • Recommend physical therapy for strengthening of rotator cuff and scapular muscles.
   • Teach home exercises (pendulum swings, isometric strengthening).
3. Activity Modifications:
   • Avoid overhead lifting for 2 weeks.
   • Reduce gym weight load by 50% when returning.
   • Avoid sleeping on the affected side.
4. Additional Interventions:
   • If pain does not improve in 3–4 weeks, consider subacromial corticosteroid injection.
   • If symptoms persist beyond 6–8 weeks, order MRI to evaluate for partial tear.
5. Patient Education:
   • Tendinitis often heals with rest and therapy.
   • Consistent exercise and posture correction improve recovery.
   • Avoid sudden heavy lifting when returning to workouts.
6. Follow-Up:
   • Recheck in 2 weeks to assess improvement.

Ankle Sprain (Lateral Ligament Injury)

Subjective

Patient is a 24-year-old female who reports right ankle pain and swelling after twisting her ankle on uneven ground yesterday afternoon. She describes hearing a small “pop” at the time of injury. Pain was immediate and swelling developed within 30 minutes.

Reports sharp pain when walking and a dull ache at rest. Rates pain 6/10 with movement and 3/10 at rest. Walking is difficult and she cannot put full weight on the ankle. Denies numbness, tingling, or discoloration of toes. No previous ankle fractures but has had minor sprains in the past.

Patient has been elevating the ankle and applying ice, which gives slight relief. She has not taken any medication.

Objective

Inspection:

Moderate swelling over lateral ankle. Mild bruising extending toward the foot. No obvious deformity.

Palpation:

Tenderness over the anterior talofibular ligament (ATFL). Mild tenderness over the calcaneofibular ligament. No tenderness over medial ankle. No bone tenderness at lateral or medial malleolus.

Range of Motion:
• Plantarflexion: Limited due to pain
• Inversion: Painful and restricted
• Eversion: Mild discomfort
• Dorsiflexion: Slightly limited

Weight Bearing:

Patient unable to fully bear weight without limping.

Special Tests:
• Anterior drawer test: Mild laxity but painful
• Talar tilt test: Pain with inversion
• Ottawa Ankle Rules: Negative for fracture

Neurovascular:

Pulses intact. Sensation normal.

Assessment

Primary Diagnosis:

Grade I–II lateral ankle sprain involving the anterior talofibular ligament (ATFL). No signs of fracture.

Differential Diagnoses:
• Calcaneofibular ligament sprain
• Peroneal tendon strain
• Bone contusion
• High ankle sprain (unlikely due to mechanism)

Symptoms consistent with moderate ligament injury without instability that suggests a severe tear.

Plan

1. Medication:
   • NSAIDs such as ibuprofen 400 mg every 6–8 hours for pain and swelling.
2. Therapy & Home Care:
   • RICE protocol for 48 hours: Rest, Ice, Compression wrap, Elevation.
   • Use an ankle brace or supportive wrap when walking.
   • Continue ice 15 minutes, 2–3 times daily.
3. Activity Guidance:
   • Avoid running, jumping, or uneven surfaces for at least 2 weeks.
   • Encourage short, gentle walking as tolerated.
   • No sports until full pain-free mobility returns.
4. Rehabilitation Exercises (Start in 2–3 Days):
   • Gentle range of motion (ankle circles, alphabet movements).
   • Once pain decreases: begin strengthening (theraband exercises, calf raises).
   • Balance training later to prevent future sprains.
5. Imaging:
   • No immediate imaging needed.
   • Consider X-ray if pain does not improve within 5–7 days or if weight bearing becomes more difficult.
6. Follow-Up:
   • Return in 1 week to evaluate healing.
   • Seek urgent care if severe swelling, loss of sensation, or inability to move ankle develops.
7. Patient Education:
   • Most ankle sprains improve within 1–3 weeks with proper care.
   • Early but gentle movement helps healing.
   • Strength training reduces risk of re-injury.

Pediatric Musculoskeletal SOAP Note

Subjective

Patient is an 8-year-old boy brought in by his mother due to right leg pain for the past 2 days. Pain started after playing on the school playground where he jumped from a low platform. He did not fall, but landed awkwardly and felt immediate discomfort.

Child describes pain as “hurting when I walk.” Mother reports limping since yesterday. Pain worsens with running, walking fast, or bending the knee. No swelling noticed at home. Child denies numbness, tingling, or night pain. No fever, recent illness, or weight loss. He is otherwise active.

Mother gave acetaminophen last night, which helped for a short time. No previous leg injuries.

Objective

General:

Child alert, cooperative, walking with a mild limp favoring right leg.

Inspection:

No visible deformity. Mild swelling around the right knee. No redness or bruising.

Palpation:

Tenderness over medial side of knee and proximal tibia. No heat. No hip tenderness.

Range of Motion:

Knee flexion mildly limited due to discomfort. Extension full. Hip ROM normal.

Strength:

Slight reduction in right quadriceps strength due to pain.

Gait:

Antalgic gait (limping to avoid pain).

Special Tests:
• McMurray: Mild discomfort, no click
• Varus/Valgus stress: Stable
• Lachman: Negative
• No signs of fracture based on palpation and gait

Neurovascular:

Normal distal pulses. Sensation intact.

Assessment

Primary Diagnosis:

• Right knee soft tissue injury (mild strain/contusion) from playground impact

Differential Diagnoses:

• Meniscus irritation
• MCL sprain (low suspicion due to stability)
• Osgood-Schlatter flare (unlikely due to sudden onset)
• Hairline fracture (low suspicion but monitor)

Clinical findings suggest a mild musculoskeletal strain without serious ligament or bone injury.

Plan

1. Pain Management:
   • Acetaminophen or ibuprofen as needed for discomfort (weight-based dosing).
2. Home Care:
   • Ice knee for 15 minutes, 2–3 times daily.
   • Rest from running, jumping, PE class, and sports for 5–7 days.
   • Elevate leg after school to reduce swelling.
3. Mobility:
   • Allow normal walking as tolerated.
   • Avoid kneeling or squatting for several days.
4. School Note:
   • Provide letter excusing child from high-impact activities.
5. Monitoring:
   • Watch for worsening swelling, redness, fever, or inability to bear weight.
   • If pain does not improve in 5–7 days, consider X-ray to rule out subtle fracture.
6. Follow-Up:
   • Recheck in one week to monitor recovery.
7. Parent/Child Education:
   • Most mild sprains in children improve quickly.
   • Encourage slow return to activities once fully pain-free.

Why Musculoskeletal SOAP Notes Matter

Musculoskeletal conditions often change quickly, so tracking progress day-by-day is important. SOAP notes provide a clear timeline of symptoms, movement limits, and treatment response. They also help clinicians decide when a patient needs imaging, therapy, or further intervention.

A detailed note protects the clinician legally and supports accurate communication between doctors, therapists, and other care providers.

Conclusion

Musculoskeletal SOAP notes make clinical documentation clear, organized, and easy to understand. When you write each section carefully, you create a complete picture of the patient’s pain, movement problems, and daily challenges. This helps guide better decisions during treatment and follow-up. A good SOAP note also supports teamwork between clinicians because anyone reading it can quickly understand what happened, what was found, and what will be done next. With practice, writing musculoskeletal SOAP notes becomes faster, smoother, and more natural. The more detailed and consistent the notes are, the easier it becomes to track progress and improve patient care over time. If you use the examples in this blog as guides, you can feel confident when documenting any muscle, joint, or movement-related complaint.