10 Common Massage Therapy SOAP Note Examples

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List of cases

1. Upper Back Tension
2. Lower Back Pain
3. Neck and Shoulder Pain
4. Sports Injury Recovery
5. Stress and Anxiety
6. Pregnancy Massage
7. Fibromyalgia Management
8. Headache Relief
9. Plantar Fasciitis
10. Post-Surgery Rehabilitation

1. Upper Back Tension

Description

The patient presents with chronic upper back tension and discomfort related to desk work, seeking massage therapy for pain relief and muscle relaxation.

SOAP Note

Patient Name: Emily Parker

Date of Visit: 09/01/2024

Subjective

Emily Parker, a 32-year-old female, presents with persistent upper back tension present for 3 months. Reports constant tightness between shoulder blades, rated 6/10 on pain scale. Symptoms worsen during workday and improve with stretching. Works as software developer, 8+ hours daily at computer. Previous massage therapy 6 months ago provided temporary relief. No recent injuries or trauma. Reports increased stress at work contributing to symptoms.

Objective

• Vital Signs:
  • BP: 118/76 mmHg
  • HR: 72 bpm
  • RR: 16/min
• Postural Assessment:
  • Forward head posture
  • Rounded shoulders
  • Elevated right shoulder
• Palpation Findings:
  • Severe tension in upper trapezius bilaterally
  • Multiple trigger points in rhomboids
  • Tender points along thoracic spine
  • Tissue temperature elevated in affected areas
• Range of Motion:
  • Cervical rotation limited bilaterally
  • Shoulder elevation restricted
  • Pain with scapular retraction

Assessment

1. Chronic Upper Back Myofascial Pain
   • Postural dysfunction
   • Work-related muscular tension
   • Bilateral upper trapezius and rhomboid involvement

Plan

1. Treatment Provided Today:

   • Swedish massage techniques to back
   • Trigger point therapy
   • Myofascial release
   • Duration: 60 minutes
   • Pressure: Medium to firm

2. Focus Areas:

   • Upper trapezius
   • Rhomboids
   • Levator scapulae
   • Thoracic paraspinals

3. Home Care Instructions:

   • Stretching exercises every 2 hours at work
   • Heat therapy 15 minutes daily
   • Ergonomic workstation assessment
   • Stress management techniques

4. Follow-up:

   • Weekly sessions for 4 weeks
   • Monitor tension patterns
   • Assess posture improvement

2. Lower Back Pain

Description

The patient presents with acute lower back pain following physical activity, seeking massage therapy for pain management and muscle relaxation.

SOAP Note

Patient Name: James Wilson

Date of Visit: 09/02/2024

Subjective

James Wilson, a 45-year-old male, presents with acute lower back pain after gardening 2 days ago. Reports dull ache and stiffness, rated 7/10, worse in morning and with prolonged sitting. No radiating pain or numbness in legs. Previous history of occasional back strain. Currently using over-the-counter pain relievers with minimal relief. No other medical conditions. Primary goal is pain reduction and improved mobility.

Objective

• Vital Signs:
  • BP: 124/78 mmHg
  • HR: 74 bpm
  • RR: 16/min
• Postural Assessment:
  • Antalgic posture
  • Right pelvic tilt
  • Reduced lumbar lordosis
• Palpation Findings:
  • Muscle spasm in lumbar paraspinals
  • Tender quadratus lumborum bilaterally
  • Tissue congestion in gluteal region
  • No heat or inflammation noted
• Range of Motion:
  • Forward flexion limited to 45°
  • Extension limited with pain
  • Lateral flexion restricted bilaterally

Assessment

1. Acute Lumbar Strain
   • Muscular tension and spasm
   • Movement restriction
   • Postural compensation

Plan

1. Treatment Provided Today:

   • Light Swedish massage techniques
   • Gentle stretching
   • Myofascial release
   • Duration: 45 minutes
   • Pressure: Light to medium

2. Focus Areas:

   • Lumbar paraspinals
   • Quadratus lumborum
   • Gluteal muscles
   • Lower thoracic region

3. Home Care Instructions:

   • Ice therapy for 20 minutes every 2 hours
   • Gentle walking
   • Avoid prolonged sitting
   • Basic stretching exercises

4. Follow-up:

   • 2-3 sessions per week for 2 weeks
   • Monitor pain levels
   • Assess movement patterns

3. Neck and Shoulder Pain

Description

The patient presents with chronic neck and shoulder pain related to occupational stress and poor posture, seeking massage therapy for pain relief and tension reduction.

SOAP Note

Patient Name: Sarah Thompson

Date of Visit: 09/03/2024

Subjective

Sarah Thompson, a 38-year-old female, presents with chronic neck and shoulder pain persisting for 4 months. Reports constant tension and occasional sharp pain, rated 5/10, worse at end of workday. Works as accountant with frequent computer use. Experiences frequent tension headaches. Previous physical therapy provided temporary relief. Reports increased stress levels affecting symptoms. No numbness or tingling in arms.

Objective

• Vital Signs:
  • BP: 120/76 mmHg
  • HR: 70 bpm
  • RR: 16/min
• Postural Assessment:
  • Forward head posture
  • Elevated and protracted shoulders
  • Upper crossed syndrome
• Palpation Findings:
  • Severe hypertonicity in upper trapezius
  • Multiple trigger points in levator scapulae
  • Tender suboccipital muscles
  • Adhesions in cervical paraspinals
• Range of Motion:
  • Cervical rotation limited to 60° bilaterally
  • Shoulder elevation painful
  • Limited cervical extension

Assessment

1. Chronic Cervicothoracic Myofascial Pain
   • Postural strain
   • Occupational stress factors
   • Muscle tension patterns

Plan

1. Treatment Provided Today:

   • Deep tissue massage
   • Trigger point therapy
   • Myofascial release
   • Duration: 60 minutes
   • Pressure: Medium to deep

2. Focus Areas:

   • Upper trapezius
   • Levator scapulae
   • Suboccipital muscles
   • Cervical paraspinals

3. Home Care Instructions:

   • Neck stretches every hour
   • Postural awareness exercises
   • Stress reduction techniques
   • Hot shower/bath before bed

4. Follow-up:

   • Weekly sessions for 6 weeks
   • Monitor headache frequency
   • Track stress levels

4. Sports Injury Recovery

Description

The patient presents with calf muscle strain from running, seeking massage therapy for recovery and return to athletic activities.

SOAP Note

Patient Name: Michael Chen

Date of Visit: 09/04/2024

Subjective

Michael Chen, a 28-year-old male, presents with right calf pain following increased running mileage 1 week ago. Reports tight, pulling sensation rated 6/10, worse with activity. Training for half marathon, currently running 20 miles/week. No previous calf injuries. Using ice and compression with some relief. Goals include returning to training schedule and preventing re-injury.

Objective

• Vital Signs:
  • BP: 122/74 mmHg
  • HR: 68 bpm
  • RR: 16/min
• Postural Assessment:
  • Slight right-sided weight bearing
  • Normal gait with mild favoring
  • Good overall alignment
• Palpation Findings:
  • Tender gastrocnemius muscle belly
  • Mild edema mid-calf
  • Tissue temperature slightly elevated
  • No significant adhesions
• Range of Motion:
  • Ankle dorsiflexion limited right side
  • Plantar flexion within normal limits
  • Pain with resistance testing

Assessment

1. Grade 1 Gastrocnemius Strain
   • Overuse injury
   • Training-related factors
   • Good healing potential

Plan

1. Treatment Provided Today:

   • Sports massage techniques
   • Cross-fiber friction
   • Lymphatic drainage
   • Duration: 45 minutes
   • Pressure: Moderate

2. Focus Areas:

   • Gastrocnemius
   • Soleus
   • Achilles tendon
   • Tibialis posterior

3. Home Care Instructions:

   • Continue ice therapy
   • Gentle stretching program
   • Gradual return to activity
   • Compression sock use

4. Follow-up:

   • Twice weekly for 2 weeks
   • Monitor healing progress
   • Assess training readiness

5. Stress and Anxiety

Description

The patient presents seeking massage therapy for stress management and relaxation, reporting physical tension and anxiety symptoms.

SOAP Note

Patient Name: Rebecca Martinez

Date of Visit: 09/05/2024

Subjective

Rebecca Martinez, a 41-year-old female, presents with general muscle tension and anxiety symptoms. Reports difficulty sleeping, constant tension in shoulders and jaw, rated 4/10. Works in high-stress corporate environment. Previous massage experience with positive results. No medications. Primary goal is stress reduction and improved sleep quality.

Objective

• Vital Signs:
  • BP: 128/82 mmHg
  • HR: 82 bpm
  • RR: 18/min
• Postural Assessment:
  • Elevated shoulders
  • Shallow breathing pattern
  • General muscle guarding
• Palpation Findings:
  • Tension in jaw muscles
  • Tight scalenes
  • General hypertonicity in back
  • Cool, clammy skin texture
• Observation:
  • Anxious demeanor
  • Rapid speech
  • Frequent sighing

Assessment

1. Stress-Related Muscle Tension
   • Anxiety manifestation
   • Sleep disruption
   • Autonomic arousal

Plan

1. Treatment Provided Today:

   • Swedish massage
   • Craniosacral therapy
   • Aromatherapy (lavender)
   • Duration: 90 minutes
   • Pressure: Light to medium

2. Focus Areas:

   • Full body relaxation
   • Scalp and face
   • Neck and shoulders
   • Feet and hands

3. Home Care Instructions:

   • Deep breathing exercises
   • Progressive relaxation
   • Epsom salt baths
   • Sleep hygiene practices

4. Follow-up:

   • Weekly sessions
   • Monitor stress levels
   • Track sleep patterns

6. Pregnancy Massage

Description

The patient presents at 28 weeks gestation seeking pregnancy massage for back pain and general discomfort.

SOAP Note

Patient Name: Jennifer Lee

Date of Visit: 09/06/2024

Subjective

Jennifer Lee, a 32-year-old female at 28 weeks gestation, presents with low back pain and leg cramping. Reports discomfort rated 5/10, worse in evening. Second pregnancy, no complications. Cleared by OB/GYN for massage. Reports difficulty sleeping and mild edema in ankles. No contraindications noted.

Objective

• Vital Signs:
  • BP: 116/72 mmHg
  • HR: 76 bpm
  • RR: 16/min
• Postural Assessment:
  • Increased lumbar lordosis
  • Forward weight shift
  • Waddling gait
• Palpation Findings:
  • Lower back tension
  • Mild ankle edema
  • Tight piriformis muscles
  • Round ligament tenderness
• Range of Motion:
  • Limited by pregnancy
  • No concerning restrictions

Assessment

1. Pregnancy-Related Musculoskeletal Discomfort
   • Postural adaptations
   • Normal pregnancy changes
   • Mild edema

Plan

1. Treatment Provided Today:

   • Prenatal massage techniques
   • Side-lying position
   • Lymphatic drainage
   • Duration: 60 minutes
   • Pressure: Light to medium

2. Focus Areas:

   • Lower back
   • Legs and feet
   • Shoulders
   • Hip area

3. Home Care Instructions:

   • Pregnancy pillow use
   • Gentle stretching
   • Walking program
   • Rest breaks during day

4. Follow-up:

   • Bi-weekly sessions
   • Monitor edema
   • Track comfort levels

7. Fibromyalgia Management

Description

The patient presents with fibromyalgia symptoms seeking gentle massage therapy for pain management and relaxation.

SOAP Note

Patient Name: Patricia Wilson

Date of Visit: 09/07/2024

Subjective

Patricia Wilson, a 52-year-old female, presents with widespread muscle pain and fatigue diagnosed with fibromyalgia 3 years ago. Reports pain levels varying between 4-8/10, worse with weather changes and stress. Currently taking duloxetine and gabapentin. Previous massage experience helpful for symptom management. Reports increased flare-up past week. Sleep disrupted by pain.

Objective

• Vital Signs:
  • BP: 118/74 mmHg
  • HR: 74 bpm
  • RR: 16/min
• Palpation Findings:
  • Multiple tender points
  • Tissue sensitivity widespread
  • No acute inflammation
  • General muscle tension
• Observation:
  • Fatigue apparent
  • Careful movement patterns
  • Normal skin temperature
• Pain Assessment:
  • Classic fibromyalgia tender points
  • Bilateral involvement
  • Variable pressure tolerance

Assessment

1. Fibromyalgia Syndrome
   • Active flare period
   • Multiple tender points
   • Sleep disruption

Plan

1. Treatment Provided Today:

   • Very gentle Swedish massage
   • Light touch therapy
   • Energy work
   • Duration: 60 minutes
   • Pressure: Very light

2. Focus Areas:

   • Full body approach
   • Attention to tender points
   • Gentle neck work
   • Light extremity work

3. Home Care Instructions:

   • Warm bath therapy
   • Gentle stretching
   • Pacing activities
   • Stress management

4. Follow-up:

   • Weekly sessions
   • Monitor pain levels
   • Track flare patterns

8. Headache Relief

Description

The patient presents with tension headache and associated neck pain seeking massage therapy for relief.

SOAP Note

Patient Name: David Chang

Date of Visit: 09/08/2024

Subjective

David Chang, a 34-year-old male, presents with tension headache present for 2 days. Reports bilateral pressure around temples and base of skull, rated 6/10. Works in IT with long hours at computer. History of similar headaches 2-3 times monthly. Currently using OTC pain relievers with minimal relief. Reports increased work stress contributing to symptoms.

Objective

• Vital Signs:
  • BP: 126/78 mmHg
  • HR: 72 bpm
  • RR: 16/min
• Palpation Findings:
  • Tight suboccipital muscles
  • Tender temporal regions
  • Cervical muscle tension
  • Trigger points in upper trapezius
• Range of Motion:
  • Reduced cervical rotation
  • Pain with extension
  • Limited lateral flexion
• Postural Assessment:
  • Forward head posture
  • Elevated shoulders
  • Upper crossed syndrome

Assessment

1. Tension Headache
   • Musculoskeletal origin
   • Stress-related factors
   • Postural contribution

Plan

1. Treatment Provided Today:

   • Cranial massage
   • Neck therapy
   • Trigger point work
   • Duration: 45 minutes
   • Pressure: Light to medium

2. Focus Areas:

   • Suboccipital region
   • Temporal area
   • Upper trapezius
   • Cervical muscles

3. Home Care Instructions:

   • Self-massage techniques
   • Posture correction
   • Screen breaks hourly
   • Stress management

4. Follow-up:

   • As needed for headaches
   • Monitor frequency
   • Track triggers

9. Plantar Fasciitis

Description

The patient presents with chronic heel pain seeking massage therapy for plantar fasciitis relief.

SOAP Note

Patient Name: Maria Rodriguez

Date of Visit: 09/09/2024

Subjective

Maria Rodriguez, a 45-year-old female, presents with left heel pain present for 4 months. Reports severe morning pain rated 7/10, improving with activity but worse by evening. Works as teacher, standing most of day. Previous physical therapy with some improvement. Wears supportive shoes and orthotics. Goals include pain reduction and return to regular walking program.

Objective

• Vital Signs:
  • BP: 120/76 mmHg
  • HR: 70 bpm
  • RR: 16/min
• Foot Assessment:
  • Tender plantar fascia
  • Tight gastrocnemius/soleus
  • Normal arch height
  • No swelling
• Palpation Findings:
  • Point tenderness at heel
  • Calf muscle tension
  • Plantar fascia thickness
  • Trigger points in sole
• Range of Motion:
  • Limited toe extension
  • Ankle dorsiflexion restricted
  • Normal inversion/eversion

Assessment

1. Chronic Plantar Fasciitis
   • Occupational factors
   • Muscle tension patterns
   • Morning pain pattern

Plan

1. Treatment Provided Today:

   • Deep tissue to calf
   • Plantar fascia release
   • Joint mobilization
   • Duration: 45 minutes
   • Pressure: Medium to firm

2. Focus Areas:

   • Plantar fascia
   • Gastrocnemius/soleus
   • Ankle joint
   • Foot intrinsics

3. Home Care Instructions:

   • Ice rolling
   • Calf stretches
   • Tennis ball exercises
   • Proper footwear

4. Follow-up:

   • Weekly for 4 weeks
   • Monitor morning pain
   • Track activity tolerance

10. Post-Surgery Rehabilitation

Description

The patient presents 6 weeks post-shoulder surgery seeking massage therapy as part of rehabilitation program.

SOAP Note

Patient Name: Robert Foster

Date of Visit: 09/10/2024

Subjective

Robert Foster, a 48-year-old male, presents 6 weeks post-rotator cuff repair surgery. Cleared by surgeon for massage therapy. Reports stiffness and discomfort rated 4/10. Currently in physical therapy twice weekly. Goals include improved range of motion and scar tissue management. No complications from surgery reported.

Objective

• Vital Signs:
  • BP: 122/78 mmHg
  • HR: 72 bpm
  • RR: 16/min
• Surgical Site:
  • Well-healed incisions
  • Minimal swelling
  • Some adhesions
  • Normal temperature
• Range of Motion:
  • Limited per protocol
  • Passive movement improving
  • Active movement restricted
• Palpation Findings:
  • Tissue tightness around scars
  • Compensatory neck tension
  • Guarding in surrounding muscles

Assessment

1. Post-Surgical Recovery
   • Normal healing progression
   • Adhesion formation
   • Compensatory patterns

Plan

1. Treatment Provided Today:

   • Light scar massage
   • Gentle ROM work
   • Lymphatic drainage
   • Duration: 45 minutes
   • Pressure: Very light

2. Focus Areas:

   • Surgical site
   • Surrounding tissue
   • Compensating muscles
   • Lymphatic flow

3. Home Care Instructions:

   • Continue PT exercises
   • Scar massage techniques
   • Ice after activity
   • Movement within limits

4. Follow-up:

   • Weekly sessions
   • Coordinate with PT
   • Monitor ROM progress