SOAPNoteAI.com

10 Common Physical Therapy SOAP Note Examples

List of cases

  1. Acute Lower Back Pain
  2. Post-ACL Reconstruction
  3. Chronic Shoulder Pain
  4. Cervical Radiculopathy
  5. Hip Osteoarthritis
  6. Tennis Elbow (Lateral Epicondylitis)
  7. Ankle Sprain
  8. Plantar Fasciitis
  9. Rotator Cuff Tear
  10. Carpal Tunnel Syndrome

1. Acute Lower Back Pain

Description

The patient reports sudden onset of lower back pain after lifting a heavy box two days ago. The pain is localized to the lower back and does not radiate. The patient rates the pain as 6/10 and reports difficulty standing for long periods.

SOAP Note

Patient Name: John Doe

Date of Visit: 07/18/2024

Subjective

John Doe presents with a chief complaint of lower back pain that began two days ago after lifting a heavy box at work. He describes the pain as sharp and localized to the lower back without radiating. John rates the pain as 6 out of 10 on the pain scale. He reports difficulty standing for long periods and performing his daily activities, especially those that require bending or lifting. John has tried over-the-counter pain medication, which provided minimal relief. He has no previous history of back problems and has not experienced any similar issues before. He is currently not taking any prescribed medications. John's primary goal is to return to his normal activities, including his job duties, without experiencing pain. Additionally, he mentions that the pain increases when he sits for prolonged periods, which is affecting his work performance.

Objective

  • Vital Signs:
    • BP: 120/80 mmHg
    • HR: 72 bpm
    • RR: 16 breaths per minute
    • Temp: 98.6°F
  • Posture:
    • Mild forward flexion posture observed
  • Gait:
    • Slight antalgic gait noted with reduced stride length
  • Lumbar Range of Motion:
    • Flexion: Limited to 45 degrees with pain
    • Extension: Limited to 10 degrees with pain
    • Lateral Flexion: Limited bilaterally to 15 degrees with pain
    • Rotation: Within normal limits, mild discomfort reported
  • Palpation:
    • Tenderness and muscle spasm noted in the lower lumbar paraspinals
    • No palpable swelling or deformity
  • Neurological Tests:
    • Reflexes: Patellar and Achilles reflexes are 2+ bilaterally
    • Sensation: Intact to light touch and pinprick in bilateral lower extremities
    • Motor: Muscle strength is 5/5 in bilateral lower extremities
  • Special Tests:
    • Straight Leg Raise: Negative bilaterally
    • Slump Test: Negative

Assessment

John presents with symptoms indicative of an acute lower back strain, likely resulting from improper lifting techniques. His primary functional limitations include difficulty standing, walking, and performing activities that require bending and lifting due to pain. The tenderness and muscle spasm observed in the lower lumbar region, along with the limited range of motion, support the diagnosis of a muscular strain. Neurological tests are within normal limits, which suggests that there is no nerve involvement. The absence of previous back issues and the acute nature of the pain indicate a good prognosis with appropriate intervention.

John's primary goal is to return to his normal activities, including his work duties, without pain. Given his motivation and the acute nature of his condition, it is expected that he will respond well to a structured physical therapy program. The plan includes manual therapy to address muscle tension, strengthening and stretching exercises to improve flexibility and support recovery, and education on proper lifting techniques to prevent future injuries. Follow-up appointments will be necessary to monitor progress and adjust the treatment plan as needed.

Plan

  1. Manual Therapy:

    • Utilize techniques such as soft tissue mobilization and myofascial release to reduce muscle tension and improve lumbar mobility.

  2. Therapeutic Exercises:

    • Strengthening:
      • Prescribe specific strengthening exercises for the core and lower back muscles to be performed daily.
      • Examples: Pelvic tilts, bird-dog exercises, and bridging exercises.
    • Stretching:
      • Implement a stretching routine targeting the hamstrings, hip flexors, and lumbar spine to improve flexibility.
      • Examples: Hamstring stretches, hip flexor stretches, and lumbar rotations.
    • Frequency:
      • Perform these exercises twice daily, with 3 sets of 10 repetitions for strengthening exercises and hold stretches for 30 seconds each.

  3. Modalities:

    • Heat Therapy:
      • Apply heat to the lower back for 15-20 minutes before exercise sessions to relax muscles and reduce pain.
    • Ice Therapy:
      • Use ice packs for 10-15 minutes post-exercise if there is any swelling or increased pain.

  4. Patient Education:

    • Educate John on proper body mechanics and lifting techniques to prevent future injuries.
    • Discuss the importance of maintaining good posture, especially during prolonged sitting at work.
    • Provide instructions on ergonomic adjustments for his workstation.

  5. Home Exercise Program (HEP):

    • Develop a home exercise program that includes the prescribed strengthening and stretching exercises.
    • Ensure John understands the exercises and their importance in his recovery process.

  6. Activity Modification:

    • Advise John to avoid activities that exacerbate his pain, such as heavy lifting and prolonged sitting without breaks.
    • Encourage frequent changes in position and short walks to reduce stiffness.

  7. Follow-Up:

    • Schedule follow-up appointments twice a week for the next two weeks to monitor progress and make necessary adjustments to the treatment plan.
    • Re-evaluate John's condition and progress at each session, and modify exercises and manual therapy techniques as needed.

ICD-10 Code: M54.5 (Low back pain)
CPT Code: 97110 (Therapeutic exercises)

2. Post-ACL Reconstruction

Description

The patient is a 25-year-old soccer player who underwent ACL reconstruction surgery 6 weeks ago. They are now starting outpatient physical therapy to regain strength, mobility, and function in the affected knee.

SOAP Note

Patient Name: Sarah Johnson

Date of Visit: 07/25/2024

Subjective

Sarah Johnson, a 25-year-old female soccer player, presents for her initial outpatient physical therapy evaluation 6 weeks post-ACL reconstruction of her right knee. She reports mild pain and stiffness in the knee, rating the pain as 3/10 at rest and 5/10 with movement. Sarah mentions difficulty with prolonged standing and walking, and she expresses concern about returning to soccer. She has been using crutches for ambulation but is eager to progress to full weight-bearing. Sarah's goals include regaining full knee mobility, strengthening her leg, and returning to competitive soccer within 6-9 months.

Objective

  • Vital Signs:
    • BP: 118/76 mmHg
    • HR: 68 bpm
    • RR: 14 breaths per minute
    • Temp: 98.4°F
  • Gait:
    • Ambulates with bilateral axillary crutches, partial weight-bearing on the right lower extremity
  • Knee Range of Motion (Right):
    • Flexion: 95 degrees (active), 100 degrees (passive)
    • Extension: Lacking 5 degrees to full extension
  • Knee Range of Motion (Left):
    • Within normal limits
  • Manual Muscle Testing (Right Lower Extremity):
    • Quadriceps: 3+/5
    • Hamstrings: 3/5
    • Hip flexors: 4/5
    • Hip abductors: 3+/5
  • Palpation:
    • Mild swelling around the right knee joint
    • Surgical incision well-healed
  • Special Tests:
    • Lachman's Test: Negative (firm endpoint)
    • Anterior Drawer Test: Negative
  • Functional Tests:
    • Unable to perform single-leg stance on the right leg
    • Difficulty with sit-to-stand without using upper extremities for support

Assessment

Sarah is a 25-year-old female 6 weeks post-ACL reconstruction of her right knee. She presents with decreased range of motion, strength deficits, and functional limitations consistent with her post-operative status. The surgical incision has healed well, and there are no signs of complications. Sarah's motivation to return to soccer and her overall good health suggest a positive prognosis for recovery. The main areas of focus for rehabilitation will be improving knee range of motion, strengthening the quadriceps and hamstrings, enhancing proprioception, and gradually progressing weight-bearing status. Given her athletic background and goals, a sport-specific rehabilitation program will be essential in the later stages of her recovery.

Plan

  1. Range of Motion Exercises:

    • Passive and active-assisted knee flexion and extension exercises
    • Patellar mobilizations
    • Frequency: 3 sets of 10 repetitions, 2-3 times daily

  2. Strengthening Exercises:

    • Quad sets
    • Straight leg raises (all planes)
    • Hamstring curls (isometric progressing to isotonic)
    • Calf raises (when full weight-bearing is achieved)
    • Frequency: 3 sets of 10 repetitions, once daily

  3. Gait Training:

    • Progress from partial to full weight-bearing as tolerated
    • Proper crutch use and gait pattern education

  4. Modalities:

    • Cryotherapy: 15-20 minutes post-exercise
    • Neuromuscular Electrical Stimulation (NMES) to quadriceps: 15 minutes

  5. Balance and Proprioception:

    • Weight shifts
    • Single-leg stance (when appropriate)
    • Use of balance board (in later stages)

  6. Patient Education:

    • Proper use of crutches
    • Home exercise program
    • Activity modification and gradual return to activities

  7. Follow-up:

    • Schedule 2-3 physical therapy sessions per week for the next 4 weeks
    • Re-evaluate progress and adjust treatment plan as needed

ICD-10 Code: Z47.31 (Aftercare following reconstruction of joint)
CPT Codes:

  • 97110 (Therapeutic exercises)
  • 97116 (Gait training)
  • 97140 (Manual therapy techniques)

3. Chronic Shoulder Pain

Description

The patient reports chronic shoulder pain and stiffness that has been present for several months. The pain is exacerbated by overhead activities and lifting.

SOAP Note

Patient Name: Jane Smith

Date of Visit: 07/20/2024

Subjective

Jane Smith presents with a chief complaint of chronic shoulder pain and stiffness that has been present for several months. She describes the pain as a dull ache that is exacerbated by overhead activities and lifting. Jane rates the pain as 7/10 and reports difficulty performing daily activities such as reaching, lifting, and sleeping due to the pain. She has tried over-the-counter pain medication, which provided minimal relief. Jane has a history of shoulder injuries and has not experienced any recent trauma. She is currently not taking any prescribed medications. Jane's primary goal is to reduce her pain and improve her functional ability.

Objective

  • Vital Signs:
    • BP: 122/78 mmHg
    • HR: 70 bpm
    • RR: 16 breaths per minute
    • Temp: 98.6°F
  • Posture:
    • Forward head posture observed
  • Range of Motion:
    • Flexion: Limited to 160 degrees with pain
    • Extension: Limited to 30 degrees with pain
    • Abduction: Limited to 90 degrees with pain
    • External Rotation: Limited to 60 degrees with pain
    • Internal Rotation: Limited to L1 with pain
  • Muscle Strength:
    • Deltoids: 4/5
    • Supraspinatus: 3+/5
    • Infraspinatus: 3+/5
    • Teres Minor: 3+/5
  • Palpation:
    • Tenderness noted in the supraspinatus and infraspinatus muscles
    • No palpable swelling or deformity
  • Special Tests:
    • Hawkins-Kennedy Test: Positive
    • Neer's Test: Positive
    • Speed's Test: Negative

Assessment

Jane presents with symptoms indicative of chronic shoulder pain and stiffness, likely resulting from a combination of factors including poor posture, muscle imbalances, and degenerative changes. Her primary functional limitations include difficulty with overhead activities, lifting, and sleeping due to pain. The limited range of motion, muscle strength deficits, and positive special tests support the diagnosis of shoulder impingement syndrome. The absence of recent trauma and the chronic nature of the pain indicate a more gradual onset of the condition. Jane's primary goal is to reduce her pain and improve her functional ability. Given her motivation and the chronic nature of her condition, it is expected that she will respond well to a structured physical therapy program. The plan includes manual therapy to address muscle tension and improve range of motion, strengthening exercises to improve muscle balance and support recovery, and education on proper posture and body mechanics to prevent future injuries. Follow-up appointments will be necessary to monitor progress and adjust the treatment plan as needed.

Plan

  1. Manual Therapy:

    • Utilize techniques such as soft tissue mobilization, joint mobilization, and myofascial release to reduce muscle tension and improve shoulder mobility.

  2. Therapeutic Exercises:

    • Strengthening:
      • Prescribe specific strengthening exercises for the rotator cuff and scapular stabilizers to be performed daily.
      • Examples: Shoulder blade squeezes, shoulder rotations, and shoulder flexion exercises.
    • Stretching:
      • Implement a stretching routine targeting the shoulder joint and surrounding muscles to improve flexibility.
      • Examples: Shoulder flexion stretches, shoulder abduction stretches, and chest stretches.
    • Frequency:
      • Perform these exercises twice daily, with 3 sets of 10 repetitions for strengthening exercises and hold stretches for 30 seconds each.

  3. Modalities:

    • Heat Therapy:
      • Apply heat to the shoulder for 15-20 minutes before exercise sessions to relax muscles and reduce pain.
    • Ice Therapy:
      • Use ice packs for 10-15 minutes post-exercise if there is any swelling or increased pain.

  4. Patient Education:

    • Educate Jane on proper posture and body mechanics to prevent future injuries.
    • Discuss the importance of maintaining good posture, especially during prolonged sitting or standing.
    • Provide instructions on ergonomic adjustments for her workstation.

  5. Home Exercise Program (HEP):

    • Develop a home exercise program that includes the prescribed strengthening and stretching exercises.
    • Ensure Jane understands the exercises and their importance in her recovery process.

  6. Activity Modification:

    • Advise Jane to avoid activities that exacerbate her pain, such as heavy lifting and overhead activities without proper technique.
    • Encourage frequent changes in position and short breaks to reduce stiffness.

  7. Follow-Up:

    • Schedule follow-up appointments twice a week for the next two weeks to monitor progress and make necessary adjustments to the treatment plan.
    • Re-evaluate Jane's condition and progress at each session, and modify exercises and manual therapy techniques as needed.

ICD-10 Code: M75.4 (Rotator cuff syndrome)
CPT Code: 97110 (Therapeutic exercises)

4. Cervical Radiculopathy

Description

The patient presents with neck pain radiating down the right arm, accompanied by numbness and tingling in the right hand. These symptoms have been present for three weeks and are affecting daily activities and sleep.

SOAP Note

Patient Name: Michael Brown

Date of Visit: 08/02/2024

Subjective

Michael Brown, a 45-year-old male, presents with complaints of neck pain radiating down his right arm to his hand. The pain began approximately three weeks ago without any specific incident or trauma. He describes the pain as sharp and burning, rating it as 6/10 at rest and 8/10 with movement. Michael reports numbness and tingling in his right hand, particularly in his thumb and index finger. He mentions difficulty sleeping due to pain and discomfort when turning his head, especially towards the right side. Michael works as a computer programmer and spends long hours at his desk, which he believes may be contributing to his symptoms. He has tried over-the-counter pain medication with minimal relief. Michael's primary goal is to alleviate the pain and regain full function of his neck and right arm.

Objective

  • Vital Signs:
    • BP: 126/82 mmHg
    • HR: 74 bpm
    • RR: 16 breaths per minute
    • Temp: 98.4°F
  • Posture:
    • Forward head posture and rounded shoulders observed
  • Cervical Range of Motion:
    • Flexion: 40 degrees with pain
    • Extension: 30 degrees with pain
    • Right Rotation: 50 degrees with increased pain and radiation
    • Left Rotation: 70 degrees with mild discomfort
    • Right Lateral Flexion: 25 degrees with pain
    • Left Lateral Flexion: 35 degrees with mild discomfort
  • Upper Extremity Range of Motion:
    • Within normal limits bilaterally
  • Muscle Strength:
    • Right upper extremity: 4/5 in C6-C7 myotomes
    • Left upper extremity: 5/5 throughout
  • Sensation:
    • Diminished light touch and pinprick sensation in right C6-C7 dermatomes
  • Reflexes:
    • Biceps (C5-C6): 2+ bilaterally
    • Triceps (C7): 1+ on right, 2+ on left
  • Palpation:
    • Tenderness noted in the right cervical paraspinal muscles and right upper trapezius
  • Special Tests:
    • Spurling's Test: Positive on the right side
    • Upper Limb Tension Test: Positive on the right side

Assessment

Michael presents with symptoms consistent with right-sided cervical radiculopathy, likely affecting the C6-C7 nerve roots. His primary functional limitations include difficulty with neck movements, especially rotation to the right, and impaired use of his right arm due to pain, numbness, and tingling. The positive Spurling's test and Upper Limb Tension Test support the diagnosis of cervical radiculopathy. The diminished sensation and slightly reduced muscle strength in the right upper extremity further corroborate this assessment.

Contributing factors likely include poor posture, prolonged desk work, and possible degenerative changes in the cervical spine. Given the duration of symptoms and their impact on daily activities and sleep, a comprehensive physical therapy approach is warranted. The prognosis is generally good with appropriate intervention, although full resolution may take several weeks to months.

Plan

  1. Manual Therapy:

    • Gentle cervical traction to decompress nerve roots
    • Soft tissue mobilization to address muscle tension in the cervical paraspinals and upper trapezius
    • Grade I-II joint mobilizations to the cervical spine to improve mobility and reduce pain

  2. Therapeutic Exercises:

    • Cervical Range of Motion Exercises:
      • Gentle active and active-assisted ROM exercises in all planes
    • Strengthening:
      • Deep cervical flexor strengthening
      • Scapular stabilization exercises
    • Stretching:
      • Upper trapezius, levator scapulae, and pectoralis stretches
    • Frequency:
      • Perform exercises 2-3 times daily, with 10 repetitions for ROM and strengthening exercises, and hold stretches for 30 seconds each

  3. Postural Education:

    • Instruct on proper sitting posture and workstation ergonomics
    • Teach chin tucks and scapular retractions for postural awareness

  4. Modalities:

    • Intermittent cervical traction: 15 minutes at 10-15 lbs
    • TENS for pain management as needed

  5. Home Exercise Program (HEP):

    • Provide written and pictorial instructions for all exercises
    • Emphasize the importance of consistent performance of HEP

  6. Activity Modification:

    • Advise on proper sleeping positions and pillow use
    • Recommend frequent breaks from prolonged sitting and computer use

  7. Patient Education:

    • Explain the nature of cervical radiculopathy and expected recovery timeline
    • Discuss the importance of maintaining good posture throughout the day

  8. Follow-Up:

    • Schedule 2-3 physical therapy sessions per week for the next 4 weeks
    • Re-evaluate progress and adjust treatment plan as needed

ICD-10 Code: M54.12 (Radiculopathy, cervical region)
CPT Codes:

  • 97110 (Therapeutic exercises)
  • 97140 (Manual therapy techniques)
  • 97012 (Traction, mechanical)

5. Hip Osteoarthritis

Description

The patient is a 68-year-old retired teacher with a diagnosis of hip osteoarthritis. She reports increasing pain and stiffness in her right hip, which is affecting her ability to perform daily activities and enjoy her retirement.

SOAP Note

Patient Name: Margaret Thompson

Date of Visit: 08/02/2024

Subjective

Margaret Thompson, a 68-year-old female, presents with complaints of worsening right hip pain and stiffness. She reports that the pain has been gradually increasing over the past year but has become more noticeable in the last three months. Margaret describes the pain as a deep ache in her right hip that radiates to her groin and sometimes down her thigh. She rates the pain as 4/10 at rest and 7/10 with activity.

Margaret reports difficulty with prolonged walking, climbing stairs, and getting in and out of her car. She mentions that the pain is worse in the morning and after sitting for long periods. Margaret has been taking over-the-counter pain medication (Tylenol) with minimal relief. She has no history of hip injuries or surgeries. Margaret's goal is to reduce pain and improve her mobility to continue her daily activities and hobbies, including gardening and playing with her grandchildren.

Objective

  • Vital Signs:
    • BP: 128/82 mmHg
    • HR: 76 bpm
    • RR: 16 breaths per minute
    • Height: 5'5" (165 cm)
    • Weight: 160 lbs (72.6 kg)
  • Gait:
    • Antalgic gait pattern with decreased weight-bearing on the right lower extremity
    • Reduced step length on the right side
  • Hip Range of Motion (Right):
    • Flexion: 90 degrees (painful at end range)
    • Extension: 5 degrees (limited by pain)
    • Internal Rotation: 15 degrees (painful)
    • External Rotation: 25 degrees (limited by stiffness)
    • Abduction: 25 degrees (painful at end range)
    • Adduction: 10 degrees (limited by pain)
  • Hip Range of Motion (Left):
    • Within normal limits for age
  • Manual Muscle Testing (Right Lower Extremity):
    • Hip Flexors: 4-/5
    • Hip Extensors: 4/5
    • Hip Abductors: 3+/5
    • Hip Adductors: 4/5
  • Palpation:
    • Tenderness over the right greater trochanter and anterior hip joint line
  • Special Tests:
    • FABER Test: Positive on the right (pain and limited range)
    • Scour Test: Positive on the right (pain and crepitus)
  • Functional Tests:
    • 30-second Chair Stand Test: 8 repetitions (below age-matched norms)
    • Timed Up and Go Test: 14 seconds (indicating increased fall risk)

Assessment

Margaret presents with signs and symptoms consistent with moderate right hip osteoarthritis. Her primary impairments include decreased hip range of motion, particularly in flexion and internal rotation, reduced strength in hip musculature, and pain with weight-bearing activities. These impairments have led to functional limitations in walking, stair climbing, and performing daily activities. Margaret's antalgic gait pattern and difficulty with prolonged walking increase her risk of falls and further functional decline if not addressed.

The chronicity of her symptoms and radiographic evidence of osteoarthritis suggest that while complete resolution of symptoms may not be achievable, significant improvements in pain management and functional capacity are possible with appropriate intervention. Margaret's motivation to stay active and engage with her grandchildren is a positive prognostic factor. The treatment plan will focus on pain management, improving hip mobility and strength, enhancing functional capacity, and educating Margaret on self-management strategies for long-term symptom control.

Plan

  1. Pain Management:

    • Apply moist heat to the right hip for 15 minutes prior to exercises
    • Gentle manual therapy techniques including soft tissue mobilization and grade I-II joint mobilizations
    • Educate on proper use of over-the-counter pain medications and ice/heat application at home

  2. Range of Motion Exercises:

    • Gentle hip circumduction
    • Supine hip flexion with assistance
    • Standing hip abduction and extension
    • Frequency: 2 sets of 10 repetitions, twice daily

  3. Strengthening Exercises:

    • Isometric hip abduction, adduction, and extension
    • Bridging exercises
    • Clamshells for hip external rotators
    • Mini squats (as tolerated)
    • Frequency: 3 sets of 10 repetitions, once daily

  4. Functional Training:

    • Gait training with emphasis on normalizing stride length and weight acceptance
    • Sit-to-stand transfers with proper technique
    • Stair climbing strategies
    • Balance exercises (static and dynamic)

  5. Aerobic Conditioning:

    • Stationary cycling: Start with 10 minutes, progressing as tolerated
    • Aquatic exercises if available (to reduce joint stress)

  6. Patient Education:

    • Explain the nature of osteoarthritis and importance of regular movement
    • Instruct on joint protection techniques during daily activities
    • Discuss weight management strategies and its impact on joint health
    • Provide guidance on proper footwear and use of assistive devices if needed

  7. Home Exercise Program (HEP):

    • Provide written and pictorial instructions for all exercises
    • Emphasize consistency and gradual progression

  8. Follow-Up:

    • Schedule 2 physical therapy sessions per week for 6 weeks
    • Re-evaluate progress at 3 weeks and adjust plan as needed

ICD-10 Code: M16.11 (Unilateral primary osteoarthritis, right hip)
CPT Codes:

  • 97110 (Therapeutic exercises)
  • 97140 (Manual therapy techniques)
  • 97530 (Therapeutic activities)

6. Tennis Elbow (Lateral Epicondylitis)

Description

The patient presents with pain on the outer side of the elbow that has been gradually worsening over the past month. The pain increases with gripping activities and wrist extension.

SOAP Note

Patient Name: Robert Thompson

Date of Visit: 08/15/2024

Subjective

Robert Thompson, a 42-year-old male, presents with complaints of pain on the outer aspect of his right elbow. The pain began gradually about a month ago and has been steadily worsening. Robert reports that the pain increases with activities that involve gripping or extending his wrist, such as shaking hands, turning doorknobs, or lifting objects. He rates the pain as 3/10 at rest and 7/10 during aggravating activities. Robert mentions that he plays recreational tennis twice a week and works as an accountant, which involves extensive computer use. He has tried over-the-counter pain medication and ice with minimal relief. Robert's primary goal is to return to playing tennis without pain and to perform his work duties comfortably.

Objective

  • Vital Signs:
    • BP: 122/78 mmHg
    • HR: 70 bpm
    • RR: 14 breaths per minute
    • Temp: 98.2°F
  • Observation:
    • No visible swelling or deformity of the right elbow
  • Palpation:
    • Tenderness over the lateral epicondyle of the right elbow
    • Increased pain with palpation of the common extensor tendon origin
  • Range of Motion (Right Elbow):
    • Flexion: 145 degrees (WNL)
    • Extension: 0 degrees (WNL)
    • Supination: 85 degrees (WNL)
    • Pronation: 80 degrees (WNL)
  • Range of Motion (Right Wrist):
    • Extension: 60 degrees with pain (70 degrees on left)
    • Flexion: 80 degrees (WNL)
  • Strength Testing (Right):
    • Wrist Extension: 4-/5 with pain
    • Grip Strength: 30 lbs (compared to 45 lbs on left)
  • Special Tests:
    • Cozen's Test: Positive
    • Mill's Test: Positive
    • Chair Test: Positive

Assessment

Robert presents with signs and symptoms consistent with right lateral epicondylitis (tennis elbow). His primary functional limitations include difficulty with gripping activities and wrist extension, which are affecting both his recreational tennis playing and his work as an accountant. The positive special tests, localized tenderness over the lateral epicondyle, and pain with resisted wrist extension support this diagnosis. Contributing factors likely include repetitive stress from tennis playing and prolonged computer use at work.

The prognosis for lateral epicondylitis is generally good with appropriate conservative management. Given Robert's motivation to return to tennis and improve his work comfort, it is expected that he will respond well to a structured physical therapy program. The plan will focus on reducing pain and inflammation, improving flexibility and strength of the wrist extensors, and addressing any biomechanical issues in his tennis technique and work ergonomics.

Plan

  1. Pain Management:

    • Educate on proper use of ice massage for 10-15 minutes, 3-4 times daily
    • Instruct on activity modification to avoid aggravating movements
    • Consider counterforce bracing for symptom relief during activities

  2. Manual Therapy:

    • Soft tissue mobilization to the common extensor tendon and surrounding musculature
    • Joint mobilizations for the radioulnar and humeroradial joints if indicated

  3. Therapeutic Exercises:

    • Stretching:
      • Wrist extensor stretch
      • Forearm supinator and pronator stretches
    • Strengthening:
      • Eccentric wrist extension exercises (start with 1 set of 15 reps, progress to 3 sets)
      • Isometric wrist extension holds
      • Progressive resistive exercises for wrist and forearm as tolerated
    • Frequency: Perform exercises 1-2 times daily

  4. Modalities:

    • Ultrasound to the lateral epicondyle area for pain relief and tissue healing
    • Consider low-level laser therapy if available

  5. Patient Education:

    • Proper ergonomics for computer use at work
    • Tennis technique analysis and modification (refer to a tennis pro if necessary)
    • Importance of warm-up and cool-down routines before and after tennis

  6. Home Exercise Program (HEP):

    • Provide written and pictorial instructions for all prescribed exercises
    • Emphasize consistency and gradual progression

  7. Follow-Up:

    • Schedule 2 physical therapy sessions per week for 4 weeks
    • Re-evaluate progress at 2 weeks and adjust plan as needed

ICD-10 Code: M77.1 (Lateral epicondylitis)
CPT Codes:

  • 97110 (Therapeutic exercises)
  • 97140 (Manual therapy techniques)
  • 97035 (Ultrasound therapy)

7. Ankle Sprain

Description

The patient is a 28-year-old recreational basketball player who sustained a right ankle sprain during a game two days ago. They present with pain, swelling, and difficulty walking.

SOAP Note

Patient Name: Emily Chen

Date of Visit: 08/15/2024

Subjective

Emily Chen, a 28-year-old female, presents with a chief complaint of right ankle pain following a basketball injury two days ago. She reports "rolling" her ankle inward while landing after a jump. Emily describes immediate pain and swelling, rating the initial pain as 8/10. Currently, she rates the pain as 6/10 at rest and 8/10 with weight-bearing activities. She reports difficulty walking and has been using crutches since the injury. Emily has been applying ice and elevating her ankle, which provides temporary relief. She denies any popping sound at the time of injury or any previous ankle injuries. Emily's goal is to return to playing basketball and resume her normal daily activities without pain.

Objective

  • Vital Signs:
    • BP: 118/76 mmHg
    • HR: 72 bpm
    • RR: 16 breaths per minute
    • Temp: 98.6°F
  • Observation:
    • Moderate swelling around the right lateral malleolus
    • Ecchymosis present on the lateral aspect of the right ankle
  • Gait:
    • Antalgic gait with decreased weight-bearing on the right lower extremity
  • Ankle Range of Motion (Right):
    • Dorsiflexion: 10 degrees (limited by pain)
    • Plantarflexion: 30 degrees (limited by pain)
    • Inversion: Unable to test due to pain
    • Eversion: 10 degrees (limited by pain)
  • Ankle Range of Motion (Left):
    • Within normal limits in all planes
  • Manual Muscle Testing (Right):
    • Dorsiflexion: 4-/5 (limited by pain)
    • Plantarflexion: 4/5 (limited by pain)
    • Inversion: Unable to test due to pain
    • Eversion: 3+/5 (limited by pain)
  • Palpation:
    • Tenderness over the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL)
    • Mild tenderness over the medial malleolus
  • Special Tests:
    • Anterior Drawer Test: Positive (increased laxity compared to left side)
    • Talar Tilt Test: Positive (increased laxity compared to left side)
    • Ottawa Ankle Rules: Negative (no bony tenderness in key areas)

Assessment

Emily presents with signs and symptoms consistent with a Grade II lateral ankle sprain, primarily affecting the anterior talofibular ligament (ATFL) and possibly the calcaneofibular ligament (CFL). Her primary functional limitations include difficulty with weight-bearing, decreased range of motion, and impaired strength in the affected ankle. The positive special tests and localized tenderness support this diagnosis. The absence of bony tenderness as per Ottawa Ankle Rules suggests that x-rays are not necessary at this time.

Given the acute nature of the injury and Emily's overall good health, the prognosis for recovery is favorable with appropriate management. The focus of treatment will be on reducing pain and swelling, gradually restoring range of motion and strength, and improving proprioception to prevent future injuries. Emily's motivation to return to basketball is a positive factor in her rehabilitation process.

Plan

  1. Pain and Edema Management:

    • PRICE protocol (Protection, Rest, Ice, Compression, Elevation)
    • Instruct on proper ice application: 15-20 minutes every 2-3 hours
    • Recommend compression wrap or ankle sleeve for edema control

  2. Manual Therapy:

    • Gentle joint mobilizations to the talocrural and subtalar joints to improve mobility
    • Soft tissue mobilization to reduce muscle guarding and promote circulation

  3. Therapeutic Exercises:

    • Range of Motion:
      • Active and passive ankle ROM exercises in all planes, pain-free
      • Ankle alphabet exercises
    • Strengthening:
      • Isometric exercises for dorsiflexion, plantarflexion, inversion, and eversion
      • Progress to resistive band exercises as tolerated
    • Proprioception:
      • Single-leg balance exercises (progress from firm to unstable surfaces)
      • Weight shifts and mini squats on affected leg
    • Frequency: Perform exercises 2-3 times daily, 10-15 repetitions each

  4. Gait Training:

    • Instruct in proper use of crutches for partial weight-bearing
    • Progress weight-bearing as tolerated with focus on normal gait pattern

  5. Modalities:

    • Cryotherapy at the end of each session
    • Consider low-level laser therapy for pain management and tissue healing

  6. Patient Education:

    • Proper ankle taping techniques for when returning to sports
    • Importance of wearing supportive footwear
    • Home exercise program and progression

  7. Follow-Up:

    • Schedule 2-3 physical therapy sessions per week for 3-4 weeks
    • Re-evaluate at each session and adjust plan as needed

ICD-10 Code: S93.401A (Sprain of lateral ligament of right ankle, initial encounter)
CPT Codes:

  • 97110 (Therapeutic exercises)
  • 97140 (Manual therapy techniques)
  • 97116 (Gait training)

8. Plantar Fasciitis

Description

The patient is a 40-year-old office worker who presents with heel pain, particularly severe in the mornings and after prolonged periods of sitting. The pain has been present for approximately two months and is affecting their ability to walk comfortably.

SOAP Note

Patient Name: Robert Thompson

Date of Visit: 08/10/2024

Subjective

Robert Thompson, a 40-year-old male office worker, presents with a chief complaint of right heel pain that has been present for approximately two months. He describes the pain as sharp and localized to the bottom of the heel, rating it as 7/10 in the morning and 5/10 throughout the day. Robert reports that the pain is most severe with the first few steps in the morning and after prolonged periods of sitting. He mentions difficulty walking for extended periods and discomfort while standing at work. Robert has tried over-the-counter insoles and pain medication with minimal relief. He has no previous history of foot problems and is generally in good health. Robert's goal is to alleviate the pain and return to his normal walking routine without discomfort.

Objective

  • Vital Signs:
    • BP: 122/78 mmHg
    • HR: 70 bpm
    • RR: 16 breaths per minute
    • Height: 5'10"
    • Weight: 185 lbs
    • BMI: 26.5
  • Gait:
    • Antalgic gait with decreased stance time on the right foot
    • Reduced push-off during terminal stance on the right
  • Foot and Ankle Range of Motion (Right):
    • Ankle Dorsiflexion: 10 degrees (limited)
    • Ankle Plantarflexion: 45 degrees (WNL)
    • Subtalar Inversion/Eversion: WNL
  • Strength Testing (Right):
    • Ankle Dorsiflexion: 5/5
    • Ankle Plantarflexion: 5/5
    • Toe Flexion: 4+/5 (limited by pain)
  • Palpation:
    • Tenderness at the medial calcaneal tubercle
    • Tightness noted in the plantar fascia and Achilles tendon
  • Special Tests:
    • Windlass Test: Positive on the right
    • Tinel's Sign: Negative bilaterally

Assessment

Robert presents with symptoms consistent with plantar fasciitis of the right foot. His primary functional limitations include pain with initial weight-bearing after rest and difficulty with prolonged walking or standing. The localized tenderness at the medial calcaneal tubercle, positive Windlass test, and limited ankle dorsiflexion support this diagnosis. Contributing factors likely include prolonged standing at work, possible inadequate footwear, and tight plantar fascia and Achilles tendon.

The prognosis for plantar fasciitis is generally good with appropriate conservative management. Given the duration of symptoms (two months), it may take several weeks to months to achieve full resolution. Robert's motivation to return to normal walking activities and his overall good health are positive factors for recovery.

Plan

  1. Manual Therapy:

    • Soft tissue mobilization to the plantar fascia and calf muscles
    • Joint mobilization to improve talocrural dorsiflexion

  2. Therapeutic Exercises:

    • Stretching:
      • Plantar fascia-specific stretches
      • Calf stretches (gastrocnemius and soleus)
      • Frequency: 3 sets of 30-second holds, 3 times daily
    • Strengthening:
      • Intrinsic foot muscle exercises (toe curls, marble pickup)
      • Calf raises (double-leg progressing to single-leg)
      • Frequency: 3 sets of 15 repetitions, once daily

  3. Modalities:

    • Ultrasound to the plantar fascia: 5 minutes at 1 MHz, 1.5 W/cm²
    • Cryotherapy: Ice massage to the plantar aspect of the heel for 5-10 minutes post-exercise

  4. Patient Education:

    • Proper footwear recommendations
    • Use of a night splint to maintain ankle dorsiflexion during sleep
    • Activity modification to avoid prolonged standing/walking

  5. Home Exercise Program:

    • Instruct in home exercises including stretching and strengthening as prescribed above
    • Recommend rolling a frozen water bottle under the foot for 5-10 minutes daily

  6. Orthotics:

    • Consider temporary use of over-the-counter orthotics with arch support

  7. Follow-Up:

    • Schedule 2 physical therapy sessions per week for 4 weeks
    • Re-evaluate progress and adjust plan as needed

ICD-10 Code: M72.2 (Plantar fascial fibromatosis)
CPT Codes:

  • 97110 (Therapeutic exercises)
  • 97140 (Manual therapy techniques)
  • 97035 (Ultrasound therapy)

9. Rotator Cuff Tear

Description

The patient is a 55-year-old office worker who presents with persistent right shoulder pain and weakness, particularly when reaching overhead or behind their back. They report a gradual onset of symptoms over the past three months, with no specific injury event.

SOAP Note

Patient Name: David Thompson

Date of Visit: 08/15/2024

Subjective

David Thompson, a 55-year-old male office worker, presents with a chief complaint of right shoulder pain and weakness that has been present for approximately three months. He reports a gradual onset of symptoms with no specific injury event. David describes the pain as a dull ache that becomes sharp with certain movements, particularly when reaching overhead or behind his back. He rates the pain as 3/10 at rest and 7/10 with aggravating activities. David mentions difficulty with daily activities such as dressing, reaching for objects on high shelves, and sleeping on his right side. He has tried over-the-counter pain medication and ice with minimal relief. David's goal is to regain full use of his right arm without pain and return to his regular gym routine.

Objective

  • Vital Signs:
    • BP: 128/78 mmHg
    • HR: 70 bpm
    • RR: 16 breaths per minute
    • Temp: 98.2°F
  • Posture:
    • Slight forward head and rounded shoulders observed
  • Shoulder Range of Motion (Right):
    • Flexion: 120 degrees with pain
    • Abduction: 100 degrees with pain
    • External Rotation: 40 degrees with pain
    • Internal Rotation: Hand reaches to L5 with pain
  • Shoulder Range of Motion (Left):
    • Within normal limits
  • Muscle Strength (Right):
    • Shoulder Flexion: 4-/5 with pain
    • Shoulder Abduction: 3+/5 with pain
    • External Rotation: 3/5 with pain
    • Internal Rotation: 4/5 with pain
  • Palpation:
    • Tenderness over the right supraspinatus and infraspinatus tendons
    • Mild atrophy of the right supraspinatus muscle noted
  • Special Tests:
    • Empty Can Test: Positive on the right
    • Hawkins-Kennedy Test: Positive on the right
    • External Rotation Lag Sign: Positive on the right (10-degree lag)

Assessment

David presents with signs and symptoms consistent with a right rotator cuff tear, likely involving the supraspinatus tendon. His primary functional limitations include difficulty with overhead activities, reaching behind his back, and sleeping on the affected side. The positive special tests, weakness in shoulder abduction and external rotation, and limited range of motion support this diagnosis. Contributing factors may include age-related degeneration, poor posture, and possible overuse from work or recreational activities.

The prognosis for rotator cuff tears can vary depending on the size and location of the tear. Given David's age and the gradual onset of symptoms, a trial of conservative management with physical therapy is appropriate. However, if significant functional deficits persist or worsen, further imaging and potential surgical consultation may be necessary.

Plan

  1. Manual Therapy:

    • Soft tissue mobilization to the rotator cuff muscles and surrounding tissues
    • Joint mobilization to improve glenohumeral and scapulothoracic mobility

  2. Therapeutic Exercises:

    • Range of Motion:
      • Active-assisted and passive range of motion exercises for the shoulder
      • Pendulum exercises
      • Frequency: 3 sets of 10 repetitions, 2-3 times daily
    • Strengthening:
      • Isometric exercises for rotator cuff muscles
      • Progressive resistive exercises for scapular stabilizers
      • Frequency: 3 sets of 10 repetitions, once daily

  3. Modalities:

    • Ultrasound to the rotator cuff insertion: 5 minutes at 1 MHz, 1.5 W/cm²
    • Ice pack application for 15 minutes post-exercise

  4. Patient Education:

    • Proper posture and body mechanics instruction
    • Activity modification to avoid painful movements
    • Importance of consistent home exercise program

  5. Home Exercise Program:

    • Instruct in home exercises including stretching and strengthening as prescribed above
    • Provide written and pictorial instructions for reference

  6. Follow-Up:

    • Schedule 2 physical therapy sessions per week for 6 weeks
    • Re-evaluate progress and adjust plan as needed

ICD-10 Code: M75.1 (Rotator cuff tear or rupture, not specified as traumatic)
CPT Codes:

  • 97110 (Therapeutic exercises)
  • 97140 (Manual therapy techniques)
  • 97035 (Ultrasound therapy)

10. Carpal Tunnel Syndrome

Description

The patient is a 42-year-old administrative assistant who presents with numbness, tingling, and pain in her right hand and wrist, particularly affecting the thumb, index, and middle fingers. These symptoms have been progressively worsening over the past three months, especially during work hours.

SOAP Note

Patient Name: Emily Chen

Date of Visit: 08/15/2024

Subjective

Emily Chen, a 42-year-old female, presents with complaints of numbness, tingling, and pain in her right hand and wrist. She reports that these symptoms have been gradually worsening over the past three months. Emily describes the sensation as a "pins and needles" feeling, primarily affecting her thumb, index, and middle fingers. The symptoms are most pronounced during work hours, where she spends significant time typing and using a computer mouse. Emily mentions that she often wakes up at night with a feeling of numbness in her hand, which she shakes to alleviate. She rates her pain as 4/10 at rest and 7/10 during prolonged computer use. Emily has not tried any treatments yet but has been wearing a wrist brace she purchased from a pharmacy. Her primary goal is to reduce the pain and numbness to continue her work without discomfort.

Objective

  • Vital Signs:
    • BP: 122/78 mmHg
    • HR: 70 bpm
    • RR: 16 breaths per minute
    • Temp: 98.2°F
  • Observation:
    • Mild swelling noted in the right wrist
    • No visible atrophy of thenar muscles
  • Range of Motion (Right Wrist):
    • Flexion: 60 degrees (normal 80)
    • Extension: 55 degrees (normal 70)
    • Ulnar Deviation: 30 degrees (normal)
    • Radial Deviation: 15 degrees (normal 20)
  • Strength Testing (Right Hand):
    • Grip strength: 3+/5
    • Pinch strength: 3/5
    • Thumb abduction: 4-/5
  • Sensation:
    • Diminished light touch sensation in the median nerve distribution of the right hand
  • Special Tests:
    • Phalen's Test: Positive at 30 seconds
    • Tinel's Sign: Positive over the right carpal tunnel
    • Durkan's Compression Test: Positive

Assessment

Emily presents with signs and symptoms consistent with right-sided carpal tunnel syndrome. Her primary functional limitations include difficulty with prolonged typing and mouse use, as well as nighttime discomfort affecting sleep. The positive special tests (Phalen's, Tinel's, and Durkan's), along with the pattern of sensory changes and mild weakness in the median nerve distribution, support this diagnosis. Contributing factors likely include repetitive wrist movements associated with her job as an administrative assistant and possibly poor ergonomics at her workstation.

The prognosis for carpal tunnel syndrome with conservative management is generally good, especially when addressed early. Given Emily's relatively recent onset of symptoms and lack of significant muscle atrophy, she is likely to respond well to a comprehensive physical therapy program focusing on nerve gliding exercises, ergonomic modifications, and activity adaptations. However, if symptoms persist or worsen despite conservative management, further medical evaluation and possible surgical intervention may be necessary.

Plan

  1. Manual Therapy:

    • Soft tissue mobilization to the flexor tendons and carpal tunnel region
    • Gentle neural mobilization techniques for the median nerve

  2. Therapeutic Exercises:

    • Nerve Gliding Exercises:
      • Median nerve gliding exercises
      • Tendon gliding exercises for flexor tendons
      • Frequency: 3-5 repetitions, held for 5-7 seconds, 3-5 times daily
    • Strengthening:
      • Gentle grip and pinch strengthening exercises
      • Wrist and forearm strengthening exercises
      • Frequency: 3 sets of 10 repetitions, once daily

  3. Modalities:

    • Ultrasound to the carpal tunnel area: 5 minutes at 1 MHz, 1.0 W/cm²
    • Paraffin bath for pain relief and to improve tissue extensibility

  4. Patient Education:

    • Ergonomic assessment and recommendations for workstation setup
    • Instruction on proper posture and hand positioning during computer use
    • Education on activity modification and work breaks

  5. Home Exercise Program:

    • Provide written and pictorial instructions for nerve and tendon gliding exercises
    • Instruct in self-massage techniques for the forearm and wrist

  6. Splinting:

    • Recommend continued use of a neutral wrist splint at night and during prolonged computer use

  7. Follow-Up:

    • Schedule 2 physical therapy sessions per week for 4 weeks
    • Re-evaluate progress and adjust plan as needed

ICD-10 Code: G56.00 (Carpal tunnel syndrome, unspecified upper limb)
CPT Codes:

  • 97110 (Therapeutic exercises)
  • 97140 (Manual therapy techniques)
  • 97035 (Ultrasound therapy)

Was this page helpful?