Physical Therapy SOAP Note example – Best 3

Physical Therapy SOAP Note Example – Knee Pain & Dysfunction

Subjective:

CC (Chief Complaint):
50-year-old Caucasian female presents with complaints of right knee pain and stiffness for the past three months. She reports difficulty with walking, climbing stairs, and getting up from a seated position. She describes the pain as dull and aching, with occasional sharp pain when bearing weight.

HPI:

• Onset: Gradual onset, no specific injury.
• Duration: Persistent for three months.
• Character:
  • Dull ache at rest, sharp pain with movement.
  • Worse in the morning and after prolonged sitting.
  • Occasional swelling, especially after prolonged activity.
• Severity: Rates pain 6/10 on most days, 8/10 after prolonged standing.
• Aggravating Factors: Walking, climbing stairs, prolonged standing.
• Relieving Factors: Rest, applying ice, NSAIDs (ibuprofen).
• Functional Limitations:
  • Difficulty squatting, kneeling, or standing for long periods.
  • Reduced ability to perform daily activities like grocery shopping and house chores.

Past Medical History:

• Osteoarthritis (diagnosed 3 years ago, worsening symptoms)
• Hypertension (well-controlled on medication)

Current Medications:

• Lisinopril 10mg PO daily (for hypertension)
• Ibuprofen 400mg PRN (for knee pain)

Allergies:

• No known drug allergies

ROS:

• GENERAL: Reports fatigue but denies fever or weight loss.
• HEENT: No visual changes, no tinnitus.
• CARDIOVASCULAR: No palpitations or chest pain.
• RESPIRATORY: No shortness of breath.
• GASTROINTESTINAL: No nausea or vomiting.
• GENITOURINARY: No urinary complaints.
• MUSCULOSKELETAL: Reports knee pain, stiffness, and occasional swelling. No numbness, tingling, or radiating pain.
• NEUROLOGICAL: No weakness or balance issues.

Objective:

Vital Signs:

• BP: 122/76 mmHg
• HR: 70 bpm
• RR: 16 bpm
• Temp: 98.1°F
• O2 Sat: 98% on room air

Physical Examination:

• Observation:
  • Mild right knee swelling with no visible deformity.
  • No skin discoloration, no signs of infection.
• Palpation:
  • Mild tenderness over the medial joint line.
  • No warmth or erythema.
• Range of Motion (ROM) Testing:
  • Right knee flexion: 110° (limited due to pain, normal is 135°)
  • Right knee extension: -5° (normal is 0°)
• Strength Testing (Manual Muscle Testing – MMT):
  • Quadriceps (Right): 3+/5 (weak)
  • Hamstrings (Right): 4/5 (mild weakness)
• Special Tests:
  • Positive McMurray’s Test (mild discomfort, suggests possible meniscus involvement).
  • Negative Lachman’s Test (no ACL instability).
  • Patellar Grind Test: Mild crepitus, consistent with patellofemoral pain syndrome.
• Gait Analysis:
  • Antalgic gait favoring the right leg, with reduced stance time on the affected limb.
• Functional Testing:
  • Sit-to-stand test: 10 reps with difficulty, using upper extremities for assistance.
  • Timed Up and Go (TUG) test: 14 seconds (borderline functional limitation).

Imaging Results (Reviewed X-ray from PCP Visit):

• Mild medial joint space narrowing consistent with osteoarthritis.
• No fractures or dislocations noted.

Assessment:

Primary Diagnosis:

🩺 M17.11 – Unilateral Primary Osteoarthritis, Right Knee

• Rationale:
  • Chronic knee pain, stiffness, and functional limitations.
  • Imaging confirms osteoarthritis with joint space narrowing.
  • Symptoms align with progressive degenerative joint disease.

Differential Diagnoses & Rationale:

1. M22.2X1 – Patellofemoral Pain Syndrome (PFPS), Right Knee
   • Considered due to anterior knee pain and crepitus.
   • Ruled out as primary diagnosis because the pain is more diffuse and involves joint degeneration rather than isolated patellar mechanics.
2. S83.241A – Right Meniscus Tear (Possible Medial Meniscus Injury)
   • McMurray’s test was mildly positive, but no history of acute trauma.
   • MRI would be needed to confirm, but symptoms are more consistent with osteoarthritis.
3. M25.561 – Knee Pain, Right (Non-Specific Diagnosis)
   • Used when a definitive diagnosis cannot be made.
   • Not needed in this case, as osteoarthritis is confirmed.
4. G57.51 – Sciatica, Right Side
   • Ruled out due to no radiating pain or neurological symptoms.

Plan (Treatment & Rationale):

1. Physical Therapy Goals (Short & Long Term):

Short-Term Goals (4-6 weeks):

• Reduce pain to 3/10 or lower with daily activities.
• Improve knee flexion to at least 125° and full extension.
• Strengthen quadriceps and hamstrings to 4+/5 MMT.
• Improve TUG test to <12 seconds for functional mobility.

Long-Term Goals (3-6 months):

• Achieve pain-free daily activities such as walking, stair climbing.
• Prevent further joint degeneration through muscle strengthening and movement modification.
• Improve overall quality of life with independent home exercise adherence.

2. Physical Therapy Treatment Plan:

Strengthening Exercises:

• Quadriceps Strengthening:
  • Straight leg raises, mini squats, step-ups.
• Hamstring Strengthening:
  • Seated hamstring curls, bridges.
• Hip Strengthening:
  • Clamshell exercises, lateral band walks.

Gait & Mobility Training:

• Balance drills, controlled weight-bearing progression.

Pain Management:

• Ice therapy: After activity for 10-15 minutes.
• TENS unit: Trial for pain modulation.
• Education on joint protection: Proper movement mechanics.

Manual Therapy Techniques:

• Soft tissue mobilization for medial knee pain relief.
• Joint mobilization to increase knee extension.

Home Exercise Program (HEP):

• Daily stretching (hamstrings, quadriceps).
• Non-weight bearing exercises (stationary bike).
• Gradual return to functional activities (walking progression).

3. Follow-Up Plan:

• 2x/week PT sessions for 6 weeks, then reassess.
• Monitor pain, ROM, and strength progress.
• Consider referral for corticosteroid injection if conservative treatment fails.

4. Safety & Education:

• Educate patient on joint protection strategies.
• Discuss proper footwear to reduce knee stress.
• Modify high-impact activities (avoid running, deep squats).

PT SOAP NOTE Example

SUBJECTIVE:

Chief Complaint: “My right knee pain is a bit better but still hurts when I go up and down stairs”

History of Present Illness: 45-year-old female presents for continued PT following right knee pain that began 6 weeks ago after increasing her running mileage in preparation for a half marathon. Patient reports improvement in pain levels since starting PT (6/10 to 4/10 on NPRS). Pain location remains consistent along anterior knee, worse with descending stairs and after sitting for prolonged periods. Reports completing 80% of prescribed home exercise program.

Pain Characteristics:

• Current pain: 2/10
• Best pain: 1/10 (morning)
• Worst pain: 4/10 (after prolonged activity)
• Location: Anterior right knee, primarily inferior to patella
• Quality: Achy, occasional sharp pain with stairs
• Aggravating factors: Descending stairs, prolonged sitting, running >10 minutes
• Alleviating factors: Ice, prescribed exercises, avoiding aggravating activities

Functional Limitations:

• Difficulty with stairs (especially descending)
• Unable to run > 10 minutes
• Pain with prolonged sitting
• Difficulty with full squat activities

Prior Level of Function:

• Independent with all ADLs
• Ran 15-20 miles/week
• Regular gym attendance 3x/week
• No functional limitations

OBJECTIVE:

AROM Right Knee:

• Flexion: 130° (135° at initial eval)
• Extension: 0° (0° at initial eval)

PROM Right Knee:

• Flexion: 135° with firm end feel
• Extension: 0° with firm end feel

Strength Testing (MMT):
Right Lower Extremity:

• Quad: 4+/5 (4/5 at initial eval)
• Hamstring: 4+/5
• Hip Abductors: 4/5
• Hip External Rotators: 4/5

Special Tests:

• Patellar Compression Test: Positive
• Clark’s Sign: Positive
• J-sign: Present
• Patellar Apprehension: Negative
• McMurray’s: Negative
• Anterior Drawer: Negative
• Lachman’s: Negative

Palpation:

• Tenderness along lateral facet of patella
• Increased tension in lateral retinaculum
• No joint line tenderness
• No effusion

Functional Tests:

• Single Leg Squat Test: Increased dynamic knee valgus noted
• Step Down Test: Moderate dynamic knee valgus with decreased control
• Y-Balance Test: Right anterior reach 58cm (compared to 65cm left)

ASSESSMENT:

Primary Diagnosis:

• Patellofemoral Pain Syndrome (M22.2X1)
  Rationale: Clinical presentation consistent with PFPS including anterior knee pain, positive patellar compression test, and pain with activities that increase patellofemoral joint stress. Symptoms and objective findings support this diagnosis.

Differential Diagnoses:

1. Patellar Tendinopathy (M76.51)
   Rationale: Similar presentation but less tenderness directly over patellar tendon
2. Meniscal Tear (M23.201)
   Rationale: Ruled out by negative McMurray’s and lack of joint line tenderness
3. ACL Sprain (S83.501A)
   Rationale: Ruled out by negative Lachman’s and anterior drawer tests

Progress Since Initial Evaluation:

• Pain decreased from 6/10 to 4/10 at worst
• Quad strength improved from 4/5 to 4+/5
• Improved patellar mobility
• Continued impairments in dynamic control with functional activities

Barriers to Progress:

• Work requires prolonged sitting
• Difficulty consistently completing full HEP due to time constraints

PLAN:

Treatment Frequency: 2x/week for 4 weeks

Today’s Interventions:

Manual Therapy (15 mins):

• Soft tissue mobilization to lateral retinaculum
• Patellar mobilizations grades III-IV
  Rationale: Address soft tissue restrictions and improve patellar mobility

Therapeutic Exercise (30 mins):

• Progressive closed chain strengthening
• Hip external rotator/abductor strengthening
• Dynamic control exercises
  Rationale: Address strength deficits and improve neuromuscular control

Neuromuscular Re-education (15 mins):

• Single leg balance progression
• Step down training with feedback
  Rationale: Improve dynamic control and proprioception

Modified HEP:

• Adjusted timing of exercises to improve compliance
• Added pain-free running progression protocol
  Rationale: Support return to running goals while maintaining appropriate load management

Short-term Goals (2-3 weeks):

1. Decrease pain to ≤2/10 with stairs
2. Improve Y-Balance anterior reach to within 5cm of left
3. Demonstrate correct form with single leg squat

Long-term Goals (6-8 weeks):

1. Return to running 30 minutes pain-free
2. Independent with maintenance HEP
3. Zero pain with all functional activities

read more on PICOT Question Generator

Next Visit: 3 days
Time Spent: 60 minutes
Treatment Time: 60 minutes

SOAP Note Example Physical Therapy Orthopedic

S: Subjective

Chief Complaint: “Lower back pain for 3 weeks, worse when bending or sitting.”
HPI:

• 35-year-old male with insidious onset of midline low back pain (LBP) radiating to the right buttock (no leg symptoms). Pain rated 7/10 at worst, 4/10 at rest.
• Aggravated by prolonged sitting, bending, and lifting. Relieved by lying supine.
• No history of trauma, recent weight changes, or bowel/bladder dysfunction.
• Reports difficulty with ADLs (e.g., putting on shoes, lifting groceries).
  PMH: None significant.
  Medications: Ibuprofen 400 mg PRN (reports minimal relief).
  Allergies: NKDA.
  Social: Office worker, sedentary lifestyle.

O: Objective

Observation:

• Antalgic gait with reduced stride length on the right.
• Mild lumbar paraspinal muscle guarding.
  Range of Motion (ROM):
• Lumbar flexion: 50% of normal, pain at end-range.
• Extension: Limited by 75%, pain at midline.
• Side-bending (R/L): Limited bilaterally by 50%.
  Strength:
• Core strength: 4/5 (pain-limited with resisted trunk flexion).
• Lower extremities: 5/5 throughout.
  Special Tests:
• Straight Leg Raise (SLR): Negative bilaterally.
• FABER Test: Negative for sacroiliac joint pain.
• Palpation: Tenderness at L4-L5 spinous processes.
  Functional Mobility:
• Difficulty transitioning sit-to-stand without arm support.

A: Assessment

Primary Diagnosis:

• Mechanical Low Back Pain (LBP), Non-Radicular (ICD-10: M54.5)
  • Rationale:
    • Pain localized to lumbar spine with movement-related aggravation.
    • No neurologic deficits (negative SLR, normal strength/sensation in legs).

Differential Diagnoses:

1. Lumbar Radiculopathy (ICD-10: M54.16)
   • Rationale for Exclusion: Absent leg pain, numbness, or weakness; negative SLR.
2. Lumbar Strain (ICD-10: S39.012A)
   • Rationale for Exclusion: No acute injury reported; insidious onset suggests overuse vs. mechanical etiology.
3. Sacroiliac Joint Dysfunction (ICD-10: M53.3)
   • Rationale for Exclusion: Negative FABER test and no localized SI joint tenderness.

P: Plan

1. Therapeutic Exercise:
   • Core Stabilization: Bird-dog, dead bug exercises (3 sets x 10 reps, 3x/week).
   • Lumbar ROM: Cat-camel stretches, seated pelvic tilts (5 minutes daily).
   • Rationale: Improve spinal stability and reduce stiffness.
2. Manual Therapy:
   • Grade IV lumbar joint mobilizations to L4-L5 (2x/week x 2 weeks).
   • Soft tissue mobilization to paraspinals.
   • Rationale: Restore joint mobility and reduce muscle guarding.
3. Modalities:
   • Heat therapy pre-exercise to relax musculature.
4. Education:
   • Body mechanics training (hip-hinge technique for lifting).
   • Avoid prolonged sitting; recommend standing desk adjustments.
5. Goals:
   • Short-term: Reduce pain to 3/10 at rest within 2 weeks.
   • Long-term: Independent ADLs (e.g., putting on shoes) within 4 weeks.
6. Follow-Up:
   • Reassess in 1 week to adjust interventions.
   • Refer to MD if red flags emerge (e.g., leg weakness, bowel/bladder changes).

Rationale for ICD-10 Selection:

• M54.5 accurately reflects non-specific mechanical LBP without neurologic involvement. Differentials excluded based on negative special tests and history.

Clinical Decision-Making:

• Focus on mechanical contributors (sedentary lifestyle, poor core stability) guided exercise and manual therapy choices. Patient education targets modifiable risk factors.