Complete Guide to Musculoskeletal SOAP Note Examples for Healthcare Providers

If you've ever struggled to document musculoskeletal visits in a way that justifies imaging, PT referrals, and specialist consultations while meeting insurance requirements, this guide is for you.

I've talked to countless primary care physicians, orthopedic surgeons, sports medicine doctors, and physical therapists who spend hours documenting MSK complaints, trying to justify MRIs, specialist referrals, and treatment interventions.

The reality is that musculoskeletal documentation has specific requirements that insurance companies scrutinize carefully.

They want to see clear mechanism of injury, objective functional limitations, documentation of conservative management, and evidence that advanced imaging or procedures are medically necessary.

That's exactly why I built SOAP Notes Doctor to handle the documentation burden while you focus on treating patients.

In this article, I'll show you exactly how to write musculoskeletal SOAP notes that meet insurance standards, with real examples you can use as templates.

🧾 What SOAP Notes Really Are (And Why They Matter for MSK Conditions)

SOAP notes might feel like bureaucratic busywork, but they serve a real purpose for orthopedic patients.

They were introduced in the 1960s by Dr. Lawrence Weed as part of the Problem-Oriented Medical Record (POMR).

His goal was straightforward: create a documentation system that anyone reviewing a chart could understand quickly and completely.

For musculoskeletal conditions specifically, SOAP notes are critical because they demonstrate:

• Clear documentation of mechanism of injury and symptom onset
• Objective assessment of range of motion and functional limitations
• Evidence of appropriate conservative treatment before advanced interventions
• Medical necessity for imaging, injections, physical therapy, or surgery
• Response to treatment and progression of care
• Work or activity restrictions based on clinical findings

SOAP stands for:

• S — Subjective: What the patient reports about pain location, onset, mechanism, aggravating/relieving factors, functional limitations, and previous treatments.
• O — Objective: Your clinical findings including inspection, palpation, range of motion measurements, special tests, gait assessment, and neurological exam.
• A — Assessment: Your clinical diagnosis with severity assessment, functional impact, and evaluation of treatment response.
• P — Plan: Your treatment plan including medications, physical therapy, imaging, injections, activity modifications, and follow-up timing.

This structure keeps your documentation organized, defensible, and insurance-friendly.

You're not just recording what happened—you're building a clinical narrative that justifies diagnostic studies and treatment interventions.

How You Can Approach Musculoskeletal SOAP Notes

There's no single correct method for writing MSK SOAP notes, but some approaches work better than others depending on your practice.

Here are two main approaches I've seen work well.

1. Traditional, Manual Documentation

This is the classic method: typing out each section after each visit. It works if you have strong clinical writing skills and consistent time built into your schedule. The challenge is it's time-consuming, and documenting detailed ROM measurements, special test results, and functional assessments can become tedious and inconsistent.

2. SOAP Notes Doctor

You record your examination findings or dictate your observations, and the tool automatically structures everything into proper SOAP format. It maintains consistency, saves hours of documentation time, and ensures you never miss critical components that insurance companies look for in orthopedic documentation.

How to Make Musculoskeletal SOAP Notes Faster

One of the biggest complaints I hear from providers treating MSK conditions is how documentation eats into their already limited time.

You've just finished a full clinic of orthopedic evaluations, each requiring detailed physical examination with multiple special tests, ROM measurements, and functional assessments, and instead of reviewing imaging or preparing for procedures, you're stuck typing detailed notes for insurance.

The pressure is real: make them too brief and you risk denials for MRIs or PT authorization; make them too detailed and you've just added hours to your day.

Here's what we built to solve this:

✅ Head to soapnotes.doctor
✅ Record your examination findings or dictate key observations
✅ Generate properly formatted SOAP notes instantly
✅ Get your evenings and weekends back

With soapnotes.doctor, you can record during or right after a visit, add rough notes about specific findings, or even upload audio later. The system converts everything into insurance-compliant SOAP notes automatically.

You still get the clinical accuracy and thoroughness that insurance companies require, but without manually typing every detail.

Maybe you noted specific findings?

"Shoulder: forward flexion 110 degrees, abduction 90 degrees, IR limited to L5, positive Hawkins-Kennedy, positive empty can, tenderness over supraspinatus insertion, strength 4/5 with abduction against resistance."

Use the tailorr feature to add them. Keep it raw and unpolished—soapnotes.doctor handles the rest.

Example 1: Acute Knee Pain After Sports Injury

Patient: 28-year-old male
Chief Complaint: Right knee pain after basketball injury 3 days ago
Visit: New injury evaluation

S – Subjective:

Patient reports acute onset of right knee pain 3 days ago while playing basketball. Mechanism: planted right foot and pivoted to change direction when he felt a "pop" in the knee followed by immediate sharp pain and swelling. Unable to continue playing. Reports significant swelling within 2 hours of injury. Pain located medial and anterior knee, rated 7/10 at rest, 9/10 with weight-bearing. Knee feels unstable, especially with pivoting movements. Reports giving-way sensation when attempting stairs. Denies locking or catching. Took ibuprofen 600mg three times yesterday with minimal relief. Has been using ice and elevation. Able to bear weight but with significant limp. No prior knee injuries to this knee. Left knee had meniscus tear repaired 5 years ago. Currently unable to work (construction worker requiring prolonged standing and climbing). No numbness or tingling in leg or foot.

O – Objective:

Vital Signs: Afebrile
General: Alert, in mild distress with movement
Gait: Antalgic gait favoring right leg, shortened stance phase on right
Inspection: Moderate effusion right knee, no ecchymosis, no erythema, no gross deformity
Palpation: Tenderness along medial joint line, tenderness over medial collateral ligament, no patellar tenderness, mild warmth, significant effusion
Range of Motion: Active flexion 90 degrees (limited by pain and effusion), passive flexion 100 degrees, extension lacking 5 degrees (unable to fully extend), normal ROM left knee for comparison
Special Tests:

• Lachman test: Positive with soft endpoint, increased anterior translation compared to contralateral
• Anterior drawer: Positive
• Pivot shift: Unable to perform due to patient guarding
• McMurray's: Negative
• Valgus stress at 30°: Mild laxity, endpoint present
• Valgus stress at 0°: Stable
• Varus stress: Stable
• Patellar apprehension: Negative
  Neurovascular: Dorsalis pedis and posterior tibial pulses 2+ bilaterally, sensation intact, capillary refill less than 2 seconds

A – Assessment:

28-year-old male with acute right knee injury consistent with anterior cruciate ligament (ACL) tear based on mechanism (non-contact pivoting injury with audible pop), immediate effusion, positive Lachman and anterior drawer tests, and subjective instability. Possible medial meniscus injury given medial joint line tenderness. Grade I medial collateral ligament sprain based on mild laxity with valgus stress at 30 degrees with endpoint. Significant functional limitation with inability to work and difficulty with activities of daily living. No evidence of neurovascular compromise. No fracture suspected based on mechanism and examination (Ottawa knee rules negative).

P – Plan:

Imaging: Ordered MRI right knee to evaluate ACL integrity, assess for meniscal pathology, and evaluate collateral ligaments and other structures. MRI medical necessity documented based on positive Lachman test, mechanism consistent with ACL injury, and functional limitations.

Immobilization: Fitted with knee immobilizer for comfort and stability during ambulation. Instructed to wear with ambulation, may remove for icing and when resting.

Weight-bearing: Weight-bearing as tolerated with crutches. Demonstrated proper crutch technique.

Pain Management: Prescribed ibuprofen 800mg PO TID with food for 7 days for pain and inflammation. Instructed on RICE protocol (rest, ice 20 minutes every 2-3 hours, compression with knee sleeve when immobilizer removed, elevation above heart level).

Activity Modification: Work excuse provided for 1 week pending MRI results and follow-up. No sports participation. Avoid pivoting, cutting, or sudden direction changes.

Follow-up: Return in 5-7 days after MRI completion for results review and treatment planning. If MRI confirms ACL tear, will discuss surgical vs. conservative management options and provide orthopedic surgery referral if patient desires surgical reconstruction.

Patient Education: Discussed natural history of ACL injuries, treatment options (conservative vs. surgical), expected recovery timeline. Provided written instructions for home care and warning signs (increased swelling, numbness, severe pain uncontrolled by medication, skin color changes).

Patient verbalized understanding of diagnosis, treatment plan, and importance of follow-up for MRI review. Demonstrated proper use of immobilizer and crutches.

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Example 2: Chronic Low Back Pain with Radiculopathy

Patient: 52-year-old female
Chief Complaint: Low back pain radiating down left leg, worsening over 3 months
Visit: Follow-up after conservative management

S – Subjective:

Patient reports chronic low back pain for 8 months, significantly worsened over past 3 months with new radiation into left posterior leg extending to lateral foot. Pain began insidiously without specific injury. Back pain rated 6/10, leg pain 7/10. Describes leg pain as burning and shooting, worse with prolonged sitting, bending forward, and coughing/sneezing. Pain improves somewhat with standing and walking. Reports numbness and tingling in left lateral foot and heel. Denies bowel or bladder dysfunction, no saddle anesthesia. Previous treatment: completed 6 weeks of physical therapy with minimal improvement, tried NSAIDs (helped initially but no longer effective), muscle relaxants provided minimal benefit. X-rays 2 months ago showed degenerative changes at L4-L5 and L5-S1. Functional limitations: difficulty with prolonged sitting (desk job as accountant), decreased ability to perform household chores, sleep interrupted 2-3 times nightly due to pain with position changes. Currently taking ibuprofen 600mg TID and cyclobenzaprine 10mg at bedtime.

O – Objective:

Vital Signs: BP 128/82, HR 72
General: Well-appearing, ambulates without assistive device
Gait: Antalgic, shortened stride on left
Inspection: Normal spinal alignment, no skin changes, no gross deformity
Palpation: Tenderness over L5-S1 paraspinal muscles bilaterally (left greater than right), no midline tenderness, muscle spasm palpable in left lumbar paraspinals
Range of Motion:

• Flexion: 60 degrees (limited, reproduces leg pain at 45 degrees)
• Extension: 20 degrees (limited by pain)
• Lateral bending: 15 degrees bilaterally
• Rotation: Within normal limits
  Special Tests:
• Straight leg raise: Positive left at 40 degrees reproducing radiating leg pain, negative right
• Crossed straight leg raise: Negative
• Slump test: Positive, reproduces leg symptoms
• FABER test: Negative bilaterally
  Neurological Exam:
• Motor: 5/5 strength hip flexion, knee extension, ankle dorsiflexion, ankle plantarflexion bilaterally except 4/5 left ankle plantarflexion
• Sensory: Decreased sensation to light touch over left lateral foot and heel (L5-S1 distribution)
• Reflexes: 2+ patellar bilaterally, 1+ left Achilles (diminished compared to 2+ right Achilles)
• Babinski: Negative bilaterally

A – Assessment:

52-year-old female with chronic low back pain with left lower extremity radiculopathy consistent with L5-S1 nerve root compression, most likely secondary to herniated disc vs. spinal stenosis. Clinical presentation consistent with sciatica: positive straight leg raise at 40 degrees, dermatomal sensory changes (L5-S1 distribution), diminished left Achilles reflex, and weakness in ankle plantarflexion. Failed conservative management including 6 weeks of physical therapy and medication management. Symptoms progressive with worsening functional impairment. No red flags for cauda equina syndrome (no bowel/bladder dysfunction, no saddle anesthesia).

P – Plan:

Advanced Imaging: Ordered MRI lumbar spine without contrast to evaluate for disc herniation, spinal stenosis, or other structural pathology. Medical necessity documented based on persistent radiculopathy symptoms, positive neurological findings (sensory changes, reflex asymmetry, weakness), positive straight leg raise, and failure of 6 weeks conservative management.

Medication Management: Changed ibuprofen to meloxicam 15mg PO daily for better anti-inflammatory coverage. Added gabapentin 300mg PO TID for neuropathic pain component, instructed to titrate up to 600mg TID over 2 weeks as tolerated. Continue cyclobenzaprine 10mg at bedtime for muscle spasm.

Activity Modification: Encouraged frequent position changes during work day, avoid prolonged sitting greater than 30 minutes. Instructed on proper body mechanics with lifting. Provided work note allowing standing desk option and frequent breaks.

Conservative Measures: Continue home exercise program from physical therapy focusing on nerve gliding exercises and core stabilization. Apply ice for acute pain episodes, heat for muscle spasm.

Specialist Referral: Will refer to spine specialist (orthopedic spine or neurosurgery) if MRI shows significant disc herniation or stenosis requiring intervention consideration. Discussed potential treatments including epidural steroid injection vs. surgical decompression depending on imaging findings.

Follow-up: Return in 10 days after MRI completion for results review and treatment planning. Patient to call immediately if develops bowel/bladder dysfunction, progressive weakness, or severe worsening of symptoms (red flags for cauda equina syndrome requiring emergency evaluation).

Patient verbalized understanding of radiculopathy diagnosis, treatment plan, and red flag symptoms requiring emergency care. Understands that MRI will guide further management decisions.

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Example 3: Rotator Cuff Tendinopathy with Impingement

Patient: 58-year-old male
Chief Complaint: Right shoulder pain for 4 months
Visit: Orthopedic evaluation after failed conservative management

S – Subjective:

Patient reports gradual onset right shoulder pain over 4 months without specific injury. Works as electrician with frequent overhead reaching. Pain rated 5/10 at rest, 8/10 with overhead activities. Pain located over lateral shoulder radiating to deltoid insertion. Reports night pain, difficulty sleeping on right side. Significant difficulty with overhead activities (reaching into cabinets, washing hair). Denies numbness or weakness in arm or hand. Previous treatment: 4 weeks of physical therapy (completed 8 sessions) with stretching and strengthening exercises, some improvement initially but plateaued. Tried ibuprofen with minimal relief. No previous shoulder injuries. No history of shoulder dislocation. Functional limitations: unable to perform work duties requiring overhead reaching (on modified duty for 2 weeks), difficulty dressing (putting on shirt).

O – Objective:

Vital Signs: Afebrile
Inspection: No atrophy, no swelling, symmetrical shoulders
Palpation: Tenderness over greater tuberosity, tenderness in subacromial space, no AC joint tenderness
Active Range of Motion (Right/Left):

• Forward flexion: 140°/180° (limited by pain)
• Abduction: 110°/180° (painful arc 70-120°)
• External rotation at side: 60°/70°
• Internal rotation: Can reach to L5 (normal to T8-T10)
  Passive Range of Motion: Slightly better than active but still limited by pain
  Strength Testing (Right):
• Forward flexion: 4/5 (limited by pain)
• Abduction: 4/5 (limited by pain)
• External rotation: 5/5
• Internal rotation: 5/5
  Special Tests:
• Neer impingement sign: Positive (reproduces pain)
• Hawkins-Kennedy test: Positive (reproduces pain)
• Empty can test (supraspinatus): Positive, weak and painful
• Full can test: Positive, painful
• Drop arm test: Negative
• External rotation lag sign: Negative
• Lift-off test: Negative
  Neurovascular: Intact sensation, normal capillary refill, radial pulse 2+

A – Assessment:

58-year-old male with right shoulder pain consistent with rotator cuff tendinopathy (likely supraspinatus) with subacromial impingement syndrome. Clinical presentation includes positive impingement signs (Neer, Hawkins-Kennedy), positive supraspinatus testing (empty can), painful arc with abduction, and night pain. Mechanism consistent with occupational overuse from repetitive overhead activities. No evidence of full-thickness rotator cuff tear (negative drop arm, negative lag signs, strength 4/5 rather than complete weakness). Failed appropriate conservative management including 4 weeks of physical therapy and NSAIDs. Significant functional impairment affecting work and activities of daily living.

P – Plan:

Advanced Imaging: Ordered MRI right shoulder without contrast to evaluate rotator cuff integrity, assess for partial vs. full-thickness tears, evaluate for other pathology (labral tears, AC joint arthritis). Medical necessity documented based on failed conservative management, positive physical examination findings, occupational impact, and need to determine extent of rotator cuff pathology to guide treatment.

Subacromial Injection: Offered diagnostic and therapeutic subacromial corticosteroid injection today. Performed injection with 1mL triamcinolone 40mg/mL and 4mL 1% lidocaine into subacromial space using lateral approach under sterile technique. Patient tolerated procedure well. Explained potential for temporary pain relief which would support impingement diagnosis.

Activity Modification: Work restrictions: no overhead reaching above shoulder level, no lifting greater than 10 lbs with right arm for 2 weeks pending injection response and MRI results. Provided work note with restrictions.

Medication: Prescribed meloxicam 15mg PO daily for 14 days for anti-inflammatory effect.

Physical Therapy: Continue home exercise program focusing on rotator cuff strengthening and scapular stabilization. Avoid aggressive overhead stretching that may worsen impingement. If injection provides relief, consider formal return to PT for advanced strengthening.

Follow-up: Return in 2 weeks after MRI and post-injection evaluation. Will review MRI findings and assess response to injection. If MRI shows full-thickness tear or if no improvement with conservative measures, will discuss surgical options (arthroscopic decompression vs. rotator cuff repair). If significant improvement with injection, may consider series of injections and continued PT.

Patient Education: Discussed rotator cuff tendinopathy, impingement syndrome, natural history, and treatment options. Explained that most cases respond to conservative treatment but surgery may be necessary if significant tear or continued failure of conservative management. Reviewed post-injection precautions (avoid strenuous use for 48 hours, apply ice if increased pain, call if fever or severe pain).

Patient verbalized understanding of diagnosis, injection procedure, and treatment plan. Understands that MRI results will guide definitive treatment recommendations.

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Key Components Insurance Companies Look For in MSK SOAP Notes

When reviewing your musculoskeletal documentation, insurance companies specifically want to see:

1. Mechanism of Injury or Onset Pattern

Document whether traumatic vs. atraumatic, acute vs. insidious onset, and specific activity or position that causes symptoms.

2. Objective ROM Measurements

Use degrees for joint measurements. Compare to contralateral side and document limitations. This justifies PT referrals and demonstrates functional impairment.

3. Special Test Results

Document specific orthopedic tests performed (Lachman, straight leg raise, Hawkins-Kennedy, etc.) and whether positive or negative. This supports clinical diagnosis.

4. Functional Limitations

Describe specific activities the patient cannot perform (work duties, ADLs, sports). Quantify impact on occupation and daily life.

5. Conservative Management Documentation

Before approving advanced imaging or procedures, insurance wants proof of conservative treatment: PT duration and response, medications tried, activity modifications attempted.

6. Medical Necessity for Imaging

Clearly state why imaging is needed: failed conservative management, neurological findings, suspicion of specific pathology requiring surgical consideration, or inability to diagnose clinically.

7. Response to Previous Interventions

Document what treatments were tried, duration, and degree of improvement or failure. This justifies escalation of care.

Common Mistakes to Avoid

Vague Pain Descriptions: Instead of "shoulder pain," document "anterolateral shoulder pain radiating to deltoid insertion, worse with overhead reaching, rated 7/10."

Missing ROM Measurements: Use specific degrees, not just "limited ROM." Document: "shoulder abduction 110 degrees (limited) vs. 180 degrees contralateral."

Skipping Special Tests: Perform and document relevant orthopedic tests. These provide objective support for your clinical diagnosis.

No Functional Impact: Insurance wants to see how the condition affects the patient's life. Document specific work limitations, ADL difficulties, or sport participation restrictions.

Inadequate Conservative Management Documentation: Before requesting MRI, clearly document PT sessions completed, medications tried with doses and durations, and response to treatment.

Requesting Imaging Too Early: Most insurance requires documentation of conservative management failure before approving advanced imaging except in cases with red flags or significant trauma.

Missing Comparison to Contralateral Side: Always compare injured side to uninjured side for ROM, strength, and stability testing when possible.

Final Thoughts

Musculoskeletal SOAP notes don't need to be overwhelming.

They need to be thorough, yes, but they don't need to consume your life.

The key is having a system that captures the right information without making you feel like a secretary instead of a clinician.

Whether you write them manually or use a tool like soapnotes.doctor, the goal is the same: clear documentation that serves your patient and satisfies insurance requirements.

Your time is better spent examining patients and developing treatment plans than fighting with documentation.

That's exactly why we built this tool.

Try it out, see how much time you get back, and let me know what you think.

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