The 2026 Guide to Rotator Cuff Injury SOAP Note Examples for Healthcare Providers

If you've ever struggled to document rotator cuff injuries in a way that justifies treatment plans while meeting insurance requirements, this guide is for you.

I've talked to countless orthopedic specialists, primary care physicians, and physical therapists who spend excessive time documenting shoulder complaints, trying to justify imaging studies, physical therapy referrals, and surgical consultations.

The reality is that rotator cuff injury documentation has specific requirements that insurance companies scrutinize carefully.

They want to see clear mechanism of injury, detailed physical examination findings, functional limitations, and evidence-based treatment progression before approving advanced imaging or specialist referrals.

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

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

🧾 What SOAP Notes Really Are (And Why They Matter for Rotator Cuff Injuries)

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

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 rotator cuff injuries specifically, SOAP notes are critical because they demonstrate:

• Clear documentation of mechanism of injury and symptom progression
• Appropriate physical examination including special tests
• Functional limitations and impact on daily activities
• Medical necessity for imaging, physical therapy, or surgical consultation
• Conservative treatment trials before invasive interventions

SOAP stands for:

• S — Subjective: What the patient reports about pain location, onset, mechanism, aggravating factors, functional limitations, and previous treatments.
• O — Objective: Your clinical findings including range of motion, strength testing, special tests (Neer's, Hawkins-Kennedy, empty can), tenderness, and any imaging results.
• A — Assessment: Your clinical diagnosis with severity assessment, differential diagnoses, and prognosis.
• P — Plan: Your treatment plan including medications, physical therapy, activity modifications, imaging orders, specialist referrals, 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 your treatment approach and any specialist involvement.

How You Can Approach Rotator Cuff Injury SOAP Notes

There's no single correct method for writing rotator cuff 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 notes can become inconsistent, especially when documenting subtle examination findings or special test results.

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 musculoskeletal injury documentation.

How to Make Rotator Cuff SOAP Notes Faster

One of the biggest complaints I hear from providers managing shoulder injuries is how documentation eats into their already limited time.

You've just finished a full clinic seeing patients with various musculoskeletal complaints, each requiring thorough examination and documentation, and instead of moving on to the next patient or finishing your day, you're stuck typing detailed notes for insurance.

The pressure is real: make them too brief and you risk denials for MRI orders or PT referrals; make them too detailed and you've just added hours to your documentation time.

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?

"Painful arc 70-120 degrees, positive Neer's and Hawkins, weakness with external rotation, night pain worse, failed 2 weeks NSAIDs."

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

Example 1: Acute Rotator Cuff Strain, Initial Visit

Patient: 45-year-old male
Chief Complaint: Right shoulder pain after lifting heavy boxes
Visit: New injury evaluation

S – Subjective:

Patient reports acute onset right shoulder pain that began 3 days ago while moving heavy boxes at work. Describes sharp pain in lateral shoulder with overhead reaching and lifting. Pain rated 6/10 at rest, 8/10 with activity. Significant night pain, worse when rolling onto right side. Difficulty reaching behind back to tuck in shirt or reaching overhead into cabinets. Denies numbness, tingling, or neck pain. No previous shoulder injuries. Took ibuprofen 400mg with minimal relief. Unable to perform usual work duties requiring overhead lifting.

O – Objective:

Vital Signs: BP 128/82
Inspection: No visible deformity, swelling, or bruising. Slight guarding with movement.
Palpation: Tenderness over anterior and lateral shoulder, particularly at supraspinatus insertion.
ROM: Active forward flexion 140° (painful), abduction 130° (painful arc 70-120°), external rotation limited to 60° with pain, internal rotation to L3 (limited by pain).
Strength: 4/5 supraspinatus (limited by pain), 4/5 external rotation, 5/5 internal rotation.
Special Tests: Neer's test positive, Hawkins-Kennedy test positive, empty can test positive with weakness and pain, drop arm test negative.
Neurovascular: Intact radial pulse, normal sensation, no atrophy noted.

A – Assessment:

Acute rotator cuff strain/tendinopathy, right shoulder, likely involving supraspinatus. Mechanism consistent with acute overload injury. No evidence of complete tear based on preserved strength, but cannot fully exclude partial tear without imaging. Differential includes subacromial bursitis and impingement syndrome.

P – Plan:

Conservative management initiated. Prescribed NSAIDs (naproxen 500mg BID with food for 2 weeks). Activity modification: avoid overhead lifting and repetitive shoulder activities. Ice application 15-20 minutes 3-4 times daily. Gentle pendulum exercises and passive range of motion starting in 2-3 days. Referred to physical therapy for progressive strengthening and rotator cuff rehabilitation protocol. If no improvement in 4 weeks or symptoms worsen, will order shoulder MRI to evaluate for partial or full-thickness tear. Work note provided: light duty, no overhead lifting over 10 lbs for 2 weeks. Follow-up in 3 weeks to reassess. Patient instructed to return sooner if sudden loss of strength, severe pain, or inability to move arm.

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Example 2: Chronic Rotator Cuff Tendinopathy, Follow-Up After PT

Patient: 58-year-old female
Chief Complaint: Ongoing right shoulder pain, completed 6 weeks physical therapy
Visit: Follow-up after conservative treatment

S – Subjective:

Patient returns after completing 6 weeks of physical therapy for chronic right shoulder pain. Reports moderate improvement in pain, now 3-4/10 at rest (previously 5-6/10). Still experiences pain with overhead activities and reaching across body. Night pain significantly improved, able to sleep on right side occasionally. Completed all PT sessions with good compliance to home exercise program. Can now perform most daily activities but still limited in reaching high shelves and carrying heavy groceries. Works as a teacher, able to write on board but avoids reaching to top portions.

O – Objective:

Inspection: No atrophy, symmetrical shoulders.
ROM: Forward flexion 160° (improved from 140°), abduction 150° (improved), external rotation 75°, internal rotation to T12.
Strength: 4+/5 supraspinatus, 5/5 external rotation, 5/5 internal rotation (all improved from initial visit).
Special Tests: Neer's test mildly positive, Hawkins-Kennedy negative (improved), empty can test minimal pain with good strength.
Palpation: Mild tenderness at supraspinatus insertion, decreased from initial exam.

A – Assessment:

Chronic rotator cuff tendinopathy, right shoulder, with partial response to conservative treatment. Significant improvement in pain, range of motion, and strength after physical therapy. Persistent symptoms suggest possible underlying partial-thickness tear or chronic degenerative changes. Patient functional status improved but not fully resolved.

P – Plan:

Order MRI right shoulder without contrast to evaluate rotator cuff integrity and assess for partial tear or degenerative changes. Continue home exercise program from PT focusing on rotator cuff strengthening and scapular stabilization. Patient may continue NSAIDs as needed for pain. Consider subacromial corticosteroid injection if MRI shows tendinopathy without significant tear. Will review MRI results and discuss treatment options including possible orthopedic referral if full-thickness tear identified. Follow-up in 2 weeks after MRI or upon results availability. Patient educated on signs requiring urgent evaluation including sudden weakness or inability to lift arm.

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Example 3: Post-MRI Evaluation, Partial Rotator Cuff Tear

Patient: 62-year-old male
Chief Complaint: Persistent shoulder pain, MRI results review
Visit: Results discussion and treatment planning

S – Subjective:

Patient presents to review MRI results for chronic right shoulder pain ongoing for 4 months. Reports persistent pain with overhead activities rated 5/10. Night pain continues to disturb sleep 2-3 nights per week. Completed 8 weeks physical therapy with modest improvement in strength but persistent pain. Denies acute injury, symptoms developed gradually. Most bothersome limitation is inability to perform yard work and difficulty with golf swing. Previously active, now significantly limited in recreational activities.

O – Objective:

ROM: Forward flexion 155°, abduction 145°, external rotation 70° (all with end-range discomfort).
Strength: 4/5 supraspinatus with pain, 5/5 other rotator cuff muscles.
Special Tests: Painful arc present, Neer's positive, Jobe's test positive with weakness.
MRI Results: Partial-thickness articular surface tear of supraspinatus tendon (approximately 50% thickness), mild subacromial bursitis, no full-thickness tear, AC joint mild degenerative changes.

A – Assessment:

Partial-thickness rotator cuff tear, right shoulder (supraspinatus), confirmed on MRI. Failed adequate trial of conservative management including physical therapy and NSAIDs. Persistent functional limitations impacting quality of life and recreational activities. Patient appropriate candidate for either continued conservative care with injection or surgical consultation.

P – Plan:

Discussed MRI findings and treatment options with patient. Offered trial of subacromial corticosteroid injection (methylprednisolone 40mg with 4mL lidocaine) as next conservative step, which may provide 3-6 months relief and allow return to activities. Patient elected to proceed with injection today, performed under sterile technique without complications. Instructed on post-injection care: ice for 24 hours, rest for 48 hours, then resume gentle activities. May experience temporary increase in discomfort for 24-48 hours. Referred to orthopedic surgery for consultation regarding potential arthroscopic repair if injection provides insufficient relief or symptoms recur. Continue home exercise program emphasizing rotator cuff strengthening. Follow-up in 4 weeks to assess injection response. Patient to contact sooner if significant weakness develops or symptoms dramatically worsen. Discussed that surgical repair generally recommended if injection fails and patient desires return to higher activity level.

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Key Components Insurance Companies Look For in Rotator Cuff Injury SOAP Notes

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

1. Mechanism of Injury

Document whether injury was acute/traumatic or chronic/degenerative. This influences treatment expectations and timelines.

2. Physical Examination Findings

Specific documentation of ROM measurements, strength testing with grading, and special test results (Neer's, Hawkins-Kennedy, empty can, drop arm).

3. Functional Limitations

Clear documentation of how the injury impacts daily activities, work duties, and quality of life. This justifies medical necessity.

4. Conservative Treatment Trials

Before approving MRI or surgery, insurance wants evidence of failed conservative care: NSAIDs, activity modification, physical therapy.

5. Imaging Justification

Document specific clinical findings that necessitate MRI: persistent pain despite treatment, weakness suggesting tear, functional limitations despite therapy.

6. Treatment Progression

Show logical progression from conservative to more aggressive interventions based on clinical response.

Common Mistakes to Avoid

Vague Pain Descriptions: Instead of "shoulder hurts," document specific location, character, aggravating factors, and functional impact.

Missing Strength Testing: Always document strength grading (0-5 scale) for all rotator cuff muscles, noting if weakness is due to pain versus true weakness.

Incomplete Special Tests: Document which tests were performed and results, not just "positive shoulder exam."

Ordering MRI Too Early: Insurance often denies MRI without documented trial of conservative treatment (4-6 weeks PT, NSAIDs).

No ROM Measurements: Document specific degrees of motion or clear limitations compared to contralateral side.

Missing Work Impact: For workers' comp or disability cases, clearly document how injury affects job duties and work capacity.

Final Thoughts

Rotator cuff injury 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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Ready to simplify your rotator cuff injury documentation?
Visit soapnotes.doctor and get your first notes generated in minutes.