Can you create a SOAP note for a 35-year-old healthy patient with acute right medial knee pain after a twisting injury while playing tennis?

SOAP Note for Acute Right Medial Knee Pain Following Tennis Injury

Subjective

Chief Complaint: Right medial knee pain

History of Present Illness:

• 35-year-old healthy patient presents with acute right medial knee pain
• Mechanism: Twisting injury while playing tennis
• Onset: Acute (specify exact timing)
• Pain location: Medial aspect of right knee
• Pain character and severity: (document on 0-10 scale)
• Associated symptoms to document:
  • Presence/absence of immediate swelling
  • Presence/absence of "pop" or "tear" sensation at time of injury
  • Ability to continue playing after injury
  • Ability to bear weight immediately after injury
  • Ability to walk/take 4 steps currently
  • Presence/absence of knee locking or catching
  • Presence/absence of knee instability or "giving way"
  • Current range of motion limitations

Past Medical History: Healthy, no significant medical history

Medications: None

Allergies: (document)

Social History: Active tennis player

Objective

Vital Signs: (document temperature, BP, HR, RR)

Physical Examination - Right Knee:

Inspection:

• Presence/absence of effusion
• Presence/absence of ecchymosis
• Presence/absence of deformity
• Comparison to contralateral knee

Palpation:

• Medial joint line tenderness (key finding for meniscal pathology) 1
• Patellar tenderness
• Fibular head tenderness
• Pes anserine tenderness
• Medial collateral ligament tenderness
• Warmth or erythema

Range of Motion:

• Active and passive flexion/extension
• Specifically document if patient can flex knee to 90 degrees (Ottawa Knee Rule criterion) 2

Special Tests:

• McMurray test (meniscal pathology)
• Thessaly test (meniscal pathology)
• Valgus stress test at 0° and 30° (MCL integrity)
• Lachman test (ACL integrity)
• Anterior drawer test
• Posterior drawer test

Functional Assessment:

• Document ability to bear weight immediately after injury 2
• Document ability to take 4 weight-bearing steps in clinic (critical for Ottawa/Pittsburgh rules) 2

Neurovascular Examination:

• Distal pulses
• Sensation
• Motor function

Assessment

Primary Diagnosis: Acute right medial knee injury, suspect medial meniscus tear

Differential Diagnoses:

• Medial meniscus tear (most likely given mechanism, age, and medial pain) 1, 3, 4
• Medial collateral ligament sprain
• Medial plica syndrome
• Pes anserine bursitis
• Patellofemoral pain syndrome (less likely given acute traumatic mechanism)

Clinical Decision-Making for Imaging:

This 35-year-old patient does NOT meet Ottawa Knee Rule criteria for mandatory radiographs since they are <55 years old 2. However, radiographs should be obtained if ANY of the following are present:

• Cannot flex knee to 90°
• Cannot bear weight (4 steps)
• Isolated patellar tenderness
• Fibular head tenderness
• Gross deformity

If Ottawa criteria are NOT met, radiographs are not indicated initially 2. The ACR Appropriateness Criteria clearly state that MRI is not routinely used as the initial imaging study for acute knee trauma 2.

Plan

Imaging:

• If Ottawa Knee Rule criteria met: Obtain AP and lateral radiographs of right knee (minimum 2 views) 2
• If Ottawa criteria NOT met: Defer radiographs; clinical follow-up in 5-7 days
• MRI consideration: Reserve for persistent symptoms after conservative management or if surgical intervention being considered for suspected meniscal pathology 1, 2

Initial Management:

• RICE protocol: Rest, Ice (20 minutes every 2-3 hours), Compression (knee sleeve/wrap), Elevation
• Weight-bearing: As tolerated with crutches if needed for comfort
• NSAIDs: Ibuprofen 600-800 mg PO TID with food, or naproxen 500 mg PO BID with food (if no contraindications)
• Activity modification: Avoid pivoting, twisting, deep squatting; no tennis until reassessment

Physical Therapy:

• Referral for structured rehabilitation focusing on:
  • Quadriceps strengthening (especially VMO)
  • Range of motion exercises
  • Proprioceptive training
  • Gradual return to sport protocol

Follow-up:

• Return in 5-7 days for reassessment
• Earlier return if: Increased swelling, inability to bear weight, fever, or worsening symptoms
• Orthopedic referral indicated if: Persistent mechanical symptoms (locking, catching), significant functional limitation after 4-6 weeks of conservative management, or confirmed meniscal tear on MRI requiring surgical consideration 1

Patient Education:

• Meniscal injuries are common in tennis players, particularly with twisting mechanisms 3, 4
• Most acute meniscal pathology improves with conservative management initially
• Preservation of meniscal tissue is priority to prevent future osteoarthritis 1
• Expected timeline: Improvement within 2-4 weeks with conservative care; if surgical intervention needed, return to sport typically 4-7 months 1

Red Flags - Return Immediately If:

• Sudden increase in swelling
• Inability to bear weight
• Fever or signs of infection
• Severe, uncontrolled pain