SOAP Note Structure for Musculoskeletal Problems
A comprehensive SOAP note for musculoskeletal problems must systematically screen for red flags, document functional impact, assess disease activity, and create an actionable treatment plan that addresses both immediate symptom control and long-term disease modification. 1
Subjective Section
Document the following specific elements:
- Chief complaint and duration: Exact location of pain, onset timing (acute vs. gradual), and total duration in days/weeks 2
- Pain characteristics: Constant vs. intermittent, night pain (red flag for malignancy/infection), morning stiffness duration (>1 hour suggests inflammatory arthritis), and pain with activity vs. rest 3, 2, 4
- Red flag symptoms requiring immediate investigation: Fever, unintentional weight loss, night sweats, progressive neurological symptoms (weakness, numbness, bowel/bladder dysfunction), history of cancer, recent infection, or immunosuppression 2
- Functional limitations: Specific activities of daily living affected (dressing, bathing, walking distance, stair climbing, work duties) and impact on participation in home, education, work, and leisure 1
- Pattern of joint involvement: Single joint (monoarticular) vs. multiple joints (polyarticular), symmetric vs. asymmetric distribution, small joints vs. large joints 3, 4
- Previous treatments tried: Medications used (NSAIDs, acetaminophen, opioids), physical therapy, injections, and their effectiveness 4
- Risk factors: Smoking status, alcohol use, obesity, occupational exposures, repetitive activities, previous injuries, family history of rheumatic diseases 1
Objective Section
Include these specific physical examination findings:
- Vital signs: Temperature (fever suggests infection), heart rate (tachycardia with infection/inflammation), blood pressure, weight/BMI 2
- Inspection: Visible joint swelling, erythema, deformities (ulnar deviation, swan neck, boutonniere), muscle atrophy, skin changes (rashes, nodules, ulcers), abnormal spinal curvature 2, 4
- Palpation: Warmth, effusion, tenderness over specific joints or spinous processes, lymphadenopathy 2
- Range of motion: Active and passive ROM for affected joints, noting limitations and pain with movement 2
- Neurological examination: Motor strength (graded 0-5/5), sensory testing (light touch, pinprick), reflexes (graded 0-4+), gait assessment (antalgic, Trendelenburg, steppage), straight leg raise test 2
- Special tests: McMurray test (knee meniscus), Phalen's/Tinel's (carpal tunnel), Finkelstein's (De Quervain's), impingement tests (shoulder) 2
- Laboratory results if obtained: ESR, CRP, rheumatoid factor, anti-CCP antibodies, ANA, complete blood count, liver transaminases, urinalysis 3, 4
- Imaging results if obtained: Radiographs showing joint space narrowing, erosions, soft tissue swelling, fractures, or alignment abnormalities 2, 4
Assessment Section
Structure your clinical reasoning as follows:
Primary diagnosis or differential diagnoses: List most likely diagnosis first, followed by alternatives based on clinical presentation 3, 5
- For inflammatory patterns: Rheumatoid arthritis (symmetric polyarticular, morning stiffness >1 hour, positive RF/anti-CCP), systemic lupus erythematosus (multisystem involvement, positive ANA/anti-dsDNA), systemic sclerosis (skin thickening, Raynaud's, positive anti-Scl-70) 3
- For mechanical patterns: Osteoarthritis (asymmetric, worse with activity, joint space narrowing on X-ray), soft tissue rheumatism, regional pain syndromes 1
- For acute monoarticular with fever: Septic arthritis (requires emergent arthrocentesis) 3
- For rapidly progressive: Consider muscular dystrophies, autoimmune connective tissue diseases, malignancy 3
Disease severity and activity: Document number of tender/swollen joints, patient global assessment score, physician global assessment score, functional status (mHAQ score if available) 4
Complications or extra-articular manifestations: Cardiac involvement, pulmonary fibrosis, vasculitis, neuropathy 3, 4
Prognosis and urgency: Classify as requiring immediate referral (septic arthritis, cauda equina), urgent referral within 2-4 weeks (inflammatory polyarthritis), or routine management 3, 2
Plan Section
Create a structured, actionable plan:
Diagnostic workup needed:
- Immediate imaging: Radiographs of symptomatic region as first-line when red flags present; MRI without and with IV contrast for suspected infection/malignancy; urgent MRI without contrast for suspected cauda equina or progressive neurological deficit 2
- Laboratory tests before treatment: Complete blood count, liver transaminases, urinalysis, ESR, CRP, RF, anti-CCP for suspected inflammatory arthritis; screening for latent tuberculosis and hepatitis B/C before biologics 3, 4
- Arthrocentesis: Emergent for monoarticular involvement with fever and acute onset to rule out septic arthritis 3
Pharmacologic management:
- For inflammatory arthritis: Methotrexate 7.5-10 mg orally once weekly, escalating to 15-25 mg weekly; NSAIDs at lowest effective dose after assessing cardiovascular, gastrointestinal, and renal risk; consider short-term corticosteroids for bridging but not as monotherapy 4
- For mechanical pain: NSAIDs at lowest effective dose, acetaminophen, topical agents 4
- For muscular dystrophy: Prednisone 0.75 mg/kg daily or deflazacort 0.9 mg/kg daily immediately upon diagnosis 3
Referrals with specific timeframes:
- Immediate (same day): Suspected septic arthritis, cauda equina syndrome, progressive neurological deficits 3, 2
- Urgent (2-4 weeks): Inflammatory polyarthritis with morning stiffness >30 minutes and symmetric joint involvement 3, 4
- Routine: Established osteoarthritis, regional pain syndromes 1
- Multidisciplinary team: Physical therapy, occupational therapy, podiatry for patients with inflammatory arthritis and deformities; orthopedic surgery if severe instability, impending skin ulceration, or intractable pain 4
Non-pharmacologic interventions:
- Exercise prescription: Land-based or water-based supervised exercises focusing on range of motion, strengthening, and aerobic conditioning, individualized based on joint involvement 4
- Lifestyle modifications: Smoking cessation, weight management to ideal BMI, balanced diet meeting calcium and vitamin D requirements, alcohol moderation, accident prevention strategies 1, 3
- Patient education: Disease course and prognosis, medication adherence importance, joint protection techniques, recognition of disease flares, self-management strategies 1, 4
Monitoring plan:
- Disease activity assessment: Every 1-3 months until remission achieved, including tender/swollen joint counts, patient and physician global assessments, ESR/CRP levels, functional assessment 4
- Radiographic monitoring: Repeat hand and foot radiographs every 6-12 months initially to assess progression in inflammatory arthritis 4
- Treatment escalation criteria: If inadequate response after 3 months of optimal methotrexate dosing, add or switch to combination DMARD therapy or consider biologic DMARD 4
Follow-up timing:
- 1-2 weeks: For patients started on new DMARD therapy to assess tolerance and side effects 4
- 4-6 weeks: For patients with red flags and negative initial imaging to reassess symptoms 2
- 3 months: For disease activity reassessment and treatment escalation decisions 4
Critical Documentation Pitfalls to Avoid
- Never delay DMARD initiation in suspected inflammatory arthritis while waiting for complete serologic workup—presence of deformities indicates established disease requiring immediate treatment 4
- Never rely on negative radiographs alone to exclude serious pathology when red flags are present—proceed to advanced imaging 2
- Never overlook foot involvement in inflammatory arthritis assessment, as this commonly causes significant disability 4
- Never prescribe NSAIDs without documenting assessment of cardiovascular, gastrointestinal, and renal contraindications 4
- Never initiate conservative management when progressive neurological deficits, structural instability, or serious pathology is present 2