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Summary: How to write a musculoskeletal (MSK) SOAP note in 2026. Includes a copy-ready MSK SOAP note template, normal musculoskeletal exam wording, what to document in the Subjective, Objective, Assessment and Plan sections, AAOS normal range of motion values, the MRC 0–5 strength scale, special tests and outcome measures by body region, six complete examples (cervical, shoulder, lumbar, hip osteoarthritis, knee, ankle sprain), matching ICD-10 codes, Medicare documentation rules for physical therapy, a free MSK SOAP note builder and FAQs.
A musculoskeletal SOAP note documents an MSK visit in four parts: Subjective (the patient's pain, history, function and goals), Objective (measured findings such as range of motion in degrees, strength graded 0–5, special tests and an outcome score), Assessment (your clinical impression and the reasoning that links the findings to it) and Plan (interventions, measurable goals, home program and visit frequency). The best MSK notes compare the involved side to the uninvolved side and tie every finding to a functional limitation, because that is what shows medical necessity.
This guide gives you a copy-ready musculoskeletal SOAP note template, normal MSK exam wording, reference tables for ROM, strength, special tests and outcome measures, six complete physical therapy SOAP note examples, the ICD-10 codes that match them, and a free builder that turns your findings into a formatted note.
What goes in each section of an MSK SOAP note
| Section | What to document for MSK | Example phrase |
|---|---|---|
| S – Subjective | Chief complaint, mechanism and onset, pain location, quality and 0–10 rating, aggravating and easing factors, 24-hour pattern, red-flag screen, prior episodes, medications, functional limits, patient goal | "Right shoulder pain x3 weeks after painting a ceiling; 7/10 overhead, 3/10 at rest; unable to wash hair." |
| O – Objective | Observation, palpation, AROM/PROM in degrees vs the other side, MMT 0–5, special tests (+/−), neuro screen when indicated, gait or functional tests, outcome measure score | "Shoulder flexion AROM 140° R / 180° L; ER strength 4/5 R with pain; Hawkins-Kennedy +." |
| A – Assessment | Clinical impression, structures involved, contributing factors, functional status, differential and red flags ruled out, prognosis, why skilled care is needed | "Signs consistent with subacromial pain syndrome limiting overhead reach; good prognosis." |
| P – Plan | Interventions, frequency and duration, short- and long-term measurable goals, home exercise program with dosage, re-assessment date, referrals | "2x/week for 6 weeks; goal: flexion ≥170° and QuickDASH ≤20 in 6 weeks." |
Musculoskeletal SOAP note template
Copy this MSK SOAP note template into your EMR or notes app and delete the lines that do not apply. It works as a physical therapy SOAP note template for an initial evaluation or a re-assessment.
S – Subjective
- Chief complaint (patient's words):
- Onset / mechanism / date of injury:
- Location, quality, radiation:
- Pain now __/10, best __/10, worst __/10
- Aggravating / easing factors; 24-hour pattern:
- Red-flag screen (night pain, weight loss, fever, bowel/bladder change, trauma):
- Past history, surgery, imaging, medications:
- Work, sport and daily-activity limits:
- Patient goal:
O – Objective
- Observation (posture, swelling, atrophy, gait):
- Palpation (tenderness by landmark, temperature, effusion):
- AROM / PROM in degrees, involved vs uninvolved:
- Strength (MMT 0–5), involved vs uninvolved:
- Special tests (name, +/−):
- Neuro screen if indicated (dermatomes, myotomes, reflexes):
- Functional test / outcome measure score:
A – Assessment
- Clinical impression and structures involved:
- Key findings supporting it:
- Contributing factors:
- Differential / red flags ruled out:
- Functional limitations and need for skilled care:
- Prognosis (good / fair / poor) and why:
P – Plan
- Interventions (manual therapy, therapeutic exercise, neuromuscular re-education, modalities, education):
- Frequency and duration:
- Short-term goals (2–3 weeks), measurable:
- Long-term goals (4–8 weeks), functional:
- Home exercise program (exercise, sets, reps, frequency):
- Re-assessment date / referrals:
Normal musculoskeletal exam documentation
For a normal physical exam in a SOAP note, document what you actually tested rather than writing "MSK normal." A complete normal MSK exam line usually reads:
MSK: No deformity, swelling, erythema or atrophy. No tenderness to palpation. Full active and passive ROM of the cervical spine and bilateral upper and lower extremities without pain. Strength 5/5 in all major muscle groups bilaterally. Gait normal and non-antalgic.
| Region | Normal finding wording |
|---|---|
| Cervical spine | Full cervical AROM in all planes without pain. No paraspinal tenderness. Spurling's negative bilaterally. |
| Shoulder | Full AROM/PROM without pain or painful arc. Rotator cuff strength 5/5. Neer and Hawkins-Kennedy negative. |
| Lumbar spine | Full lumbar AROM without pain. No midline tenderness. Straight leg raise negative bilaterally. |
| Hip | Full hip ROM including internal rotation without pain. FABER and FADIR negative. |
| Knee | No effusion. Knee ROM 0–135° bilaterally. Lachman and McMurray negative. Ligaments stable to varus and valgus stress. |
| Ankle / foot | No swelling or ecchymosis. Full ROM. Anterior drawer and talar tilt negative. Able to bear weight for four steps. |
If any finding is abnormal, record the measurement and the comparison side. A note that reads "knee flexion 95° R / 135° L" supports skilled care; "decreased ROM" does not.
How to write the Subjective section
The Subjective section captures the patient's story. For musculoskeletal complaints, use the OPQRST order so nothing is missed: Onset, Provocation and palliation, Quality, Region and radiation, Severity, and Timing. Then add the items that drive MSK decisions:
- Mechanism of injury: lifting with a flexed spine, a fall on an outstretched hand, an inversion sprain.
- Red-flag screen: night pain that does not change with position, unexplained weight loss, fever, saddle numbness or bowel and bladder change. Record that you asked, even when the answers are negative.
- Function in the patient's words: "cannot lift my child," "stop after 10 minutes of walking." These become your goals.
- Prior care: earlier episodes, injections, surgery, imaging and medications.
How to write the Objective section
The Objective section holds only what you measured or observed. Record range of motion in degrees with a goniometer or inclinometer, grade strength on a 0–5 scale, name each special test with its result, and add one standardized outcome measure. For more detail, see our guide to objective SOAP notes.
Normal range of motion reference values
Use these American Academy of Orthopaedic Surgeons (AAOS) average values as a reference, as compiled in Hendriks et al., PRS Global Open. Published norms vary with age, sex and method, so the uninvolved side is usually the better comparison.
| Joint | Motion and average range |
|---|---|
| Cervical spine | Flexion 45°, extension 45°, rotation 60°, lateral flexion 45° |
| Shoulder | Flexion 180°, abduction 180°, extension 60° |
| Elbow | Flexion 150°, extension 0° |
| Wrist | Flexion 80°, extension 70° |
| Hip | Flexion 120°, extension 20°, abduction 40°, adduction 20° |
| Knee | Flexion 135°, extension 0° |
| Ankle | Dorsiflexion 20°, plantarflexion 50° |
Manual muscle testing scale
Most clinicians grade strength with the Medical Research Council (MRC) scale, often adding + or − within a grade.
| Grade | Meaning |
|---|---|
| 0 | No contraction |
| 1 | Flicker or trace of contraction, no movement |
| 2 | Active movement with gravity eliminated |
| 3 | Active movement against gravity |
| 4 | Active movement against gravity and some resistance |
| 5 | Normal power |
Special tests and outcome measures by region
| Region | Special tests to document | Outcome measure (score range) |
|---|---|---|
| Cervical spine | Spurling's, distraction, upper limb tension test | Neck Disability Index (0–50) |
| Shoulder | Neer, Hawkins-Kennedy, empty can, drop arm, external rotation lag sign | QuickDASH (0–100) or SPADI (0–100) |
| Lumbar spine | Straight leg raise, slump, prone instability test | Oswestry Disability Index (0–100%) |
| Hip | FABER, FADIR, Thomas test, log roll | HOOS (0–100 per subscale) |
| Knee | Lachman, anterior drawer, McMurray, Thessaly, varus and valgus stress | KOOS (0–100 per subscale) |
| Ankle / foot | Anterior drawer, talar tilt, squeeze test, Ottawa ankle rules | LEFS (0–80) |
On the NDI, ODI, QuickDASH and SPADI, higher scores mean more disability. On the HOOS, KOOS and LEFS, higher scores mean better function.
How to write the Assessment section
The Assessment is where you show clinical reasoning. A strong SOAP assessment example names the likely pain source, lists the findings that support it, notes contributing factors, states what you ruled out and gives a prognosis. It should also say why the patient needs a therapist's skill. That is the line payers look for.
Weak: "Pt tolerated treatment well."
Strong: "Findings consistent with lateral ankle sprain (ATFL): tenderness over ATFL, positive anterior drawer, DF limited to 5°. Ottawa rules negative. Limited single-leg stance prevents return to running. Good prognosis with progressive loading and balance training."
How to write the Plan section
The Plan turns the assessment into action. List the interventions, frequency and duration, measurable goals with dates, the home exercise program with sets and reps, and when you will re-assess. Write goals in a measurable form, for example: "Patient will lift 10 lb from floor to waist with neutral spine and pain ≤2/10 within 4 weeks."
Free MSK SOAP note builder
MSK SOAP note builder
Pick a region, enter your findings and click Build note. The tool compares your ROM to the AAOS average and to the other side, then formats a SOAP note you can copy. Nothing you type is stored or sent anywhere.
ROM reference values: AAOS averages (Hendriks et al., PRS Global Open). Review and edit every generated note before it goes into the medical record; the tool does not replace clinical judgment.
Musculoskeletal SOAP note examples
Each musculoskeletal SOAP note example below is a complete initial evaluation. Patients are fictional. Use them to see the level of detail an MSK exam template should capture, then adapt them to your own findings.
1. Cervical spine: mechanical neck pain
2. Shoulder: subacromial pain
3. Lumbar spine: low back pain with leg symptoms
4. Hip: osteoarthritis
5. Knee: medial knee pain after a twisting injury
6. Ankle: lateral ankle sprain
ICD-10 codes that match these examples
Code the condition the note supports, to the highest specificity the findings allow, and add laterality. Injury codes such as S39.012 and S93.401 also need a 7th character for the encounter type.
| Example | ICD-10-CM code | Description |
|---|---|---|
| Cervical spine | M54.2 | Cervicalgia |
| Shoulder | M75.41 or M25.511 | Impingement syndrome of right shoulder / Pain in right shoulder |
| Lumbar spine | M54.16 | Radiculopathy, lumbar region (use M51.16 instead when a lumbar disc disorder is diagnosed) |
| Low back strain | S39.012- | Strain of muscle, fascia and tendon of lower back |
| Hip osteoarthritis | M16.11 | Unilateral primary osteoarthritis, right hip |
| Knee | M25.561 | Pain in right knee (add a meniscus or ligament code once confirmed) |
| Ankle sprain | S93.401- | Sprain of unspecified ligament of right ankle |
For a wider list, see our ICD-10 codes for low back pain and the musculoskeletal ICD-10 code library.
Medicare documentation rules for MSK physical therapy notes
If you bill Medicare, your MSK notes have to meet the documentation rules in the Medicare Benefit Policy Manual, Chapter 15, Section 220.3 (summarized by ASHA):
- Evaluation and plan of care: the plan must list goals, frequency, duration and type of treatment, and be certified by the physician or NPP.
- Progress reports: at least once every 10 treatment days, or once per certification interval if that is shorter.
- Treatment notes: every visit, with each service provided and the total timed-code minutes, so the units billed can be checked. Use our 8-minute rule calculator to match minutes to units.
- Discharge summary: at the end of the episode, covering the period since the last progress report.
Payers deny MSK claims most often when the note does not show measurable change or skilled need. Re-measure the same ROM, strength and outcome score you recorded at evaluation in every progress report.
Common MSK SOAP note mistakes
- "ROM decreased" or "WFL" with no degrees or comparison side.
- Special tests listed without a result, or only the positive ones recorded.
- No outcome measure, so progress cannot be shown.
- Goals with no number or date, such as "improve strength."
- Copy-pasted notes that repeat the same findings every visit.
- An Assessment that restates findings without saying what they mean.
For the full framework, see our guide to writing physical therapy SOAP notes, the musculoskeletal assessment documentation guide, neurological SOAP notes and pediatric SOAP note examples. Need shorthand? See our list of physical therapy abbreviations.
Write MSK SOAP notes faster
SPRY's AI scribe drafts the SOAP note from the visit for you to review and sign. It runs inside SPRY's PT EMR and billing platform, with plans starting at $79 per month. You can also try the free SOAP note generator or book a demo.
Frequently asked questions
What is a musculoskeletal SOAP note?
A musculoskeletal SOAP note is a clinical record of a visit for a muscle, joint, bone or ligament problem, written in four parts: Subjective, Objective, Assessment and Plan. It records the patient's pain and function, measured findings such as ROM and strength, the clinician's impression and the treatment plan.
How do you chart a musculoskeletal assessment?
Chart observation, palpation, active and passive ROM in degrees, strength on the 0–5 scale, special tests with results, a neuro screen when symptoms spread, and one outcome measure. Always compare the involved side with the uninvolved side.
How do you document a normal musculoskeletal exam?
List what you tested: no deformity, swelling or tenderness; full active and passive ROM without pain; strength 5/5 in major muscle groups bilaterally; normal gait. Avoid writing only "MSK normal."
What is an example of the Assessment section in a PT SOAP note?
"Findings consistent with right subacromial pain syndrome with rotator cuff weakness. Full-thickness tear less likely. Limits overhead work and sleep. Good prognosis with strengthening and activity modification." It names the problem, the evidence, the functional impact and the prognosis.
What outcome measures should I use in an MSK SOAP note?
Pick one per region: Neck Disability Index for the neck, QuickDASH or SPADI for the shoulder and arm, Oswestry for the low back, HOOS for the hip, KOOS for the knee and LEFS for the lower extremity. Repeat the same measure at each progress report.
How often do Medicare PT notes need a progress report?
At least once every 10 treatment days, or once per certification interval if that is shorter, under the Medicare Benefit Policy Manual, Chapter 15, Section 220.3.
Can AI write musculoskeletal SOAP notes?
AI scribes can draft the note from the visit conversation and your measurements, but the clinician must review, edit and sign it. See AI SOAP notes for how this works.
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