4/26/2017
Instructions for the day: Review PowerPoint on SOAP notes,
then complete your 7th anchor. You CANNOT use ACL injury as
I have done so in the example at the end. Make up numbers
and facts as needed.
 Provide an organized structure for decision making and
problem solving in sports injury management
 Document patient care
 Serve as a vehicle of communication between onside
clinicians and other healthcare professionals
S
 Subjective evaluation
O
 Objective evaluation
A
 Assessment
P
 Plan
 Primary complaint
 MOI
 Location of pain
 Onset and behavior of symptoms
 Functional impairments
 Pain perception
 Previous injuries to the area
 Family history
 May include observation
 Measureable documentation so repeated measurements can
track progress
 Edema
 Ecchymosis
 Atrophy
 ROM
 Strength
 Joint stability
 Functional disability
 Motor and sensory function
 Cardiovascular endurance
 Special Tests (positive and negative)
 After objective testing, analyze and assess individual’s
status and prognosis
 Suspected injury and severity of the injury should be
documented
 Short term goals (STGs) and long term goals (LTGs) should
also be documented
 What is going to be done to treat injury
 Frequency and duration of treatment
 On-going patient education
 Criteria for D/C (discharge, or return to play – how will you
and they know they are done and ready to return?)
 Write as if you didn’t already know what the injury was. What
would you have to do to complete a thorough evaluation? (HINT:
not all of your special tests would be positive, right?)
 Can be bulleted or in paragraph form
 Be as thorough as possible
 May need to look back on your notes for some signs and
symptoms of an injury… though does not have to be an injury we
have covered in class.
 Don’t know what details to put in? Make it up!
 Subjective:
 MOI: rebounding in basketball
 History of knee injury: None prior
 Heard a “pop” and pain
 Observation:
 Unable to walk on both feet
 Cannot straighten knee while standing
 Tenderness on anterior knee
 Copious effusion
 Yellowish discoloration
 Objective:
 ROM measurements: extension: 15, flexion: 100
(compare bilaterally)
 Swelling: 30 mm at 10mm above patella, 40 mm at
patella (compare bilaterally)
 Test/results:
 Lachman: visual protrusion of tibia (+)
 Anterior drawer: visual protrusion of tibia (+)
 Posterior drawer: no PCL damage (-)
 Thessely: no catching (-)
 Assessment:
 Grade 3 Anterior Cruciate Ligament sprain
 STG: Reduce swelling by 50% in 48 hours by ice and
elevation, regain normal ROM in 1 week by
stretching, schedule surgery
 LTG: Reduce swelling and regain ROM completely
before surgery, complete surgery and begin PT
 (*These goals would be different if written by a
physical therapist at the beginning of PT – when to
start walking w/o crutches, when to start running,
etc.)
 Plan:
 RICE immediately – ice 20 minutes, 5 times a day
 ACE bandage to reduce swelling
 ROM stretching 3 times per day
 Referral to orthopedic surgeon
 Follow up with me in 3 days
 Educate about importance of decreasing swelling
and regaining ROM before surgery
 Complete PT after surgery before RTP (~9 months)
 18 y/o Sally was playing basketball when she went to rebound a ball, but landed on
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
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someone else’s foot when her knee gave our on her and she collapsed to the ground in
immense pain. She heard a loud “pop”. She has no prior history of injury to this knee.
She c/o instability in the knee when she tries to walk.
Upon observation she has a noticeable limp and is apprehensive to straighten her knee
while standing or laying down. She has copious effusion with some ecchymosis which is
accompanied by tenderness in her anterior knee.
Her ROM measurements on affected knee read: 15-100 degrees, on contralateral knee:
0-130 degrees. Girth measurements read: 30 & 40 mm on affected knee, 20 & 30 on
contralateral knee. Positive Lachman’s and anterior drawer tests, negative posterior
drawer and Thessaly’s test.
My assessment is a grade 3 anterior cruciate ligament sprain. Her short term goals are
to reduce swelling, regain ROM, see orthopedic surgeon. Her long term goals include
surgery, and completing PT.
For now Sally will complete a RICE regimen, icing for 20 minutes at least 5 times a day. I
have contacted her parents to inform them of the situation. She has been instructed on
the importance of decreasing swelling and increasing ROM before surgery. I have given
her an ACE bandage to wear during the day and at night if desired. I have also referred
her to a surgeon and a physical therapist. She will follow up with me in 3 days.