SOAP Note

Athletes name: ****** Sport: mens tennis

Date: 11/11/2013 Age: 19 y/o

S: C/o R knee P! on the Ant aspect, but mostly below the patella. Gradual onset of symptoms over the past couple weeks. P! is worse when leg is in full Ext or when pt is running; feels weak when pt plants foot to change direction. P! is 3/10 when at rest and 6/10 when practicing; P! is dull and constant once practicing.

O: Pt has P! w/ active Ext of R knee. Pt also experiences P! w/ passive Flex of R knee. Weakness and P! were noted w/ resisted testing of knee Ext. All other ROM test results were WNL. During palpation P! was noted on Inf patellar tendon and over tibial tuberosity; slight P! w/ palpation of Sup patellar tendon. For special tests an Apleys compression, Ant drawer, and Lachmans test were conducted on the pt. All tests were Neg.

A: Due to special test results, an ACL spr. and a meniscal Injury have been R/O. Pts P! is mostly confined to the Inf patellar tendon area w/ gradual onset of symptoms indicating most likely patellar tendonitis. STG are to reduce pain to a 3/10 during practice and to try to reduce any inflammation w/in a week. LTG are to have pt continue w/ full participation in practice while treating symptomatically, eliminate P! during practice w/in two months.

P: Have pt heat and stretch before practice. Pt should wear a patellar tendon strap during activity and ice and stretch after practice. Continue to monitor pt, implement muscle strengthening program for quads PRN. Instructions to take NSAIDs for reduction of P! and inflammation will be given four days post injury PRN.

---Wade Price, ATS