Examples
50 massage SOAP note examples
Fifty worked SOAP notes across relaxation, deep tissue, sports, prenatal, geriatric, and injury-rehab sessions — each with a different client and complaint. They're written the way a real note reads: concise, section-by-section, and within massage scope. Use them to see how the format flexes to the situation, then adapt the structure to your own clients.
New to the format first? Start with how to write SOAP notes for massage therapy, then generate a blank one with the free SOAP note template generator or draft a full note from a description with the free SOAP note generator.
Session types covered
RelaxationDeep tissueSportsPrenatalInjury rehabGeriatric
1. General stress and tension
Relaxation- Subjective
- Client c/o general stress, poor sleep for ~3 weeks, no specific pain. Goal: relax and unwind. Rates overall tension 5/10.
- Objective
- Full-body Swedish, moderate pressure, 60 min supine and prone. Noted bilat upper trap and posterior neck HT. Breathing shallow at start.
- Assessment
- Client visibly relaxed by mid-session; breathing deepened, upper traps softened. Tension appears stress-driven rather than injury-related.
- Plan
- Suggested weekly sessions during high-stress period. Recommended box breathing before bed. Rebook in 1 week.
2. Chronic right upper trap tightness
Deep tissue- Subjective
- Desk worker, c/o persistent right upper trap and levator tightness, worse by end of workday. 6/10. Ongoing ~6 months.
- Objective
- Deep tissue to right upper trap, levator scap, rhomboids. Sustained compression on 2 active TrPs in right upper trap. Firm pressure, 45 min.
- Assessment
- Right upper trap released noticeably; TrPs less reactive by end. Pattern consistent with sustained desk posture and monitor position.
- Plan
- Home care: doorway pec stretch, monitor-height adjustment. Rebook in 2 weeks; reassess levator involvement.
3. Runner — tight calves pre-event
Sports- Subjective
- Recreational runner, half-marathon in 5 days. c/o tight gastrocs bilat, wants maintenance, no pain. Goal: keep legs loose.
- Objective
- Pre-event style, gastroc/soleus bilat, moderate-to-firm, brisk pace. AROM ankle dorsiflexion mildly limited bilat. Avoided deep static work.
- Assessment
- Calves responded well; dorsiflexion improved slightly post-session. Tissue healthy, no acute findings — appropriate for pre-event maintenance.
- Plan
- Light session only until event. Hydration reminder. Post-race recovery massage recommended 2–3 days after.
4. Second trimester low back ache
Prenatal- Subjective
- 28 weeks pregnant, c/o dull low back ache, worse standing. 4/10. Cleared by OB for massage. Goal: comfort.
- Objective
- Side-lying with bolstering. Gentle-to-moderate work to QL, glutes, low back bilat. 50 min. Avoided deep abdominal and contraindicated points.
- Assessment
- Low back eased; client reported reduced ache post-session. Findings consistent with normal pregnancy load on lumbar/pelvic region.
- Plan
- Side-lying pelvic tilts for home. Rebook every 2 weeks through third trimester. Continue OB clearance.
5. Post-whiplash neck (MVA, cleared)
Injury rehab- Subjective
- 6 weeks post rear-end MVA, medically cleared for massage. c/o stiff neck, limited rotation. Rotation worse to left. 5/10.
- Objective
- Gentle myofascial to cervical paraspinals, SCM, scalenes. AROM cervical rotation ~60% left, ~80% right. Light pressure, 40 min.
- Assessment
- Rotation improved during session, esp. left. Guarding reduced. Progress consistent with soft-tissue recovery stage.
- Plan
- Continue weekly. Gentle AROM exercises per referring provider. Coordinate with PT. Reassess rotation next visit.
6. Low back — manual labor
Deep tissue- Subjective
- Warehouse worker, c/o bilat low back tightness after lifting. 6/10, worse bending. No radiating symptoms (denies leg pain/numbness).
- Objective
- Deep tissue to erector spinae, QL bilat, glute max. Firm pressure, 50 min. No neuro signs elicited. Erectors dense bilat.
- Assessment
- Erectors and QL released; ROM in flexion improved. Absence of radiating symptoms suggests muscular, not nerve, involvement.
- Plan
- Hip-hinge lifting reminder, cat-cow for home. Rebook 2 weeks. Refer out if leg symptoms appear.
7. First-time client, apprehensive
Relaxation- Subjective
- New client, never had massage. Nervous. c/o mild shoulder tension, mostly curious. No pain rating given.
- Objective
- Swedish, light-to-moderate, checked in on pressure often. 60 min. General bilat shoulder and back HT, mild.
- Assessment
- Client relaxed as session progressed; comfort with touch increased. No red flags. Good candidate for ongoing relaxation work.
- Plan
- Invited feedback on pressure for next time. No home care needed. Rebook at client's discretion.
8. Cyclist — hip flexor tightness
Sports- Subjective
- Avid cyclist, c/o tight hip flexors and anterior hip, bilat. 4/10. Worse after long rides. Goal: improve hip mobility.
- Objective
- Deep tissue to iliopsoas region (indirect), rectus femoris, TFL bilat. Moderate-firm, 50 min. Hip extension limited bilat.
- Assessment
- Anterior hip released; hip extension improved post-session. Pattern typical of prolonged cycling flexion posture.
- Plan
- Couch stretch and hip flexor mobility drills. Rebook 2–3 weeks. Suggested bike-fit check.
9. Rotator cuff — post-PT maintenance
Injury rehab- Subjective
- 6 months post rotator cuff strain, discharged from PT. c/o occasional right shoulder ache, wants to maintain. 3/10.
- Objective
- Right infraspinatus, teres minor, subscap (accessible), deltoid. Moderate. AROM shoulder near full, mild end-range discomfort abduction.
- Assessment
- Cuff musculature responded well. Minor end-range discomfort only. Consistent with well-healed strain in maintenance phase.
- Plan
- Continue PT home exercises. Monthly maintenance massage. Flag return of night pain to physician.
10. Tension headaches
Deep tissue- Subjective
- c/o recurring tension headaches, 2–3x/week, band-like. Links to neck tightness. Headache today 4/10. ~2 months ongoing.
- Objective
- Suboccipital release, upper trap, SCM, temporalis. Moderate. 45 min. Suboccipitals very tight bilat, reproduced familiar tension on palpation.
- Assessment
- Suboccipital tension likely contributing to headache pattern. Client reported head felt 'lighter' post-session.
- Plan
- Suboccipital self-release with towel, screen breaks. Rebook 1 week. Refer to physician if headaches worsen or change character.
11. Older adult — general mobility
Geriatric- Subjective
- 78 y/o, c/o general stiffness, mild hip and knee achiness. 3/10. On blood thinner (noted). Goal: comfort and mobility.
- Objective
- Gentle Swedish, light pressure throughout given medication. 45 min. Avoided deep work. General bilat lower-limb stiffness.
- Assessment
- Client comfortable, mobility felt easier standing post-session. Light pressure appropriate given anticoagulant use.
- Plan
- Gentle daily walking, warm bath. Rebook every 2 weeks, maintain light pressure. Monitor for bruising.
12. Weightlifter — thoracic tightness
Sports- Subjective
- Powerlifter, c/o mid-back/thoracic tightness after heavy pressing. 5/10. Feels 'stuck' in extension.
- Objective
- Deep tissue to thoracic erectors, rhomboids, lats bilat. Firm, 50 min. Thoracic paraspinals dense; limited thoracic extension.
- Assessment
- Thoracic mobility improved; client reported easier extension. Pattern consistent with heavy anterior-chain training load.
- Plan
- Thoracic foam-roll extensions, banded lat stretch. Rebook 2 weeks. Suggested warm-up mobility before pressing.
13. Ankle sprain — subacute
Injury rehab- Subjective
- Lateral ankle sprain 3 weeks ago, cleared, out of acute phase. c/o residual stiffness, mild swelling by evening. 3/10.
- Objective
- Light lymphatic-style drainage plus gentle work to peroneals, gastroc. Very light around lateral ankle. AROM improving. 40 min.
- Assessment
- Residual swelling and stiffness consistent with subacute healing. Tissue tolerating gentle work well, no acute reactivity.
- Plan
- Ankle alphabet, calf raises per provider. Elevate evenings. Rebook 1 week; progress pressure as tolerated.
14. Grief and emotional stress
Relaxation- Subjective
- Client recently bereaved, c/o full-body tension and exhaustion, wants a calm, nurturing session. No specific pain. Emotional.
- Objective
- Slow Swedish, moderate, unhurried pacing. 75 min. Generalized bilat tension, esp. shoulders and jaw. Held space, minimal talking per request.
- Assessment
- Client relaxed deeply, became tearful mid-session (expected release). No physical red flags. Tension diffuse and stress-linked.
- Plan
- Encouraged rest and hydration. No structured home care. Rebook at client's pace; offered flexible scheduling.
15. Sciatic-type glute tightness (non-neuro)
Deep tissue- Subjective
- c/o deep right glute ache, occasional referral into posterior thigh. Denies numbness/tingling or below-knee symptoms. 5/10.
- Objective
- Deep work to glute max, med, and piriformis region, right. Moderate-firm. 45 min. Right piriformis reproduced local ache, no shooting/neuro signs.
- Assessment
- Presentation appears myofascial (piriformis/glute) rather than true nerve compression given no distal neuro signs. Local ache reduced.
- Plan
- Piriformis and glute stretches. Rebook 2 weeks. Refer to physician if numbness, tingling, or below-knee symptoms develop.
16. Tennis player — forearm/elbow
Sports- Subjective
- Tennis player, c/o lateral forearm tightness and elbow ache (common extensor). 4/10. Worse after matches. ~1 month.
- Objective
- Deep tissue to wrist extensors, brachioradialis, right. Cross-fiber at common extensor origin, moderate. 40 min. Extensor mass tender.
- Assessment
- Extensor overload pattern consistent with racquet load. Tenderness reduced post-session; grip felt easier per client.
- Plan
- Eccentric wrist-extensor loading, forearm stretch. Rebook 1–2 weeks. Suggested grip-size and technique review; refer if worsening.
17. Third trimester — swollen legs
Prenatal- Subjective
- 34 weeks, c/o swollen lower legs and tired feet by evening. OB-cleared. No calf pain, no redness/warmth (denies). Goal: relieve heaviness.
- Objective
- Side-lying, gentle lymphatic-style toward proximal, light effleurage to lower legs and feet. 45 min. Mild bilat pitting edema, no unilateral signs.
- Assessment
- Bilateral, symmetrical edema consistent with normal late-pregnancy fluid retention; no signs suggesting clot (no unilateral pain/warmth).
- Plan
- Elevate legs, stay hydrated. Rebook weekly. Advised to report any unilateral calf pain, warmth, or redness to OB immediately.
18. Plantar fasciitis-type foot pain
Deep tissue- Subjective
- c/o sharp right heel/arch pain, worst first steps in morning. 6/10 AM, eases with movement. ~2 months.
- Objective
- Deep work to plantar fascia (right), gastroc, soleus. Moderate-firm. 40 min. Plantar fascia and calf tight; medial arch tender.
- Assessment
- Presentation consistent with plantar fascia tension pattern and tight posterior chain. Arch tenderness reduced; calf released.
- Plan
- Frozen-bottle roll AM, calf stretch, supportive footwear. Rebook 1–2 weeks. Refer to podiatrist if no improvement in 4 weeks.
19. Shift worker — disrupted sleep
Relaxation- Subjective
- Night-shift nurse, c/o fatigue and neck/shoulder tension from disrupted sleep. 4/10. Goal: reset and relax.
- Objective
- Swedish with focus on neck, shoulders, scalp. Moderate. 60 min. Bilat upper trap HT, tight scalp/occiput.
- Assessment
- Tension stress- and posture-related. Client very relaxed, nearly asleep by end. No red flags.
- Plan
- Wind-down routine before day-sleep, blackout environment. Rebook every 2–3 weeks around schedule.
20. Swimmer — shoulder maintenance
Sports- Subjective
- Competitive swimmer, c/o general shoulder fatigue, bilat, no pain. Wants maintenance during training block. 3/10.
- Objective
- Deltoid, rotator cuff (accessible), pecs, lats bilat. Moderate. 50 min. Pecs and lats tight bilat; cuff unremarkable.
- Assessment
- Anterior tightness typical of high swim volume. Good tissue quality. Appropriate maintenance session, no acute findings.
- Plan
- Doorway pec stretch, band external rotations. Rebook every 2 weeks through training block.
21. Post-surgical scar (knee, well-healed)
Injury rehab- Subjective
- 8 months post knee arthroscopy, cleared. c/o tightness around scar and mild quad tension. 2/10. Goal: mobility.
- Objective
- Scar mobilization (well-healed, closed), quad and IT band work, right. Moderate. 40 min. Scar mobile in most directions, one adherent area.
- Assessment
- Scar generally mobile; one adherent region improved with direct work. Quad tension reduced. Consistent with mature post-surgical tissue.
- Plan
- Self scar-massage daily, quad stretch. Rebook 3 weeks. Continue any remaining PT exercises.
22. TMJ / jaw tension
Deep tissue- Subjective
- c/o jaw tightness and clicking, clenches at night. 4/10. Facial and temporal tension. Referred by dentist for muscular work.
- Objective
- Intra- and extra-oral masseter, temporalis, pterygoid (accessible), with consent and gloves. Light-moderate. 40 min. Masseters very tight bilat.
- Assessment
- Significant masseter/temporalis tension consistent with clenching. Jaw felt looser, opening easier post-session.
- Plan
- Jaw-relaxation cues, avoid gum. Coordinate with dentist re: night guard. Rebook 2 weeks.
23. Couples/relaxation — busy parent
Relaxation- Subjective
- Parent of young kids, c/o 'no time', general fatigue and neck tension. 4/10. Goal: 60 minutes of pure relaxation.
- Objective
- Full-body Swedish, moderate, warm towels. 60 min. Bilat upper trap and low back mild HT. Nothing acute.
- Assessment
- Diffuse stress-pattern tension. Client fully relaxed. No red flags requiring follow-up.
- Plan
- No structured home care. Encouraged regular self-care time. Rebook monthly if helpful.
24. CrossFit — DOMS recovery
Sports- Subjective
- CrossFit athlete, 2 days post heavy leg day, c/o severe quad/glute soreness (DOMS). 6/10, tender to touch. No sharp/joint pain.
- Objective
- Lighter flushing work to quads, glutes, hamstrings bilat. Light-moderate (tender). 50 min. Diffuse muscle soreness, no localized injury signs.
- Assessment
- Presentation consistent with DOMS, not injury (diffuse, symmetrical, no joint/sharp pain). Soreness eased with flushing work.
- Plan
- Hydration, light movement, sleep. Rebook post-heavy sessions. Advised sharp or one-sided pain warrants assessment.
25. Text-neck / forward head posture
Deep tissue- Subjective
- Student, c/o neck ache and upper-back tightness from phone/laptop use. 5/10. Worse evenings. Ongoing.
- Objective
- Deep tissue to cervical extensors, upper trap, rhomboids; pec stretch. Moderate. 45 min. Forward-head posture, tight suboccipitals and pecs.
- Assessment
- Classic forward-head/upper-crossed pattern. Posterior neck released; posture felt taller post-session per client.
- Plan
- Chin tucks, pec stretch, device-height changes. Rebook 2 weeks. Postural retraining emphasized over passive relief alone.
26. Hamstring strain — late stage
Injury rehab- Subjective
- Grade 1 hamstring strain 5 weeks ago, cleared, running again lightly. c/o mild residual tightness, right. 2/10. No sharp pain.
- Objective
- Moderate work to right hamstring, glute; cross-fiber near healed area (non-tender). 40 min. Mild tightness, good tissue glide, no acute signs.
- Assessment
- Late-stage healing; tissue tolerating load well, no reactivity. Residual tightness only. Safe to progress activity.
- Plan
- Continue eccentric hamstring loading (Nordic progressions) per provider. Rebook 2–3 weeks. Gradual running increase.
27. Pre-travel / long-flight prep
Relaxation- Subjective
- Client flying long-haul tomorrow, c/o general stiffness, wants to feel loose before travel. 3/10. No specific complaint.
- Objective
- Swedish full-body with attention to hips, low back, neck. Moderate. 60 min. General mild HT, nothing acute.
- Assessment
- General tension only. Session appropriate as pre-travel maintenance; client relaxed and mobile post-session.
- Plan
- In-flight: walk aisles, ankle pumps, hydrate. Rebook after trip if desired. No red flags.
28. Golfer — one-sided rotation tightness
Sports- Subjective
- Golfer, c/o right-sided low back and hip tightness, worse after rounds. 4/10. Rotation feels asymmetric.
- Objective
- Deep tissue to right QL, glute, thoracolumbar; addressed left thoracic rotators. Moderate-firm. 50 min. Asymmetric tightness R>L.
- Assessment
- Rotational asymmetry consistent with repetitive golf swing pattern. Right-side tension reduced; rotation felt more even post-session.
- Plan
- Thoracic rotation mobility, hip stretch. Rebook 2–3 weeks. Suggested swing/rotation assessment with coach.
29. IT band / lateral knee tightness
Deep tissue- Subjective
- Runner, c/o lateral right knee/thigh tightness (IT band). 4/10 late in runs, no locking or giving way. ~3 weeks.
- Objective
- Work to TFL, glute med, vastus lateralis, IT band region, right. Moderate-firm. 45 min. TFL and glute med tight; lateral thigh tender.
- Assessment
- Pattern consistent with lateral chain/TFL overload rather than intra-articular issue (no locking/instability). Lateral tension reduced.
- Plan
- Glute med strengthening, foam roll lateral thigh, cadence check. Rebook 2 weeks. Refer if knee locks or gives way.
30. Anxiety management (adjunct to care)
Relaxation- Subjective
- Client with diagnosed anxiety (under care of physician), uses massage as adjunct. c/o chest/shoulder tightness, shallow breathing. 4/10.
- Objective
- Slow, predictable Swedish; chest, shoulders, neck, diaphragm area (gentle). 60 min. Elevated shoulders, shallow breath at start.
- Assessment
- Client's breathing deepened and shoulders dropped through session. Massage well-tolerated as adjunct; not a substitute for medical care.
- Plan
- Diaphragmatic breathing practice. Rebook weekly. Continue physician-directed care; coordinate as needed.
31. Frozen shoulder — early thawing
Injury rehab- Subjective
- Dx adhesive capsulitis (by physician), entering thawing phase. c/o stiff right shoulder, limited reach. 5/10. Cleared for gentle work.
- Objective
- Gentle work to periscapular muscles, deltoid, pec; pain-free ROM only. Light-moderate. 40 min. AROM abduction ~90°, external rotation limited.
- Assessment
- Capsular restriction with periscapular guarding. Modest ROM gain within pain-free range. Progress consistent with early thawing.
- Plan
- Pain-free pendulum and wall-walk exercises per physician/PT. Rebook weekly. Stay within pain-free range.
32. Bruxism-related neck and jaw combo
Deep tissue- Subjective
- c/o combined jaw tension and upper neck ache, grinds teeth. 5/10. Wakes with tight jaw. Referred by dentist.
- Objective
- Masseter/temporalis (extra-oral), suboccipitals, upper cervical. Moderate. 45 min. Masseters and suboccipitals very tight bilat.
- Assessment
- Jaw and upper-cervical tension linked, consistent with bruxism. Both regions released; client reported reduced tightness.
- Plan
- Jaw-rest posture, warm compress. Coordinate with dentist re: guard. Rebook 2 weeks.
33. Basketball — calf and Achilles load
Sports- Subjective
- Basketball player, c/o tight calves and mild Achilles stiffness bilat. 3/10. No sharp pain, no morning Achilles pain. Maintenance.
- Objective
- Deep tissue to gastroc, soleus; gentle around Achilles bilat. Moderate. 45 min. Calves tight; Achilles non-reactive to gentle palpation.
- Assessment
- Calf tightness from jumping/sprint load; Achilles unremarkable (no reactivity). Appropriate maintenance, no signs of tendinopathy today.
- Plan
- Calf stretch, eccentric heel drops preventively. Rebook 2 weeks. Advised morning Achilles pain warrants assessment.
34. Post-illness fatigue (recovered)
Relaxation- Subjective
- Recovered from flu 2 weeks ago, c/o lingering fatigue and body achiness, fully recovered otherwise. 3/10. Goal: gentle reset.
- Objective
- Gentle full-body Swedish, light-moderate. 60 min. Diffuse mild achiness, no localized findings, no fever/acute illness signs.
- Assessment
- Diffuse post-viral achiness resolving. Tolerated gentle work well. No red flags; appropriate given full recovery.
- Plan
- Rest, hydration, gradual return to activity. Rebook as desired. Advised to wait if illness recurs.
35. Rhomboid / interscapular knot
Deep tissue- Subjective
- c/o pinpoint ache between right shoulder blade and spine, 'knot'. 5/10. Worse reaching forward. ~2 weeks.
- Objective
- Deep work to rhomboids, mid-trap, right; sustained pressure on TrP. Firm. 40 min. Palpable taut band right rhomboid, reproduced familiar ache.
- Assessment
- Active trigger point in right rhomboid reproducing complaint. TrP reactivity reduced post-treatment; ache eased.
- Plan
- Ball self-release against wall, scapular retraction. Rebook 1–2 weeks. Address desk ergonomics.
36. First trimester — cautious first visit
Prenatal- Subjective
- 9 weeks pregnant, first prenatal massage, c/o mild neck/shoulder tension, some nausea. OB-cleared. Anxious about safety. 3/10.
- Objective
- Semi-reclined and side-lying, gentle Swedish to neck, shoulders, back. Light-moderate. 45 min. Avoided contraindicated points; mild upper-back HT.
- Assessment
- Well-tolerated; nausea did not worsen. Tension mild and postural. Client reassured about safe positioning.
- Plan
- Gentle neck stretches, ginger for nausea (per OB). Rebook in 2–3 weeks. Continue OB clearance.
37. Chronic low back — flare-up
Injury rehab- Subjective
- History of chronic low back pain, c/o current flare, bilat lumbar. 6/10. Denies leg symptoms, bowel/bladder changes. Cleared for massage.
- Objective
- Moderate work to erectors, QL, glutes bilat; avoided direct pressure on most tender point. 45 min. Guarding present, no neuro signs.
- Assessment
- Muscular flare of known chronic LBP; no red-flag signs present. Guarding reduced, mobility improved during session.
- Plan
- Gentle McGill-style core routine per provider, heat. Rebook 1 week. Refer immediately if leg weakness/numbness or bladder changes.
38. Scalene / thoracic outlet-type tightness
Deep tissue- Subjective
- c/o neck tightness with occasional tingling into right forearm when carrying bags. Denies constant numbness. 4/10. Under physician review.
- Objective
- Gentle-moderate to scalenes, pec minor, upper trap, right. 40 min. Scalenes and pec minor tight; positional tingling noted, not constant.
- Assessment
- Positional neurovascular-type tightness (scalene/pec minor) possible; symptoms intermittent and posture-linked. Improved with release.
- Plan
- Postural correction, avoid heavy one-shoulder bags. Coordinate with physician. Rebook 1–2 weeks; refer if symptoms become constant.
39. Marathoner — post-race recovery
Sports- Subjective
- Ran marathon 3 days ago, c/o global lower-body soreness and heavy legs. 5/10, easing. No sharp/localized pain.
- Objective
- Flushing work to quads, hamstrings, calves, glutes bilat. Light-moderate. 60 min. Diffuse soreness, no localized injury findings.
- Assessment
- Normal post-marathon DOMS/recovery. Diffuse and symmetrical, no injury signs. Legs felt lighter post-session per client.
- Plan
- Easy walking, hydration, gradual return to running. Rebook 1 week. Flag any persistent one-sided pain.
40. Caregiver burnout
Relaxation- Subjective
- Full-time caregiver for parent, c/o exhaustion, neck/shoulder and low back tension. 5/10. Little time for self. Goal: restorative.
- Objective
- Full-body Swedish, moderate, focus neck/shoulders/low back. 75 min. Bilat upper trap and lumbar HT, jaw tension.
- Assessment
- Diffuse tension consistent with sustained physical and emotional caregiving load. Client relaxed; tension reduced across regions.
- Plan
- Encouraged scheduled respite and self-care. Simple neck/low-back stretches. Rebook every 2 weeks if feasible.
41. Wrist/forearm — office and mouse use
Deep tissue- Subjective
- Graphic designer, c/o right forearm tightness and wrist ache from mouse use. 4/10. Worse end of workday. ~1 month.
- Objective
- Deep work to wrist flexors/extensors, pronators, right; light around carpal tunnel. Moderate. 40 min. Forearm flexors tight, no neuro signs.
- Assessment
- Overuse forearm tension from repetitive mouse work; no signs of nerve entrapment today. Forearm released, grip easier.
- Plan
- Ergonomic mouse/wrist setup, forearm stretches, micro-breaks. Rebook 2 weeks. Refer if numbness/tingling develops.
42. Post-immobilization stiffness (wrist)
Injury rehab- Subjective
- Out of cast 2 weeks (wrist fracture, healed, cleared). c/o stiffness and weakness, reduced ROM. 3/10. Working with OT.
- Objective
- Gentle mobilization to wrist, forearm, hand; light. 30 min. AROM wrist reduced all directions, tissue tight from immobilization.
- Assessment
- Expected post-immobilization stiffness. Mild ROM gains within comfort. Progress coordinates with OT plan.
- Plan
- Continue OT home program. Warm soak before exercises. Rebook weekly. Stay within pain-free range.
43. Climber — hands, forearms, lats
Sports- Subjective
- Rock climber, c/o tight forearms, hands, and lats after heavy climbing week. 4/10. No joint pain. Maintenance.
- Objective
- Deep tissue to forearm flexors, intrinsic hand muscles, lats bilat. Moderate-firm. 50 min. Forearms and lats very tight, joints unremarkable.
- Assessment
- Grip- and pull-dominant load pattern typical of climbing. Good tissue quality; tension reduced, grip felt looser.
- Plan
- Forearm and lat stretches, grip-recovery days. Rebook 2 weeks. Advised finger-joint pain warrants rest/assessment.
44. Sensory-sensitive client (light touch only)
Relaxation- Subjective
- Client with sensory sensitivity, requests light pressure only, predictable pacing. c/o general tension. 3/10. Communication plan agreed.
- Objective
- Light, slow Swedish, consistent pressure, verbal check-ins per plan. 50 min. Mild general HT; client comfortable throughout.
- Assessment
- Light approach well-tolerated; client relaxed and reported comfort. Communication plan effective. No red flags.
- Plan
- Maintain same approach next time. No home care. Rebook at client's pace; keep pressure and pacing consistent.
45. Glute med / lateral hip (desk + walking)
Deep tissue- Subjective
- c/o lateral left hip ache, worse after long walks and side-lying at night. 4/10. No groin pain. ~3 weeks.
- Objective
- Deep work to glute med/min, TFL, lateral hip, left. Moderate-firm. 45 min. Glute med tender, TFL tight; no groin/joint findings.
- Assessment
- Lateral hip pattern (glute med/TFL) consistent with load and side-sleeping, not hip joint (no groin pain). Tenderness reduced.
- Plan
- Glute med strengthening, pillow between knees at night. Rebook 2 weeks. Refer if groin pain or deep joint pain appears.
46. Dancer — hip and hamstring flexibility
Sports- Subjective
- Ballet dancer, c/o tight hamstrings and hip flexors limiting extension. No pain. Goal: support flexibility. Maintenance.
- Objective
- Moderate work to hamstrings, hip flexors, adductors bilat. 50 min. Hamstrings and hip flexors tight but healthy; good tissue glide.
- Assessment
- Tightness reflects training load, not injury. Tissue quality good. Appropriate maintenance to support flexibility work.
- Plan
- Continue dynamic warm-up and PNF stretching. Rebook every 2 weeks during performance season.
47. Neck — post-concussion protocol (cleared stage)
Injury rehab- Subjective
- Cleared to progress after concussion, c/o residual neck stiffness and tension headaches. 4/10. Coordinating with care team.
- Objective
- Gentle cervical and suboccipital work, upper trap; slow, low-stimulus environment. Light-moderate. 40 min. Upper cervical tight, no dizziness provoked.
- Assessment
- Cervicogenic tension likely contributing to headaches. Tolerated gentle work without symptom provocation. Progress within cleared parameters.
- Plan
- Gentle cervical mobility per care team, low-stimulus recovery. Rebook weekly. Stop and refer if symptoms provoked.
48. Multi-area — new client, several complaints
Deep tissue- Subjective
- New client, c/o neck tightness (5/10), low back ache (4/10), and tight calves. Desk job plus weekend hiking. Goal: address the worst first.
- Objective
- Prioritized neck/upper back, then low back; brief calf work. Moderate-firm. 75 min. Bilat upper trap, lumbar erectors, and gastrocs all tight.
- Assessment
- Combined postural (desk) and activity (hiking) pattern. Prioritized neck per client; all areas responded. Established baseline for follow-up.
- Plan
- Focus neck/low back next visit. Neck and calf stretches, hydration. Rebook 2 weeks to continue and reassess.
49. Hospice / comfort-focused (in-home)
Relaxation- Subjective
- In-home comfort care client, limited mobility, c/o general discomfort, wants gentle soothing touch. Care team aware. Very light only.
- Objective
- Very gentle hand, foot, and shoulder massage in bed, supported positioning. Very light. 30 min. Frail tissue; prioritized comfort over technique.
- Assessment
- Client visibly comforted and calmer. Gentle approach appropriate given frailty. Goal is comfort, not treatment.
- Plan
- Continue brief, gentle comfort sessions. Coordinate timing with care team. Rebook per family/team preference.
50. Soccer player — pre-season screening feel
Sports- Subjective
- Soccer player, pre-season, c/o general lower-body tightness, wants to start the season loose. No pain. Goal: baseline maintenance.
- Objective
- Full lower-body deep tissue: quads, hamstrings, calves, glutes, adductors bilat. Moderate-firm. 60 min. Adductors and hip flexors tightest.
- Assessment
- General pre-season tightness, tissue healthy, no injury findings. Noted adductor tightness worth monitoring given sport demands.
- Plan
- Adductor and hip mobility work, dynamic warm-ups. Rebook every 2–3 weeks in season. Flagged adductors to monitor.
Turning examples into your own notes
The examples above are scaffolding. The fastest way to go from a finished session to a finished note is to describe what happened and let the structure assemble itself. That's what TouchTrace does: you speak or type a recap, and it returns a structured SOAP draft you review and edit before saving — so your notes stay consistent without eating into your day. For more on the format and compliance, see the massage therapy documentation guide.
Stop staring at a blank note
Describe the session out loud and TouchTrace drafts the SOAP note for you — varied, structured, and yours to edit. Try it free.
Frequently asked questions
- Can I copy these SOAP note examples for my own clients?
- Use them as structural templates, not copy-paste text. Every real note has to reflect the actual client in front of you — their words, your findings, your plan. These examples show you how each section reads and what level of detail works; adapt the wording to the real session.
- Why do the examples vary so much in length and detail?
- Because real sessions do. A relaxation session for a first-time client needs less clinical detail than an injury-rehab visit coordinating with a physician. Good documentation matches the detail to the situation rather than forcing every note into the same mold.
- How do these stay within massage scope of practice?
- Notice the Assessment sections describe tissue response, patterns, and progress — not medical diagnoses. Where a presentation could be something outside massage scope, the note describes what was observed and includes a referral in the Plan. That's the safe, defensible way to write Assessment.
- What should I do when a client has several complaints at once?
- Prioritize with the client (see example 48), document what you focused on and why, and note what you'll address next time. Trying to fix everything in one session usually means doing none of it well — the note should reflect a clear, agreed priority.