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Soft Tissue Injuries

When an injured patient enters our office, our responsibility is to get that patient back to preinjury status as fast as possible. Unfortunately, most patients with acute injuries end up with impairments that result in permanent damage to the body.

It is very important for examining doctors to document the history of the accident, the mechanism of the impact, the resulting treatment post-accident and the life altering effects of the injuries.

The most common types of soft injuries include sprains and strains, contusions, herniated discs, pinched nerves.


  • Accident report – (
  • Insurance Request Form filled out and /mailed/faxed for other driver’s insurance information (Form HSMV 83392) mail/fax to:

Customer Service Correspondence Center
2900 Apalachee Parkway, Room A216, MS 99
Tallahassee, Florida 32399-0585
Fax: 850-617-5216

  • Pictures of the accident
  • Medical records (Hospital/Past care pertaining to injured body parts)
  • Pictures of the injuries (Contusions)
  • Imaging test results
  • Consent for Care signed
  • Authorization to release Medical Information signed
  • Medical Lien form signed


  • History of accident
  • Past surgeries, trauma and medical history
  • Post-accident treatment
  • Missed work time as a result of the injuries
  • Functional limitations on activities for daily living (Bending, lifting, Insomnia etc)
  • Review of Systems – (Neuromuscular, ears, eyes, head, neurological, musculoskeletal)
  • Past-History – (Old accidents – aggravations of pre-existing conditions)
  • Outcomes Assessment Completed –(i.e. Visual Analog scale or Oswestry assessments)

EXAMINATION - symptoms related to the soft tissue injury:

*Sometimes these symptoms take days or weeks to emerge after the injury.

  • Swelling
  • Neck, mid and lower back pain and/or stiffness
  • Skin discoloration
  • Inability to bear weight on a joint
  • Pain while moving a joint
  • Cognitive problems – trouble remembering or concentrating

Physical Exam: Height, Weight, Blood Pressure, Pulse

Musculoskeletal Exam: Digital Palpation, muscle tension, Spinal misalignments

Range of Motion: limitation of spine and extremity mobility

Muscle Testing: Cervical -Thoracic-Lumbar, Upper and lower extremities

Neurological Exam: Dermatomes, Reflexes, Cranial Nerves

Orthopedic Exam: Orthopedic tests: Spine and extremities, Grip Strength


  • Radiology – (include overread by Board Certified Radiologist)
  • MRI
  • CT Scan
  • NCV


  • Referral for EMC (Emergency Medical Condition)
  • Referral for Orthopedic/Neurology/Physiatrist


  • Orthopedic Supports
  • At home supplies: Cold/Heat Packs


  • Initial Treatment Plan for 3-4 weeks
  • At-home instructions:
  • Work restrictions

Case Preparation:

  • Initial Report including radiology reports and initial billing sent to attorney
  • Phone call to attorney/paralegal to update on patient status
  • When patient reaches MMI - Final report sent including Impairment rating, medical records, billing records with payments and all diagnostic reports

Documentation is the key to substantiate accident-related injuries and be prepared to testify in court on the validity of the patient’s injuries.