S46.091
Other injury of muscle(s) and tendon(s) of the rotator cuff of right shoulder
Clinical Classification Guidelines
Medical Intelligence & Overview
Injury of the muscles and tendons of the rotator cuff in the right shoulder is a common condition that can affect individuals of various ages and activity levels. The rotator cuff is a group of muscles and tendons that stabilize the shoulder joint and allow for a wide range of movements. Injuries to this area can result from traumatic incidents, overuse, or degenerative changes, leading to pain, weakness, and reduced mobility in the shoulder.
Causes & Symptoms
Clinical Causes: Traumatic injuries such as falls or direct blows to the shoulder Repetitive overhead movements in sports or work activities Degenerative changes due to aging leading to weakening of tendons Sudden lifting or pulling heavy objects Chronic overuse without adequate rest or recovery Previous shoulder injuries increasing vulnerability Poor posture contributing to muscle imbalance
Key Symptoms: Sharp or dull pain in the shoulder, especially when moving or lifting the arm Weakness or a feeling of instability in the shoulder Limited range of motion, making certain movements difficult or painful Tenderness around the shoulder joint Swelling or inflammation in severe cases Pain that worsens at night or with specific activities A clicking or popping sensation during shoulder movement
Diagnostic & Treatment
Diagnosis Path: The diagnosis of rotator cuff muscle and tendon injuries typically involves a combination of clinical examination and imaging tests. Healthcare providers may perform specific shoulder maneuvers to evaluate pain and strength, as well as assess the range of motion. Imaging modalities such as MRI or ultrasound are often used to visualize muscle and tendon integrity, helping to determine the extent of the injury and guide treatment planning.
Treatment Protocols: Management of injuries involving the rotator cuff muscles and tendons usually focuses on reducing pain, restoring function, and preventing further damage. Treatment options include:
Clinical Advice & FAQs
Billing Guidance
Is S46.091 a billable ICD-10 code?
Yes, S46.091 is a specific, billable code that can be used to indicate a diagnosis for reimbursement purposes.
Documentation
How do I report S46.091?
Clinical documentation must specify the nature of Other injury of muscle(s) and tendon(s) of the rotator cuff of right shoulder and any associated comorbidities for accurate reporting.
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