S46.81
Strain of other muscles, fascia and tendons at shoulder and upper arm level
Clinical Classification Guidelines
Medical Intelligence & Overview
A strain of the muscles, fascia, and tendons at the shoulder and upper arm level refers to an injury where these tissues are overstretched or torn. This type of injury is common among athletes, manual laborers, or individuals involved in activities that require sudden or repetitive arm movements. The condition can result in pain, swelling, and limited mobility of the shoulder and upper arm area, impacting daily activities and work performance.
Causes & Symptoms
Clinical Causes: Sudden or excessive lifting or pulling of heavy objects Repetitive overhead activities, such as throwing or swimming Direct trauma or blow to the shoulder or upper arm Sudden jerking or twisting movements Poor posture leading to muscle overuse Overexertion during sports or physical activities
Key Symptoms: Pain at the shoulder or upper arm, especially with movement Swelling or tenderness around the affected area Muscle weakness or reduced strength in the shoulder and arm Limited range of motion or stiffness Bruising or discoloration may be present in more severe cases A feeling of pulling or tearing sensation during injury
Diagnostic & Treatment
Diagnosis Path: Diagnosis typically involves a physical examination where a healthcare provider assesses pain points, tenderness, swelling, and range of motion. They may also inquire about recent activities or injuries. Imaging studies such as an MRI or Ultrasound can be ordered to confirm the extent of tissue damage, differentiate from other injuries like fractures, or rule out other shoulder problems.
Treatment Protocols: Management focuses on allowing the tissues to heal and reducing pain and inflammation. Typical treatment options include:
Clinical Advice & FAQs
Billing Guidance
Is S46.81 a billable ICD-10 code?
Yes, S46.81 is a specific, billable code that can be used to indicate a diagnosis for reimbursement purposes.
Documentation
How do I report S46.81?
Clinical documentation must specify the nature of Strain of other muscles, fascia and tendons at shoulder and upper arm level and any associated comorbidities for accurate reporting.
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