Name of the Condition

• Incomplete Rotator Cuff Tear or Rupture of Unspecified Shoulder, Not Specified as Traumatic
• Commonly referred to as partial rotator cuff tear.

Summary

• An incomplete rotator cuff tear involves partial damage to the tendon fibers in the shoulder. Unlike a full tear, some fibers remain intact, affecting shoulder strength and flexibility.

Causes

• Wear and tear over time, especially in individuals over 40.
• Repetitive overhead activities or heavy lifting.
• Poor posture or shoulder alignment.
• Previous shoulder injuries.

Risk Factors

• Aging, as rotator cuff tendons naturally degenerate over time.
• Occupations or sports involving repetitive shoulder movement, such as painting or tennis.
• Smoking, which can affect blood supply to the rotator cuff.

Symptoms

• Shoulder pain, especially when raising or lowering the arm.
• Weakness in the shoulder.
• A crackling sensation when moving the shoulder in certain ways.

Diagnosis

• Physical examination to test range of motion and pain response.
• Imaging tests like MRI or ultrasound to assess any tears or inflammation.

Treatment Options

• Physical therapy to strengthen shoulder muscles and improve flexibility.
• Nonsteroidal anti-inflammatory drugs (NSAIDs) for pain relief.
• Corticosteroid injections to reduce inflammation.
• Surgery in severe cases to repair the damaged tendon.

Prognosis and Follow-Up

• Many people recover full function with appropriate treatment, though some may experience lingering weakness or discomfort.
• Regular follow-up appointments to monitor progress and adjust treatment.

Complications

• Permanent weakness or stiffness if untreated.
• Progression to a full-thickness tear requiring surgical intervention.

Lifestyle & Prevention

• Regular shoulder exercises to maintain strength and flexibility.
• Avoiding repetitive overhead activities or taking breaks to prevent fatigue.
• Maintaining good posture and ergonomic practices.

When to Seek Professional Help

• Persistent shoulder pain not relieved by rest or over-the-counter medications.
• Sudden loss of shoulder movement or strength.
• Swelling or significant bruising around the shoulder after an activity.

Additional Resources

• American Academy of Orthopaedic Surgeons (AAOS)
• National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)

Tips for Medical Coders

• Confirm the tear is documented as "incomplete" and "unspecified shoulder" to accurately use M75.110.
• Double-check that the condition is noted as "not specified as traumatic" before coding.
• Avoid confusion with full-thickness tears or diagnoses related to specific traumatic injuries.