Name of the Condition

• Incomplete rotator cuff tear or rupture of the left shoulder, not specified as traumatic
• Medical Term: Partial-thickness tear of the rotator cuff

Summary

• This condition involves a partial tear of the tendons that stabilize and facilitate movement in the shoulder joint, specifically on the left side, without any specific trauma causing it. This type of tear may lead to shoulder pain and limited mobility.

Causes

• Causes can include repetitive use or overuse of the shoulder, age-related degeneration, or strain from activities involving overhead motion. The exact cause may often be unclear.

Risk Factors

• Advanced age, repetitive shoulder activities (such as those in certain sports or occupations), and a history of shoulder problems can increase the likelihood of developing this condition.

Symptoms

• Pain in the shoulder, especially when lifting or twisting the arm, weakness in the shoulder, and limited range of motion. Symptoms may worsen at night or after activity.

Diagnosis

• Diagnosis typically involves a clinical evaluation of symptoms, physical examination, and imaging studies such as MRI or ultrasound to assess the extent of the tear.

Treatment Options

• Treatment may involve rest, physical therapy to strengthen surrounding muscles, and non-steroidal anti-inflammatory drugs (NSAIDs) for pain. Severe cases or persistent symptoms might require surgical intervention to repair the tear.

Prognosis and Follow-Up

• Many people experience improvement with conservative treatment, although full recovery can be slow. Regular follow-ups may be necessary to monitor healing and adjust treatment as needed.

Complications

• If untreated, the condition could lead to progressive shoulder weakness, chronic pain, or further tears, significantly impairing shoulder function.

Lifestyle & Prevention

• Engaging in shoulder-strengthening exercises, avoiding repetitive overhead activities, and practicing good posture can help manage or prevent the condition.

When to Seek Professional Help

• Seek medical attention if you experience persistent shoulder pain, sharp pain during arm movement, or any new, severe symptoms affecting shoulder function.

Additional Resources

• American Academy of Orthopaedic Surgeons (www.aaos.org)
• National Institute of Arthritis and Musculoskeletal and Skin Diseases (www.niams.nih.gov)

Tips for Medical Coders

• Ensure clarity on the side affected (left shoulder) and the non-traumatic nature of the tear.
• Avoid common errors such as coding for a complete rupture or a traumatic tear if the documentation specifies otherwise.