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Complete rotator cuff tear or rupture of unspecified shoulder, not specified as traumatic
ICD10CM code
Name of the Condition
- Complete Rotator Cuff Tear or Rupture of Unspecified Shoulder, Not Specified as Traumatic (ICD-10 Code: M75.120)
Summary
- This condition involves a complete tear or rupture of the rotator cuff in the shoulder. The rotator cuff is a group of muscles and tendons that stabilize the shoulder joint. The tear can impair shoulder function and cause pain, but may not be related to a specific traumatic event.
Causes
- Most rotator cuff tears occur due to age-related wear and tear of the tendons. Degeneration of the tendons over time makes them more susceptible to tearing. Other contributing factors include repetitive shoulder motions associated with certain sports or occupations.
Risk Factors
- Age, particularly those over 40
- Occupations or tasks involving repetitive overhead activities
- Previous shoulder injuries
- Family history of shoulder problems
Symptoms
- Persistent shoulder pain, especially at night
- Weakness in the shoulder and arm
- Difficulty raising the arm or lifting objects
- Audible cracking or popping sounds when moving the shoulder
Diagnosis
- Physical examination and assessment of shoulder mobility and strength
- Imaging tests such as an MRI or ultrasound to visualize the tear
- X-rays to rule out other shoulder issues
Treatment Options
- Conservative treatments: Rest, ice application, physical therapy, and anti-inflammatory medications to reduce pain and improve function.
- Corticosteroid injections: To reduce inflammation and pain.
- Surgery: In cases where conservative treatments fail; surgery may involve tendon repair or shoulder replacement.
Prognosis and Follow-Up
- With proper treatment, many patients experience significant improvement in symptoms.
- Regular follow-ups with a healthcare provider are essential to monitor recovery progress and make necessary treatment adjustments.
Complications
- Chronic shoulder pain and dysfunction if left untreated
- Muscle atrophy or weakening of shoulder muscles
- Increased risk of developing arthritis in the shoulder joint over time
Lifestyle & Prevention
- Engage in shoulder-strengthening exercises to maintain muscle integrity
- Avoid repetitive overhead movements that strain the shoulder
- Use proper techniques for activities that involve shoulder use
When to Seek Professional Help
- Severe shoulder pain that does not improve with rest or limited movement
- Inability to move the shoulder or arm normally
- Sudden shoulder swelling or bruising
Additional Resources
Tips for Medical Coders
- Ensure the diagnosis is clearly documented as a complete tear or rupture of the rotator cuff without a specified traumatic event.
- Double-check the laterality of the shoulder (left, right, or unspecified) for accurate coding.
- Avoid confusion with partial tears or conditions specified as traumatic.