Name of the Condition

• Complete Rotator Cuff Tear or Rupture of Right Shoulder, Not Specified as Traumatic
• Also known as Full-Thickness Rotator Cuff Tear of Right Shoulder

Summary

A complete rotator cuff tear involves the full thickness of one or more tendons of the rotator cuff being torn away from the bone in the shoulder. This condition affects the shoulder's ability to function properly, causing pain and weakness.

Causes

• Age-related degeneration of the tendons
• Repetitive overhead activities or heavy lifting
• Diminished blood supply to the rotator cuff tendons
• A fall on the shoulder or sudden stress is possible, though not specified in this code as traumatic

Risk Factors

• Age, particularly over 60
• Certain occupations or sports involving repetitive shoulder use
• Family history of shoulder problems
• Smoking, which can affect blood supply to the tendons

Symptoms

• Difficulty lifting the arm or shoulder
• Shoulder pain, particularly at night or when at rest
• Weakness in the arm or shoulder
• Limited range of motion in the shoulder

Diagnosis

• Physical examination to assess movement and pain
• Imaging tests such as MRI or ultrasound to visualize the tear
• X-rays to rule out other conditions

Treatment Options

• Conservative Treatment: Rest, physical therapy, and anti-inflammatory medications
• Surgical Repair: Reattaching the torn tendon, often using minimally invasive arthroscopic techniques
• Rehabilitation: Post-surgery physical therapy to restore strength and mobility

Prognosis and Follow-Up

• With appropriate treatment, individuals can regain shoulder function, though full recovery can take several months.
• Regular follow-up appointments are crucial to monitor progress and adapt therapy as needed.

Complications

• Chronic shoulder pain and weakness
• Degenerative joint issues in the shoulder
• Permanent loss of range of motion if not treated effectively

Lifestyle & Prevention

• Engage in regular shoulder-strengthening exercises
• Avoid repetitive overhead activities or modify techniques to reduce strain
• Maintain a healthy weight and lifestyle to support joint health

When to Seek Professional Help

• Persistent shoulder pain or weakness
• Difficulty performing tasks involving arm movements
• Sudden inability to lift the arm

Additional Resources

• American Academy of Orthopaedic Surgeons (AAOS)
• National Institutes of Health (NIH) - National Institute of Arthritis and Musculoskeletal and Skin Diseases

Tips for Medical Coders

• Ensure documentation specifies the shoulder involved (right shoulder for M75.121).
• Verify that the condition is not specified as traumatic before using this code.
• Be cautious of common errors such as incorrect laterality coding or assuming trauma without documentation.