S43.439 Superior glenoid labrum lesion of unspecified shoulder

Name of the Condition

• Superior Glenoid Labrum Lesion of Unspecified Shoulder

Summary

A superior glenoid labrum lesion is an injury to the labrum, a ring of cartilage that cushions the glenoid (socket) of the shoulder joint. This condition affects the top (superior) portion of the labrum, which can lead to pain, instability, and reduced shoulder function.

Causes

Causes include acute trauma (such as falls or direct shoulder impact), repetitive overhead activities (e.g., throwing sports), or sudden traction on the biceps tendon. Age-related degeneration may also contribute.

Risk Factors

• Participation in overhead sports (baseball, volleyball, etc.)
• Occupational activities with repetitive shoulder motion
• Previous shoulder injuries
• Age-related wear and tear

Symptoms

• Shoulder pain, especially with movement or lifting
• Clicking, popping, or catching sensations during shoulder motion
• Reduced range of motion or strength
• Feelings of instability in the shoulder

Diagnosis

Diagnosis involves a physical examination to assess pain, range of motion, and stability. Imaging tests like MRI or CT arthrogram may be used to visualize labral damage. Arthroscopic evaluation can confirm the lesion and guide treatment.

Treatment Options

• Rest and activity modification to reduce strain
• Physical therapy to strengthen shoulder muscles and improve stability
• Anti-inflammatory medications for pain relief
• Arthroscopic surgery for severe or persistent cases to repair or remove damaged tissue

Prognosis and Follow-Up

Prognosis depends on the severity of the lesion and treatment adherence. Most patients improve with conservative care, but recovery may take weeks to months. Follow-up visits monitor healing and adjust therapy as needed.

Complications

• Chronic shoulder instability
• Persistent pain or reduced function
• Re-injury if activity restrictions are not followed
• Surgical complications (e.g., infection, stiffness) in rare cases

Lifestyle & Prevention

• Avoid repetitive overhead motions or use proper technique
• Strengthen shoulder muscles through targeted exercises
• Use protective gear during sports
• Maintain flexibility with regular stretching

When to Seek Professional Help

Seek care if shoulder pain is severe, worsening, or accompanied by locking/catching sensations. Immediate attention is needed for trauma-related injuries or sudden loss of function.

Tips for Medical Coders

Document the shoulder affected (right/left/unspecified) and any associated injuries. Ensure clinical notes support the lesion’s location and severity. For subsequent encounters, specify if the visit relates to active treatment, evaluation, or aftercare.