Name of the Condition

• Superior Glenoid Labrum Lesion of Unspecified Shoulder, Subsequent Encounter (ICD-10 Code: S43.439D)
• Commonly referred to as a SLAP tear (Superior Labrum Anterior and Posterior tear)

Summary

A Superior Glenoid Labrum Lesion involves damage to the ring of cartilage (labrum) that surrounds the socket of the shoulder joint. A subsequent encounter may refer to a follow-up visit after the initial diagnosis, focusing on continued treatment or evaluation of healing progress.

Causes

• Acute trauma, such as falling on an outstretched arm
• Repetitive overhead motions typical in sports like baseball or swimming
• Age-related wear and tear

Risk Factors

• Participation in sports involving overhead arm use
• Occupational activities with repetitive shoulder movements
• Age 40 and older, due to wear and tear

Symptoms

• Shoulder pain, particularly with overhead movements
• A catching, locking, or grinding sensation in the shoulder
• Decreased range of motion or strength in the shoulder

Diagnosis

• Physical examination (e.g., testing range of motion, evaluating pain points)
• Imaging tests such as MRI or CT arthrogram to visualize labral tears
• Arthroscopic evaluation, considered both diagnostic and occasionally therapeutic

Treatment Options

• Medications: Pain relievers and anti-inflammatory drugs to reduce pain and inflammation
• Physical Therapy: Strengthening and stabilizing shoulder muscles
• Surgery: Arthroscopic repair or debridement of the labrum for severe or persistent cases.

Prognosis and Follow-Up

• Generally good with appropriate treatment, although complete recovery may take several months.
• Regular follow-up is crucial to monitor progress and adjust treatment as necessary.

Complications

• Chronic shoulder instability
• Decreased shoulder function
• If untreated, potential progression of shoulder joint damage

Lifestyle & Prevention

• Engaging in regular strengthening exercises focused on shoulder stability
• Proper warm-up and stretching routines before sports activities
• Using proper techniques in sports and ergonomic adjustments in work settings

When to Seek Professional Help

• Persistent or severe pain in the shoulder area
• Noticeable decrease in shoulder mobility or strength
• Symptoms of catching or locking in the shoulder joint

Additional Resources

• American Shoulder and Elbow Surgeons (ASES) - ases-assn.org
• OrthoInfo by the American Academy of Orthopaedic Surgeons - orthoinfo.aaos.org

Tips for Medical Coders

• Ensure correct encounter code is used – this is a subsequent encounter, not initial.
• Verify the shoulder side if specified, though S43.439D indicates unspecified.
• Avoid confusing with other shoulder or labral injury codes.