Name of the Condition

• Other injury of muscle(s) and tendon(s) of the rotator cuff of right shoulder, initial encounter.
• Also known as a rotator cuff injury to the right shoulder.

Summary

• This condition involves damage to the muscles and tendons that make up the rotator cuff in the right shoulder, often causing pain and impairing movement. It is typically identified during the first medical evaluation following the injury.

Causes

• Causes may include acute trauma, such as a fall or lifting heavy objects, repetitive overhead activities, or degenerative changes over time.

Risk Factors

• Increased age, participation in sports or occupations requiring overhead arm movement, previous shoulder injuries, and poor conditioning are common risk factors.

Symptoms

• Symptoms may include shoulder pain, weakness, limited range of motion, and a crackling sensation when moving the shoulder.

Diagnosis

• Diagnosis can involve a physical examination, imaging tests such as MRI or ultrasound, and possibly arthroscopy to assess the extent of the injury.

Treatment Options

• Treatment may include rest, ice, anti-inflammatory medications, physical therapy to strengthen shoulder muscles, and in severe cases, surgery to repair the damaged rotator cuff.

Prognosis and Follow-Up

• Many patients recover well with appropriate treatment, although some may experience long-term limitations in shoulder movement. Follow-up care is crucial to monitor recovery and prevent re-injury.

Complications

• If untreated, complications could include chronic shoulder pain, impaired shoulder function, and the development of a more serious shoulder condition like a frozen shoulder.

Lifestyle & Prevention

• Prevention tips include regular shoulder-strengthening exercises, avoiding repetitive overhead activities when possible, and employing ergonomic practices during sports and work.

When to Seek Professional Help

• Medical attention should be sought if there is severe shoulder pain, inability to move the shoulder, or if symptoms worsen despite home care.

Additional Resources

• American Academy of Orthopaedic Surgeons (AAOS) and the Mayo Clinic offer resources for patients seeking more information.

Tips for Medical Coders

• Ensure the code S46.091A is used specifically for initial encounters of right shoulder rotator cuff injuries.
• Verify documentation specifies the right shoulder and that "initial encounter" correctly applies to the current episode of care.