Name of the Condition

• Strain of right Achilles tendon, initial encounter
• ICD code: S86.011A

Summary

A strain of the right Achilles tendon refers to an injury where the tendon fibers are overstretched or torn. This tendon connects the calf muscles to the heel bone and is crucial for activities involving foot movement, such as walking, running, and jumping.

Causes

• Sudden increase in physical activity
• Intense exercise without proper warm-up
• Overuse or repetitive strain during sports or activities

Risk Factors

• Participation in sports that involve running or jumping
• Wearing improper footwear
• Having an uneven or stiff walking surface
• Previous lower limb injuries

Symptoms

• Pain along the back of the leg or near the heel
• Swelling and tenderness
• Stiffness, especially in the morning or after activity
• Difficulty walking and reduced range of motion

Diagnosis

• Physical examination by a healthcare provider
• Patient history analysis, focusing on recent activities and symptoms
• Imaging tests like MRI or ultrasound to assess tendon damage

Treatment Options

• Rest and avoiding activities that worsen symptoms
• Ice application to reduce swelling
• Compression bandages to minimize movement and swelling
• Elevation of the foot to reduce swelling
• Nonsteroidal anti-inflammatory drugs (NSAIDs) for pain relief
• Physical therapy to restore strength and flexibility

Prognosis and Follow-Up

• With proper treatment, many individuals recover fully and can return to normal activities.
• Follow-up appointments may be necessary to monitor progress.
• Adherence to a rehabilitation program is critical to prevent re-injury.

Complications

• Chronic pain or tendonitis if left untreated
• Increased risk of tendon rupture
• Prolonged recovery time due to persistent inflammation

Lifestyle & Prevention

• Gradually increase activity level to avoid stress on the tendon
• Use proper footwear suited to the activity and foot structure
• Perform regular stretching and strengthening exercises for the calf muscles
• Proper warm-up before engaging in physical activities

When to Seek Professional Help

• Severe pain or difficulty in moving the affected foot
• Symptoms persist despite rest and conservative treatments
• Suspected tendon rupture, which may require urgent medical intervention

Additional Resources

• American Orthopaedic Foot & Ankle Society (AOFAS): www.aofas.org
• Achilles Tendon Rupture Support Group

Tips for Medical Coders

• Double-check that the injury is specifically to the right Achilles tendon.
• Ensure accurate documentation of the encounter as "initial" to use code S86.011A.
• Be aware that similar codes exist for the left Achilles tendon or subsequent encounters.