ICD-10: M75.12

The ICD-10 code M75.12 refers to a complete rotator cuff tear or rupture that is not specified as traumatic. This condition is significant in the field of orthopedics and is commonly encountered in clinical practice, particularly among individuals who engage in repetitive overhead activities or those who are aging.

Clinical Description

Definition

A complete rotator cuff tear involves a full-thickness tear of one or more of the rotator cuff tendons, which are crucial for shoulder stability and movement. The rotator cuff consists of four muscles: supraspinatus, infraspinatus, teres minor, and subscapularis. A complete tear can lead to significant functional impairment and pain, affecting the patient's ability to perform daily activities.

Etiology

While the code M75.12 specifies that the tear is not traumatic, it is essential to understand that rotator cuff tears can occur due to various non-traumatic factors, including:

• Degenerative Changes: Age-related wear and tear is a common cause, particularly in individuals over 40 years old.
• Repetitive Stress: Activities that involve repetitive overhead motions, such as swimming, tennis, or certain occupations, can contribute to the development of tears.
• Impingement Syndrome: This occurs when the rotator cuff tendons are compressed during shoulder movements, leading to inflammation and potential tearing over time.

Symptoms

Patients with a complete rotator cuff tear may experience:

• Severe Shoulder Pain: Often worsening with movement or at night.
• Weakness: Difficulty lifting the arm or performing overhead activities.
• Limited Range of Motion: Stiffness and reduced mobility in the shoulder joint.
• Crepitus: A sensation of grinding or popping during shoulder movement.

Diagnosis

Diagnosis typically involves a combination of:

• Clinical Examination: Assessment of shoulder strength, range of motion, and pain levels.
• Imaging Studies: MRI or ultrasound is often used to visualize the rotator cuff and confirm the presence of a complete tear.

Treatment Options

Management of a complete rotator cuff tear may vary based on the severity of the tear, the patient's age, activity level, and overall health. Treatment options include:

• Conservative Management: Physical therapy, anti-inflammatory medications, and corticosteroid injections may be recommended to alleviate pain and improve function.
• Surgical Intervention: In cases where conservative treatment fails, surgical options such as arthroscopic repair or open repair may be considered to restore shoulder function.

Conclusion

The ICD-10 code M75.12 is crucial for accurately diagnosing and managing complete rotator cuff tears that are not classified as traumatic. Understanding the clinical implications, symptoms, and treatment options associated with this condition is essential for healthcare providers to deliver effective care and improve patient outcomes. Proper coding also facilitates appropriate billing and insurance reimbursement, ensuring that patients receive the necessary interventions for their shoulder injuries.

The ICD-10 code M75.12 refers to a complete rotator cuff tear or rupture that is not specified as traumatic. This condition is a significant cause of shoulder pain and dysfunction, particularly in adults. Understanding its clinical presentation, signs, symptoms, and patient characteristics is essential for effective diagnosis and management.

Clinical Presentation

Overview of Rotator Cuff Tears

The rotator cuff is a group of muscles and tendons that stabilize the shoulder and allow for a wide range of motion. A complete tear of the rotator cuff can lead to significant impairment in shoulder function. While some tears are the result of acute trauma, M75.12 specifically addresses those that are not classified as such, often resulting from chronic degeneration or overuse.

Common Patient Characteristics

• Age: Most commonly affects individuals over the age of 40, with a higher prevalence in those aged 60 and above due to degenerative changes in the shoulder.
• Occupation: Patients may have occupations or hobbies that involve repetitive overhead activities, such as athletes, construction workers, or manual laborers.
• Comorbidities: Conditions such as diabetes, obesity, and previous shoulder injuries can increase the risk of rotator cuff tears.

Signs and Symptoms

Pain

• Location: Patients typically report pain in the shoulder, which may radiate down the arm.
• Nature of Pain: The pain is often described as a deep ache, worsening with overhead activities or lifting objects. It may also be present at rest, particularly at night, disrupting sleep.

Range of Motion

• Limited Mobility: Patients may experience a reduced range of motion, particularly in abduction (lifting the arm away from the body) and external rotation.
• Stiffness: Stiffness in the shoulder joint can develop, further limiting functional use.

Weakness

• Muscle Weakness: Affected individuals often report weakness in the shoulder, making it difficult to perform daily activities such as reaching, lifting, or carrying objects.

Functional Impairment

• Difficulty with Activities of Daily Living (ADLs): Tasks such as dressing, grooming, and reaching for items can become challenging.
• Impact on Quality of Life: Chronic pain and functional limitations can significantly affect a patient’s quality of life, leading to frustration and decreased physical activity.

Diagnostic Considerations

Physical Examination

• Tenderness: Palpation of the shoulder may reveal tenderness over the rotator cuff area.
• Special Tests: Clinicians may perform specific tests, such as the drop arm test or the empty can test, to assess rotator cuff integrity and function.

Imaging Studies

• Ultrasound or MRI: These imaging modalities are often used to confirm the diagnosis of a complete rotator cuff tear, providing detailed visualization of the soft tissues.

Conclusion

The clinical presentation of a complete rotator cuff tear or rupture not specified as traumatic (ICD-10 code M75.12) is characterized by pain, limited range of motion, weakness, and functional impairment, particularly in older adults or those engaged in repetitive overhead activities. Accurate diagnosis through physical examination and imaging is crucial for developing an effective treatment plan, which may include physical therapy, corticosteroid injections, or surgical intervention depending on the severity of the tear and the patient's overall health status. Understanding these aspects can help healthcare providers deliver targeted care and improve patient outcomes.

The ICD-10 code M75.12 refers specifically to a "Complete rotator cuff tear or rupture not specified as traumatic." This code is part of a broader classification system used for diagnosing and coding various medical conditions. Below are alternative names and related terms associated with this code.

Alternative Names

1. Complete Rotator Cuff Tear: This term is often used interchangeably with the ICD-10 code M75.12, emphasizing the severity of the tear without specifying the cause.

2. Rotator Cuff Rupture: Similar to a tear, a rupture indicates a complete disruption of the rotator cuff tendons.

3. Non-Traumatic Rotator Cuff Tear: This term highlights that the injury did not result from a specific traumatic event, which is a key distinction in the coding.

4. Chronic Rotator Cuff Tear: While not explicitly stated in the ICD-10 code, many cases of complete rotator cuff tears are chronic, resulting from degeneration over time rather than acute injury.

5. Full-Thickness Rotator Cuff Tear: This term describes the extent of the tear, indicating that it goes through the entire thickness of the tendon.

Related Terms

1. Rotator Cuff Syndrome: This broader term encompasses various conditions affecting the rotator cuff, including tears, tendinitis, and impingement.

2. Shoulder Pain: While not specific to rotator cuff tears, this term is often associated with the symptoms resulting from such injuries.

3. Shoulder Impingement: This condition can occur alongside rotator cuff tears and may contribute to pain and dysfunction in the shoulder.

4. Tendinopathy: This term refers to the degeneration of the rotator cuff tendons, which can lead to tears over time.

5. Shoulder Instability: Although primarily related to joint stability, this condition can be a consequence of rotator cuff injuries.

6. Subacromial Pain Syndrome: This term is often used to describe pain in the shoulder that may arise from rotator cuff issues, including tears.

Conclusion

Understanding the alternative names and related terms for ICD-10 code M75.12 is essential for accurate diagnosis, treatment planning, and coding in medical records. These terms help healthcare professionals communicate effectively about the condition and its implications for patient care. If you need further information on treatment options or management strategies for rotator cuff tears, feel free to ask!

The ICD-10 code M75.12 refers to a complete rotator cuff tear or rupture that is not specified as traumatic. This diagnosis is significant in the context of shoulder injuries, particularly as it pertains to the management and treatment of rotator cuff conditions. Below, we will explore the criteria used for diagnosing this condition, including clinical presentations, diagnostic imaging, and relevant guidelines.

Clinical Presentation

Symptoms

Patients with a complete rotator cuff tear typically present with a range of symptoms, including:

• Pain: Often localized to the shoulder, which may radiate down the arm.
• Weakness: Difficulty in lifting the arm or performing overhead activities.
• Limited Range of Motion: Patients may experience stiffness and reduced mobility in the shoulder joint.
• Crepitus: A sensation of grinding or popping during shoulder movement.

History

A thorough patient history is essential. Clinicians will inquire about:

• Onset of Symptoms: Whether the symptoms developed gradually or suddenly.
• Activity Level: Any recent activities that may have contributed to shoulder strain, even if not traumatic.
• Previous Injuries: History of shoulder injuries or surgeries.

Diagnostic Imaging

Ultrasound

Ultrasound is often the first-line imaging modality used to assess rotator cuff integrity. It can effectively visualize tears and assess the degree of damage.

MRI

Magnetic Resonance Imaging (MRI) is considered the gold standard for diagnosing rotator cuff tears. It provides detailed images of soft tissues and can confirm the presence of a complete tear, as well as assess any associated injuries to the shoulder structures.

X-rays

While X-rays do not directly show soft tissue injuries, they are useful for ruling out other conditions, such as fractures or arthritis, that may contribute to shoulder pain.

Clinical Guidelines

Assessment Tools

Clinical practice guidelines recommend using specific assessment tools to evaluate shoulder function and pain levels. These may include:

• Visual Analog Scale (VAS): For pain assessment.
• Constant-Murley Score: To evaluate shoulder function.
• American Shoulder and Elbow Surgeons (ASES) Score: For assessing shoulder outcomes.

Differential Diagnosis

It is crucial to differentiate a complete rotator cuff tear from other shoulder conditions, such as:

• Partial rotator cuff tears
• Tendonitis
• Shoulder impingement syndrome
• Labral tears

Conclusion

The diagnosis of a complete rotator cuff tear or rupture not specified as traumatic (ICD-10 code M75.12) involves a comprehensive approach that includes a detailed patient history, clinical examination, and appropriate imaging studies. By adhering to established clinical guidelines and utilizing diagnostic tools, healthcare providers can accurately identify this condition and develop effective treatment plans tailored to the individual patient's needs. This thorough diagnostic process is essential for ensuring optimal outcomes in managing shoulder injuries.

The ICD-10 code M75.12 refers to a complete rotator cuff tear or rupture that is not specified as traumatic. This condition is prevalent among individuals, particularly those engaged in repetitive overhead activities or those experiencing age-related degeneration. Understanding the standard treatment approaches for this diagnosis is crucial for effective management and recovery.

Overview of Rotator Cuff Tears

Rotator cuff tears can significantly impact shoulder function and quality of life. The rotator cuff is a group of muscles and tendons that stabilize the shoulder and allow for a wide range of motion. A complete tear means that the tendon is fully detached from the bone, which can lead to pain, weakness, and limited mobility in the shoulder joint.

Standard Treatment Approaches

1. Conservative Management

Most patients with a complete rotator cuff tear may initially be treated conservatively, especially if they are not experiencing severe symptoms. Conservative management typically includes:

• Physical Therapy: A structured rehabilitation program focusing on strengthening the shoulder muscles, improving flexibility, and restoring range of motion. Physical therapists may employ modalities such as ultrasound or electrical stimulation to alleviate pain and promote healing[1].

• Activity Modification: Patients are advised to avoid activities that exacerbate shoulder pain, particularly overhead movements. This helps in reducing strain on the rotator cuff and allows for potential healing[2].

• Medications: Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen can be prescribed to manage pain and inflammation associated with the tear[3].

• Corticosteroid Injections: In some cases, corticosteroid injections may be administered to reduce inflammation and provide temporary pain relief, facilitating participation in physical therapy[4].

2. Surgical Intervention

If conservative treatments fail to provide relief or if the patient's quality of life is significantly affected, surgical options may be considered. Surgical approaches include:

• Arthroscopic Repair: This minimally invasive procedure involves the use of small incisions and a camera to guide the repair of the torn tendon. The surgeon reattaches the tendon to the bone using sutures or anchors[5].

• Open Repair: In cases where the tear is extensive or complex, an open surgical approach may be necessary. This involves a larger incision to access the shoulder joint directly and repair the tendon[6].

• Tendon Transfer: For patients with irreparable tears, a tendon transfer may be performed, where another tendon is relocated to restore function to the shoulder[7].

3. Postoperative Rehabilitation

Post-surgery, a comprehensive rehabilitation program is essential for recovery. This typically includes:

• Initial Rest and Immobilization: The shoulder may be immobilized in a sling for several weeks to allow for healing[8].

• Gradual Rehabilitation: Once healing progresses, physical therapy resumes with a focus on restoring range of motion, followed by strengthening exercises. The timeline for rehabilitation can vary based on the extent of the tear and the surgical technique used[9].

• Long-term Follow-up: Regular follow-up appointments are crucial to monitor recovery and adjust rehabilitation protocols as needed.

Conclusion

The management of a complete rotator cuff tear not specified as traumatic (ICD-10 code M75.12) typically begins with conservative treatment options, progressing to surgical intervention if necessary. A tailored rehabilitation program is vital for restoring shoulder function and improving the patient's quality of life. Early diagnosis and appropriate treatment are key to successful outcomes in individuals suffering from this condition. For those experiencing persistent symptoms, consulting with a healthcare professional specializing in shoulder injuries is recommended to determine the best course of action.

References

1. Clinical Practice Guidelines for the Management of Rotator Cuff Injuries.
2. Increasing incidence of rotator cuff repairs—A nationwide study.
3. Etiology of rotator cuff tears.
4. Shoulder Injuries, Epidemiology, ICD10, Coding Degenerative.
5. Increasing incidence of rotator cuff surgery: A nationwide study.
6. Rotator Cuff Injuries in the Pediatric Population.
7. 2025 ICD-10-CM Diagnosis Code M75.121.
8. 2025 ICD-10-CM Diagnosis Code M75.122.
9. Increasing incidence of rotator cuff surgery: A nationwide study.