ICD-10: M75.122

The ICD-10 code M75.122 refers to a complete rotator cuff tear or rupture of the left shoulder, which is not specified as being traumatic in nature. This condition is significant in the field of orthopedics and rehabilitation, as it can greatly affect a patient's range of motion and overall shoulder function.

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 and their associated tendons: supraspinatus, infraspinatus, teres minor, and subscapularis. A complete tear can lead to significant pain, weakness, and loss of function in the affected shoulder.

Etiology

The etiology of a complete rotator cuff tear can vary. In the case of M75.122, the tear is not specified as traumatic, which suggests that it may be due to degenerative changes, overuse, or age-related wear and tear rather than a specific injury. Factors contributing to non-traumatic tears include:

• Age: The risk of rotator cuff tears increases with age, particularly in individuals over 40.
• Repetitive overhead activities: Occupations or sports that require repetitive shoulder movements can lead to wear on the rotator cuff.
• Impingement syndrome: This occurs when the rotator cuff tendons are compressed during shoulder movements, leading to inflammation and potential tearing.

Symptoms

Patients with a complete rotator cuff tear may experience a range of symptoms, including:

• Severe shoulder pain: Often worsening with movement or at night.
• Weakness in the shoulder: Difficulty lifting the arm or performing overhead activities.
• Limited range of motion: Stiffness and reduced ability to move the shoulder.
• Crepitus: A sensation of grinding or popping during shoulder movement.

Diagnosis

Diagnosis typically involves a combination of clinical evaluation and imaging studies. Key diagnostic methods include:

• Physical examination: Assessment of shoulder strength, range of motion, and pain levels.
• Imaging: MRI or ultrasound is commonly used to visualize the rotator cuff and confirm the presence of a tear.

Treatment Options

Non-Surgical Management

For many patients, especially those with non-traumatic tears, conservative treatment options may be effective. These can include:

• Physical therapy: Focused on strengthening the shoulder muscles and improving flexibility.
• Medications: Nonsteroidal anti-inflammatory drugs (NSAIDs) can help manage pain and inflammation.
• Corticosteroid injections: These may provide temporary relief from pain and inflammation.

Surgical Intervention

If conservative measures fail to alleviate symptoms or if the tear significantly impairs function, surgical options may be considered. Surgical interventions can include:

• Arthroscopic rotator cuff repair: Minimally invasive surgery to reattach the torn tendon to the bone.
• Open repair: A more invasive procedure that may be necessary for larger or more complex tears.
• Shoulder arthroplasty: In cases of severe damage, joint replacement may be indicated.

Conclusion

The ICD-10 code M75.122 encapsulates a significant clinical condition that can impact a patient's quality of life. Understanding the nature of a complete rotator cuff tear, particularly when it is not associated with a traumatic event, is crucial for effective diagnosis and treatment. Early intervention and appropriate management strategies can lead to improved outcomes and restoration of shoulder function.

The ICD-10 code M75.122 refers to a complete rotator cuff tear or rupture of the left shoulder that is not specified as traumatic. Understanding the clinical presentation, signs, symptoms, and patient characteristics associated with this condition is crucial for effective diagnosis and management.

Clinical Presentation

Overview of Rotator Cuff Tears

A rotator cuff tear involves damage to the group of muscles and tendons that stabilize the shoulder joint. The rotator cuff is essential for shoulder movement and function, and tears can significantly impair these abilities. In the case of M75.122, the tear is complete, indicating that the tendon is fully detached from the bone.

Patient Characteristics

Patients with a complete rotator cuff tear may present with various characteristics, including:

• Age: Most commonly seen in individuals over 40 years old, as degenerative changes in the rotator cuff tendons increase with age[2].
• Activity Level: Often seen in individuals who engage in repetitive overhead activities, such as athletes (e.g., swimmers, baseball players) or manual laborers[3].
• Medical History: A history of shoulder pain or previous shoulder injuries may be present, although the current tear is not specified as traumatic[1].

Signs and Symptoms

Common Symptoms

Patients with a complete rotator cuff tear typically report the following symptoms:

• Pain: Persistent pain in the shoulder, which may radiate down the arm. Pain is often worse at night or with overhead activities[2].
• Weakness: Significant weakness in the shoulder, particularly when attempting to lift the arm or perform overhead activities[3].
• Limited Range of Motion: Difficulty in moving the shoulder, especially in raising the arm or reaching behind the back[1].
• Crepitus: A sensation of grinding or popping in the shoulder during movement, which may be noted by the patient or observed during physical examination[2].

Physical Examination Findings

During a clinical examination, healthcare providers may observe:

• Atrophy: Muscle wasting around the shoulder, particularly in the supraspinatus and infraspinatus muscles[3].
• Positive Special Tests: Specific tests such as the Drop Arm Test or the Empty Can Test may elicit pain or demonstrate weakness, indicating rotator cuff pathology[1].
• Tenderness: Tenderness upon palpation of the rotator cuff region, particularly over the greater tuberosity of the humerus[2].

Conclusion

In summary, a complete rotator cuff tear of the left shoulder (ICD-10 code M75.122) is characterized by significant pain, weakness, and limited range of motion, primarily affecting older adults or those engaged in repetitive shoulder activities. Understanding these clinical presentations and patient characteristics is essential for healthcare providers to formulate an effective treatment plan, which may include physical therapy, medication, or surgical intervention depending on the severity of the tear and the patient's functional needs.

The ICD-10 code M75.122 refers specifically to a complete rotator cuff tear or rupture of the left shoulder that is not specified as traumatic. This condition is commonly encountered in clinical settings, particularly in orthopedics and rehabilitation. Below are alternative names and related terms that may be used to describe this condition:

Alternative Names

1. Left Shoulder Rotator Cuff Tear: A straightforward term that specifies the location and nature of the injury.
2. Complete Left Rotator Cuff Rupture: Emphasizes the severity of the injury, indicating that the tear is complete.
3. Non-Traumatic Rotator Cuff Tear: Highlights that the injury did not result from a specific traumatic event, which is important for diagnosis and treatment considerations.
4. Chronic Rotator Cuff Tear: Often used when the tear develops over time rather than from an acute injury.
5. Left Shoulder Tendon Tear: A broader term that may encompass various tendon injuries in the shoulder, including the rotator cuff.

Related Terms

1. Rotator Cuff Injury: A general term that includes various types of injuries to the rotator cuff, not limited to complete tears.
2. Shoulder Impingement Syndrome: While not the same as a complete tear, this condition can be related and may occur alongside rotator cuff injuries.
3. Shoulder Pain: A common symptom associated with rotator cuff tears, which can be used in broader discussions about shoulder conditions.
4. Shoulder Instability: This term may be relevant in cases where the rotator cuff tear contributes to instability in the shoulder joint.
5. Tendinopathy: Refers to a condition involving the tendons, which can include degeneration or inflammation, often seen in conjunction with rotator cuff issues.

Clinical Context

Understanding these alternative names and related terms is crucial for healthcare professionals when documenting patient conditions, coding for insurance purposes, and communicating effectively with colleagues. Accurate terminology ensures that patients receive appropriate care and that their medical records reflect their conditions accurately.

In summary, the ICD-10 code M75.122 encompasses a range of terminologies that describe a complete rotator cuff tear of the left shoulder, particularly in non-traumatic contexts. Familiarity with these terms can enhance clarity in clinical discussions and documentation.

The diagnosis of a complete rotator cuff tear or rupture, particularly for the ICD-10 code M75.122, involves a combination of clinical evaluation, imaging studies, and specific criteria. Below is a detailed overview of the criteria typically used for diagnosing this condition.

Clinical Evaluation

Patient History

• Symptom Onset: The clinician will assess the onset of symptoms, which may include pain, weakness, and limited range of motion in the shoulder.
• Activity Level: Understanding the patient's activity level and any recent changes or injuries can provide context for the diagnosis.
• Previous Injuries: A history of shoulder injuries or surgeries may influence the diagnosis.

Physical Examination

• Range of Motion: The clinician will evaluate both active and passive range of motion in the shoulder joint.
• Strength Testing: Specific tests to assess the strength of the rotator cuff muscles may be performed, including external and internal rotation tests.
• Special Tests: Tests such as the Drop Arm Test, Empty Can Test, or Hawkins-Kennedy Test may be utilized to assess for rotator cuff pathology.

Imaging Studies

Ultrasound

• Dynamic Assessment: Ultrasound can be used to visualize the rotator cuff in real-time, allowing for assessment of tears during shoulder movement.

MRI (Magnetic Resonance Imaging)

• Detailed Imaging: MRI is often the gold standard for diagnosing rotator cuff tears, providing detailed images of soft tissues, including the rotator cuff tendons.
• Tear Characteristics: The MRI can help determine the size, location, and extent of the tear, which is crucial for treatment planning.

Diagnostic Criteria

ICD-10 Code Specifics

• M75.122 specifically refers to a complete rotator cuff tear or rupture of the left shoulder that is not specified as traumatic. This means that the diagnosis does not stem from a specific injury but may be due to degenerative changes or other non-traumatic factors.

Documentation Requirements

• Clinical Findings: Documentation must include clinical findings that support the diagnosis, such as the presence of a complete tear confirmed by imaging.
• Exclusion of Traumatic Causes: It is essential to document that the tear is not due to a specific traumatic event, which may involve ruling out acute injuries.

Conclusion

Diagnosing a complete rotator cuff tear or rupture, particularly for the ICD-10 code M75.122, requires a comprehensive approach that includes patient history, physical examination, and imaging studies. The absence of a traumatic cause is a critical aspect of this diagnosis, necessitating thorough documentation and evaluation to ensure accurate coding and appropriate treatment planning. If further clarification or additional information is needed, consulting with a healthcare professional specializing in musculoskeletal disorders is advisable.

When addressing the standard treatment approaches for a complete rotator cuff tear or rupture of the left shoulder, classified under ICD-10 code M75.122, it is essential to consider both non-surgical and surgical options, as well as rehabilitation strategies. This condition typically involves significant pain and functional impairment, necessitating a comprehensive treatment plan.

Non-Surgical Treatment Approaches

1. Physical Therapy

Physical therapy is often the first line of treatment for rotator cuff tears. It focuses on:
- Strengthening Exercises: Targeting the shoulder muscles to improve stability and function.
- Range of Motion Exercises: Aiding in restoring flexibility and reducing stiffness.
- Manual Therapy: Techniques such as joint mobilization to alleviate pain and improve movement.

2. Medications

• Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): Medications like ibuprofen or naproxen can help reduce pain and inflammation.
• Corticosteroid Injections: These may be administered to provide temporary relief from pain and inflammation, particularly if conservative measures are insufficient.

3. Activity Modification

Patients are often advised to modify activities that exacerbate shoulder pain. This may include avoiding overhead movements or heavy lifting until symptoms improve.

Surgical Treatment Approaches

If non-surgical treatments fail to provide adequate relief or if the tear is significant, surgical intervention may be necessary. Common surgical options include:

1. Arthroscopic Rotator Cuff Repair

This minimally invasive procedure involves:
- Surgical Repair: The torn tendon is reattached to the humerus using sutures and anchors.
- Debridement: Removal of any damaged tissue or bone spurs that may be contributing to pain.

2. Open Rotator Cuff Repair

In cases where the tear is extensive or complex, an open surgical approach may be utilized, allowing for better visualization and access to the shoulder structures.

3. Shoulder Replacement

In severe cases, particularly when there is significant joint damage, a partial or total shoulder replacement may be considered.

Post-Surgical Rehabilitation

Following surgery, a structured rehabilitation program is crucial for recovery. This typically includes:
- Initial Rest and Immobilization: Using a sling to protect the shoulder for a few weeks post-surgery.
- Gradual Physical Therapy: Starting with passive range of motion exercises, progressing to active exercises as healing allows.
- Strengthening Exercises: Introduced later in the rehabilitation process to restore function and strength.

Conclusion

The management of a complete rotator cuff tear or rupture of the left shoulder (ICD-10 code M75.122) involves a combination of non-surgical and surgical approaches tailored to the patient's specific condition and needs. Early intervention with physical therapy and medication can often alleviate symptoms, while surgical options are available for more severe cases. A comprehensive rehabilitation program post-treatment is essential for optimal recovery and return to daily activities. Regular follow-ups with healthcare providers ensure that the treatment plan remains effective and adjustments are made as necessary.