Find information on muscle strain of the back diagnosis, including clinical documentation tips, ICD-10 codes (M62.831, M62.838, S39.012A, S39.012D), and medical coding guidelines. Learn about back muscle strain symptoms, treatment, and proper healthcare documentation for accurate reimbursement. This resource offers guidance for physicians, coders, and healthcare professionals dealing with dorsalgia, lumbago, thoracic back pain, and other related back muscle strain diagnoses.
Also known as
Strain of back muscles
Injury to back muscles from overexertion or trauma.
Other muscle disorders of back
Includes other specified disorders affecting back muscles.
Injury of other trunk muscles
Covers strains of muscles in the thorax and abdomen.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the back strain traumatic?
Yes
Site specified?
No
Site specified?
When to use each related code
| Description |
|---|
| Muscle Strain of the Back |
| Lumbago |
| Spinal Stenosis Lumbar |
Q: What are the most effective differential diagnosis strategies for differentiating a lumbar muscle strain from more serious back pain etiologies like a herniated disc or spinal stenosis in a clinical setting?
A: Differentiating a lumbar muscle strain from more serious conditions requires a thorough clinical evaluation. Begin with a detailed patient history focusing on the mechanism of injury, onset, location, and nature of the pain. Physical examination should assess range of motion, palpation for tenderness, neurological deficits (reflexes, strength, sensation), and provocative tests. Red flags like bowel/bladder changes, saddle anesthesia, or progressive neurological deficits warrant immediate imaging (MRI) to rule out serious pathology. For isolated muscle strain, pain is typically localized, worsens with movement and palpation, and lacks neurological involvement. Consider implementing standardized questionnaires like the Oswestry Disability Index to quantify functional limitations and track progress. Explore how imaging can be judiciously used if symptoms persist despite conservative management or red flags are present. Learn more about the clinical presentation of specific spinal pathologies to enhance diagnostic accuracy.
Q: How can clinicians effectively integrate evidence-based conservative management strategies for acute lower back muscle strain into their practice, and when is it appropriate to consider referral for advanced imaging or specialist consultation?
A: Evidence-based conservative management for acute lower back muscle strain emphasizes patient education, pain relief, and restoration of function. Initially, advise patients on activity modification, avoiding aggravating movements while promoting early mobilization as tolerated. Pharmacological management can include NSAIDs, short-term muscle relaxants, and topical analgesics. Consider implementing a structured rehabilitation program incorporating exercises to improve flexibility, strength, and core stability. Manual therapy techniques like spinal manipulation or mobilization may also be beneficial. Referral for advanced imaging (MRI) is warranted if red flags are present, neurological deficits emerge, or symptoms persist beyond 4-6 weeks despite conservative treatment. Explore how specialist consultation (orthopedics, physiatry) can be helpful for complex cases, persistent pain, or when considering interventional procedures.
Patient presents with complaints of back pain consistent with a muscle strain. Onset of low back pain occurred on [Date of Onset] while [Mechanism of Injury - e.g., lifting heavy boxes, twisting awkwardly]. Pain is described as [Character of pain - e.g., sharp, dull, aching, throbbing] and located in the [Location - e.g., lumbar region, paraspinal muscles, right side of back]. Pain is aggravated by [Aggravating factors - e.g., bending, lifting, sitting for prolonged periods] and alleviated by [Alleviating factors - e.g., rest, ice, over-the-counter pain medication]. Patient denies any radiating pain, numbness, tingling, or weakness in the lower extremities. Physical examination reveals [Objective findings - e.g., tenderness to palpation in the lumbar paraspinal muscles, decreased range of motion in lumbar flexion and extension, no muscle spasms or neurological deficits]. Diagnosis of lumbar muscle strain is made based on patient history, physical examination findings, and absence of red flags suggesting a more serious condition. Differential diagnosis includes lumbar disc herniation, spinal stenosis, and vertebral fracture, which have been ruled out based on the clinical presentation. Treatment plan includes rest, ice therapy for 20 minutes every 2-3 hours, over-the-counter pain relievers such as ibuprofen or naproxen, and gentle stretching exercises as tolerated. Patient education provided regarding proper body mechanics, lifting techniques, and activity modification. Follow-up appointment scheduled in [Duration - e.g., one week] to assess response to treatment. ICD-10 code M62.839 (Other muscle strain of back) is assigned.