Find information on left shoulder sprain diagnosis, including clinical documentation, medical coding, ICD-10 codes (S43), and treatment options. Learn about shoulder pain, joint instability, soft tissue injuries, and the diagnostic process for a sprained left shoulder. Resources for healthcare professionals, physicians, and coders seeking accurate and up-to-date information on left shoulder sprains are available. Explore details on symptoms, physical examination findings, and proper documentation for a left shoulder sprain diagnosis.
Also known as
Sprain of left shoulder and acromioclavicular joint
Covers sprains and strains of the left shoulder and AC joint.
Sprain of left sternoclavicular joint
Includes sprains of the left sternoclavicular (SC) joint.
Sprain of other and unspecified parts of left shoulder girdle
Sprains of other ligaments and unspecified areas of the left shoulder.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the acromioclavicular joint involved?
Yes
What type of AC joint sprain?
No
Is the glenohumeral joint involved?
When to use each related code
| Description |
|---|
| Sprain of Left Shoulder |
| Strain of Left Shoulder |
| Left Shoulder Dislocation |
Coding left shoulder sprain without specifying laterality can lead to claim rejection or inaccurate data analysis. Use ICD-10 codes precisely.
Documenting and coding must reflect the specific type of sprain (AC joint, glenohumeral, etc.) for accurate reimbursement and quality reporting.
Insufficient documentation of the cause, severity, and associated injuries can lead to coding errors and compliance issues. Ensure thorough documentation.
Q: What are the most effective differential diagnosis strategies for left shoulder sprain vs. other shoulder injuries like rotator cuff tear, frozen shoulder, or dislocation in a clinical setting?
A: Differentiating a left shoulder sprain from other shoulder injuries requires a thorough clinical evaluation. Start with a detailed patient history, focusing on mechanism of injury, onset of pain, and any prior shoulder issues. Physical examination should assess range of motion, palpation for tenderness over ligaments (e.g., acromioclavicular, coracoclavicular), and specific tests for rotator cuff pathology (e.g., empty can, drop arm) and instability. Imaging, such as plain radiographs to rule out fractures and dislocations, or MRI for suspected rotator cuff tears or labral pathology, can further aid diagnosis. Consider implementing a standardized shoulder examination protocol to ensure consistent and accurate assessment. Explore how advanced imaging techniques, such as MR arthrography, can provide further clarity in complex cases.
Q: How can clinicians accurately assess the severity of a left shoulder sprain (grades 1-3) and tailor evidence-based treatment plans accordingly for optimal patient outcomes?
A: Accurate grading of a left shoulder sprain relies on correlating clinical findings with the degree of ligamentous damage. Grade 1 sprains involve mild stretching of ligaments with minimal functional loss. Grade 2 sprains represent partial tearing with moderate pain, swelling, and some instability. Grade 3 sprains involve complete ligament rupture, significant pain, instability, and substantial functional impairment. Evidence-based treatment for Grade 1 and 2 sprains typically involves initial rest, ice, compression, and elevation (RICE), followed by a progressive rehabilitation program focusing on restoring range of motion, strength, and proprioception. Grade 3 sprains may require surgical intervention for optimal ligament repair and stability restoration. Learn more about the latest rehabilitation protocols for shoulder sprains and how to tailor them to individual patient needs and functional goals.
Patient presents with left shoulder pain and limited range of motion following a reported fall yesterday. The patient describes the mechanism of injury as an outstretched hand fall. On examination, there is tenderness to palpation over the anterior aspect of the left shoulder, specifically at the acromioclavicular joint and the anterior glenohumeral joint. Pain is exacerbated with active and passive range of motion, particularly with abduction and external rotation. There is no obvious deformity, crepitus, or ecchymosis noted. Strength testing reveals mild weakness in abduction and external rotation secondary to pain. Neurovascular examination of the left upper extremity is intact. Differential diagnosis includes left shoulder sprain, AC joint separation, rotator cuff tear, and proximal humerus fracture. Based on the clinical presentation and examination findings, the diagnosis of left shoulder sprain is most likely. Radiographs of the left shoulder were obtained to rule out fracture or dislocation and are negative for acute bony pathology. Treatment plan includes rest, ice, compression, elevation (RICE), over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen for pain management, and referral to physical therapy for range of motion and strengthening exercises. Patient education provided on proper shoulder mechanics and activity modification to avoid re-injury. Follow-up scheduled in one week to assess progress and adjust treatment plan as needed. ICD-10 code S43.401A, Sprain of unspecified ligament of left shoulder, initial encounter, is assigned.