What is the ICD-10 code and treatment for a possible left arm deltoid muscle tear?

Management of Left Arm Deltoid Muscle Tear: ICD-10 Coding and Treatment

The appropriate ICD-10 code for a left arm deltoid muscle tear is S46.812A (Strain of other muscles, fascia and tendons at shoulder and upper arm level, left arm, initial encounter), and treatment should begin with conservative measures including rest, ice, NSAIDs, and physical therapy, progressing to surgical repair only if conservative management fails after 3-6 months.

ICD-10 Coding

For a left arm deltoid muscle tear, the most appropriate ICD-10 code is:

• S46.812A - Strain of other muscles, fascia and tendons at shoulder and upper arm level, left arm, initial encounter

If the tear is confirmed rather than suspected, additional specificity may be added:

• S46.312A - Strain of muscle, fascia and tendon of the long head of biceps, left arm, initial encounter (if involving the long head of biceps)
• S46.112A - Strain of muscle, fascia and tendon of the rotator cuff of left shoulder, initial encounter (if involving the rotator cuff)

Diagnostic Approach

Imaging Studies

1. Ultrasound - First-line imaging modality for deltoid muscle tears

   • Non-invasive, low-cost, and universally available 1
   • Can accurately detect and assess deltoid muscle tears

2. MRI - Gold standard for definitive diagnosis

   • Provides detailed assessment of:
     • Location of tear (anterior, middle, or posterior deltoid)
     • Size and extent of tear (partial vs. full thickness)
     • Associated pathologies (rotator cuff tears, bursitis)
     • Muscle atrophy and tendon retraction 2, 3

Common Findings

• Middle (acromial) portion of the deltoid is most frequently affected in patients with rotator cuff tears 3
• Tears may occur at the muscle belly near the musculotendinous junction or as avulsion from the acromial origin 2
• Associated findings may include subcutaneous edema or fluid-like signal overlying the deltoid 2

Treatment Algorithm

Phase 1: Conservative Management (0-6 weeks)

1. RICE Protocol

   • Rest the affected arm
   • Ice application for 15-20 minutes every 2-3 hours
   • Compression with elastic bandage
   • Elevation of the arm when possible

2. Pain Management

   • NSAIDs are strongly recommended as first-line treatment
     • Ibuprofen 1.2g daily (can be increased to 2.4g daily if needed)
     • Can be combined with acetaminophen (up to 4g daily) for inadequate relief

3. Early Rehabilitation

   • Begin with gentle range of motion exercises as pain allows
   • Avoid activities that exacerbate pain

Phase 2: Progressive Rehabilitation (6-12 weeks)

1. Physical Therapy

   • Focus on:
     • Progressive strengthening of deltoid and rotator cuff muscles
     • Scapular stabilization exercises
     • Range of motion exercises

2. Manual Therapy

   • Soft tissue mobilization
   • Joint mobilization techniques

3. Functional Exercises

   • Gradually introduce activities that mimic daily tasks

Phase 3: Advanced Rehabilitation (12+ weeks)

1. Sport-specific or occupation-specific training
2. Progressive resistance training
3. Continued monitoring of symptoms

Surgical Intervention

Consider surgical consultation if:

• Pain persists despite 3-6 months of well-managed conservative treatment
• Functional limitations significantly impact quality of life
• Progressive weakness or deterioration is evident

Surgical options include:

• Primary repair of the deltoid to the acromion using transosseous suture repair technique 4
• For massive tears associated with rotator cuff pathology, deltoid flap repair may be considered 5

Return to Activity Criteria

Return to full activity is permitted when the patient demonstrates:

1. Complete resolution of pain during and after activity
2. Full range of motion compared to uninjured side
3. Strength symmetry >90% compared to uninjured side
4. Successful completion of functional tests specific to planned activities

Monitoring and Follow-up

• Regular follow-up appointments to assess progress
• Repeat imaging may be necessary to evaluate healing

Special Considerations

• Deltoid tears are often associated with rotator cuff pathology, so assessment of the rotator cuff is essential 2, 3
• Older patients with chronic rotator cuff tears are at higher risk for spontaneous deltoid detachment 1
• Steroid injections should be used cautiously as they may be associated with deltoid tears in patients with rotator cuff pathology 3