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S46.0 – Rotator Cuff Injury
S46.0 is the ICD-10 code for injury of the muscles and tendons of the rotator cuff of the shoulder, including tears and strains.
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S46.0 is the ICD-10 code for injury of the muscles and tendons of the rotator cuff of the shoulder, including tears and strains.
What Does the Diagnosis S46.0 Mean?
The ICD-10 code S46.0 refers to an injury of the muscle(s) and tendon(s) of the rotator cuff of the shoulder. The rotator cuff is a group of four muscles and their associated tendons that surround, stabilize, and enable movement of the shoulder joint. Injuries in this area are among the most common shoulder conditions and can result from acute trauma as well as chronic overuse.
Anatomy of the Rotator Cuff
The rotator cuff consists of four muscles:
- Supraspinatus – responsible for arm abduction (lifting the arm to the side)
- Infraspinatus – responsible for external rotation
- Teres minor – assists in external rotation
- Subscapularis – responsible for internal rotation
Together, these muscles hold the head of the humerus (upper arm bone) in the glenoid socket and enable precise shoulder movement.
Causes
Rotator cuff injuries (S46.0) may occur due to various causes:
- Acute trauma: Falls onto an outstretched arm, direct blows to the shoulder, or sudden traction forces
- Chronic overuse: Repetitive overhead activities, common in athletes (tennis, swimming, throwing sports) and manual laborers
- Degenerative changes: Age-related wear and tear of tendons, particularly in individuals over 50 years of age
- Shoulder impingement syndrome: Repeated pinching of tendon tissue beneath the acromion, which can precede a full tear
Symptoms
Typical symptoms associated with an S46.0 diagnosis include:
- Shoulder pain, often radiating into the upper arm
- Pain that worsens with specific movements, particularly abduction and overhead activities
- Weakness of the shoulder muscles
- Reduced range of motion in the shoulder joint
- Nighttime pain that may disrupt sleep
- In complete tears: significant loss of strength, sometimes with a visible indentation in the muscle
Diagnosis
The diagnosis of a rotator cuff injury is established through:
- Clinical examination: Specific tests such as the Jobe test, Painful Arc test, and Hawkins-Kennedy test help identify affected structures
- Ultrasound (sonography): A fast and cost-effective imaging method for evaluating tendon tears
- MRI (magnetic resonance imaging): The gold standard for accurately assessing the extent and location of the injury
- X-ray: Used to rule out bony injuries or calcifications
Treatment
Conservative Treatment
For partial tears and minor injuries, conservative management is typically the first line of treatment:
- Rest and temporary reduction of shoulder loading
- Pain management with non-steroidal anti-inflammatory drugs (NSAIDs)
- Physical therapy to strengthen surrounding muscles and improve joint stability
- Corticosteroid injections to reduce inflammation and relieve pain if needed
Surgical Treatment
Complete tears or cases where conservative treatment fails may require surgical intervention:
- Arthroscopic repair: Minimally invasive suturing of the torn tendon
- Open or mini-open repair: Used for larger or more complex tears
Postoperative Rehabilitation
Structured rehabilitation is essential following surgery or intensive conservative treatment. This typically includes several weeks of physical therapy with a gradual increase in activity. Full recovery can take between 3 and 12 months depending on the severity of the injury.
References
- Maffulli N., Longo U.G., Berton A., Loppini M., Denaro V.: Biological treatments for rotator cuff tears. Current Stem Cell Research & Therapy, 7(6):464–470, 2012.
- Tashjian R.Z.: Epidemiology, natural history, and indications for treatment of rotator cuff tears. Clinics in Sports Medicine, 31(4):589–604, 2012.
- World Health Organization (WHO): International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10), Code S46.0.
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