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S46.1 ICD-10: Biceps Tendon Injury Explained
S46.1 is an ICD-10 diagnosis code referring to an injury of the muscle and tendon of the long head of the biceps at the shoulder and upper arm level.
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S46.1 is an ICD-10 diagnosis code referring to an injury of the muscle and tendon of the long head of the biceps at the shoulder and upper arm level.
What Does the ICD-10 Code S46.1 Mean?
The ICD-10 code S46.1 refers to an injury of the muscle and tendon of the long head of the biceps at the level of the shoulder and upper arm. ICD-10 is the International Classification of Diseases, used by physicians and hospitals worldwide for standardized diagnosis coding. This type of injury can occur as a result of acute trauma such as a fall or sports accident, or due to chronic overuse and degenerative changes in the tendon.
Causes
Injuries classified under S46.1 are commonly caused by:
- Acute trauma: Falling onto an outstretched arm, direct impact to the shoulder or upper arm
- Sports injuries: Common in weightlifting, climbing, tennis, and throwing sports
- Degenerative changes: Pre-existing tendon damage from chronic overuse increases the risk of rupture
- Occupational overload: Repetitive heavy lifting or pulling movements at work
Symptoms
Typical symptoms of an S46.1 injury include:
- Sudden, sharp pain in the front of the shoulder or upper arm
- Swelling and bruising (hematoma) in the affected area
- Weakness when flexing the elbow or supinating (rotating) the forearm
- A palpable gap or visible deformity of the muscle belly (known as the Popeye sign in complete rupture)
- Limited range of motion in the shoulder and elbow
Diagnosis
Diagnosis of an S46.1 injury is established through:
- Clinical examination: Palpation, strength testing, and specific shoulder tests (e.g., Speed test, Yergason test)
- Ultrasound (sonography): A quick and cost-effective method for visualizing tendons and muscles
- MRI (Magnetic Resonance Imaging): Detailed assessment of the extent of injury, especially for partial tears
- X-ray: Used to rule out associated bony injuries
Treatment
Conservative Treatment
For partial tears or strains, conservative management is often the first approach:
- Immobilization and rest (arm sling if necessary)
- Ice application for pain relief and reduction of swelling in the first 48 hours
- Pain management with anti-inflammatory medications (e.g., ibuprofen, diclofenac)
- Physiotherapy to restore strength and range of motion
Surgical Treatment
For complete ruptures, especially in younger or physically active patients, surgery may be required:
- Biceps tenodesis: Reattachment of the tendon to the bone
- Tenotomy: Cutting the tendon (often preferred in older patients with minimal symptoms)
Rehabilitation
Following treatment, structured physiotherapy is essential to restore full arm function. The duration of rehabilitation ranges from several weeks to months depending on the severity of the injury.
References
- World Health Organization (WHO): International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10), Chapter XIX – Injury, Poisoning (S46.1), 2019.
- Netter, F.H.: Atlas of Human Anatomy. Elsevier, 7th Edition, 2019.
- Churgay, C.A.: Diagnosis and treatment of biceps tendinitis and tendinosis. American Family Physician, 2009.
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