ICD 10 CM S39.002D | Description & Clinical Information

ICD 10 S39.002D describes an unspecified injury to the muscle, fascia, and tendon of the lower back that may result from a traumatic impact to the body, and this code is used when the provider does not document the specific type of injury, and it is applicable to subsequent encounters.

Official Description Of S39.002D

The ICD 10 CM book defines ICD 10 code S39.002D as:

When To Use S39.002D

The diagnosis describes by the ICD-10-CM code S39.002D pertains to an unspecified injury of muscle, fascia, and tendon in the lower back region. This type of injury can result in a wide range of symptoms such as pain, bruising, tenderness, swelling, stiffness, spasm, muscle weakness, and even bleeding. It is a common diagnosis in patients of all ages and backgrounds, and can occur due to a variety of reasons such as sports injuries, falls, lifting heavy objects, or even poor posture.

When a patient presents with these symptoms, it is important for the medical provider to conduct a comprehensive assessment, including a detailed medical history and a physical examination. During the physical examination, the provider will assess the degree of damage to the tissues and the severity of the injury. This will be followed by imaging techniques, such as X-rays or more advanced diagnostic tools like CT scans and MRI, to rule out any fractures or determine whether any tears are partial or complete.

Treatment options for an injury in the lower back could range from non-invasive to surgical interventions, depending on the severity of the injury. Initial treatment of muscle, fascia, and tendon injury often begins with conservative methods like medication management with analgesics, muscle relaxants, and nonsteroidal anti-inflammatory drugs or NSAIDs. In more severe cases, bracing or splinting may be used to prevent movement, relieve pain, and reduce swelling. If patients do not respond to conservative management, surgery may be necessary to address the underlying issue and restore proper function.

Rehabilitation and ongoing care are essential for patients who experience muscle, fascia, and tendon injuries to the lower back. Physical therapy and rehabilitation programs can help patients regain strength and improve their range of motion. This type of ongoing care can help minimize the risk of future injury and prevent a recurrence of symptoms.

In conclusion, a diagnosis of S39.002D describes an unspecified injury of muscle, fascia, and tendon in the lower back region. Medical providers diagnose this condition by conducting a thorough physical examination and using diagnostic imaging such as X-rays, CT scans, and MRI to help guide treatment options. Treatment options range from conservative management with medication and bracing to surgical interventions. Rehabilitation programs are often recommended to help patients regain full function and minimize the risk of future injury. It is important for patients with these types of injuries to seek prompt medical attention to receive a proper diagnosis and ensure the most effective treatment possible.