ICD 10 CM S46.111 | Description & Clinical Information

ICD 10 S46.111 describes a medical condition characterized by the tearing or pulling apart of the fibers that make up the muscles of the upper arm, the fibrous connective tissue that covers, protects, and supports other structures, or the fibrous tissue that connects muscle to bone and helps to bend the elbow, resulting from either overuse or trauma.

Official Description Of S46.111

The ICD 10 CM book defines ICD 10 code S46.111 as:

Clinical Information

The diagnosis describes by the ICD 10 CM S46.111 code refers to a strain of the muscle, fascia, or tendon of the long head of the biceps in the right arm. While this may seem like a relatively minor issue, it can cause significant pain and discomfort, as well as a range of other symptoms that can limit a person’s movement and ability to function normally.

Common symptoms associated with this diagnosis include pain, disability, bruising, tenderness, swelling, muscle spasm or weakness, and limited range of motion. In some cases, patients may also experience an audible crackling sound associated with movement, which can be an indication of a more serious injury.

When diagnosing this condition, a healthcare provider will typically start by taking a detailed medical history and performing a physical examination. They will pay specific attention to the injured structure and the type of injury, as this can help to determine the most appropriate course of treatment.

For more serious injuries, imaging techniques such as X-rays and magnetic resonance imaging (MRI) may be used to help diagnose the extent of the damage. These tests can provide a more detailed view of the internal structures of the arm, allowing healthcare providers to make more accurate diagnoses and develop more effective treatment plans.

Treatment options for this condition can vary depending on the severity of the injury. For less severe strains, simple measures like rest, ice, and over-the-counter pain medications like nonsteroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants may be all that is necessary to address the symptoms and promote healing.

For more severe injuries, a splint or cast may be necessary to prevent movement and reduce pain or swelling. In some cases, patients may also benefit from exercises designed to improve flexibility, strength, and range of motion in the affected arm.

For the most severe cases, surgery may be required to repair more extensive damage to the muscle or tendon. This is typically only considered when more conservative approaches have failed or when the injury is severe enough to significantly impact a person’s ability to function normally.

Overall, prompt and accurate diagnosis of strains to the muscle, fascia, or tendon of the long head of the biceps in the right arm is essential for effective treatment and optimal outcomes. Patients who experience any of the symptoms associated with this condition should seek medical attention to ensure that they receive the most appropriate care and support for their individual needs.