Infraspinatus (muscle) (tendon) sprain

This code signifies a sprain or tear of the infraspinatus muscle or its tendon, located in the rotator cuff of the shoulder. This injury typically involves overstretching or tearing of the muscle fibers or the connective tissue that attaches the muscle to bone. It results in pain, weakness, and limited range of motion in the shoulder.

Use this code when documentation explicitly states a sprain or strain of the infraspinatus muscle or tendon. This diagnosis is often made following a physical examination revealing tenderness over the infraspinatus, pain with external rotation, or weakness during resisted external rotation. Supporting documentation would include physician notes detailing the mechanism of injury, physical exam findings, and diagnostic imaging results if performed (e.g., MRI showing a partial tear).

• Differentiate from a rotator cuff tear (840.4) if the documentation specifies only the infraspinatus and not a broader rotator cuff injury.
• Ensure the documentation clearly identifies the infraspinatus specifically; avoid using this code for general shoulder sprains without specific muscle involvement.
• Consider an external cause code (E-code) if the injury resulted from a specific accident or trauma.