Muscle Strain ICD-10-CM Codes | 2025

Learn 2025 ICD-10 codes for muscle strain injuries to the hip, thigh, and pelvis. Includes billable codes, encounter types, symptoms, and treatments.

By Wynona Jugueta on Aug 8, 2025.

Fact Checked by Ericka Pingol.

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What are Muscle Strain ICD-10-CM Codes?

Muscle strain ICD-10 codes fall primarily under the S76 category, covering injuries to the muscle, fascia, and tendon of the hip, thigh, pelvis, and surrounding regions. Below are some of the most frequently used and billable ICD-10-CM codes for muscle strain, categorized by location and encounter type:

S76: Injury of muscle, fascia, and tendon of hip
S76.01: Strain of muscle, fascia, and tendon of hip
S76.1: Injury of quadriceps muscle, fascia, and tendon
S76.11: Strain of quadriceps muscle, fascia, and tendon
S76.2: Injury of adductor muscle, fascia, and tendon of thigh
S76.21: Strain of adductor muscle, fascia, and tendon of thigh
S76.3: Injury of muscle, fascia, and tendon of the posterior muscle group at thigh level
S76.31: Strain of muscle, fascia, and tendon of the posterior muscle group at thigh level
S76.8: Injury of other specified muscles, fascia, and tendons at thigh level
S76.81: Strain of other specified muscles, fascia, and tendons at thigh level
S76.9: Injury of unspecified muscles, fascia, and tendons at thigh level
S76.91: Strain of unspecified muscles, fascia, and tendons at thigh level

These ICD-10 codes help healthcare providers accurately document and diagnose muscle strain injuries, ensuring appropriate treatment and care for patients experiencing these conditions.

Which Muscle Strain ICD-10-CM Codes are billable?

These codes are valid and commonly billable when supported by clinical documentation of injury.

Clinical information

Muscle strain refers to the overstretching or tearing of muscle fibres, often resulting from excessive physical activity, trauma, or repetitive use. It can occur in any muscle group but is particularly common in the lower back, hamstrings, and hip or thigh regions. The severity of a strain can range from mild, involving minimal fibre damage, to severe, with partial or complete muscle tears.

Clinically, patients with muscle strain may present with the sudden onset of pain, swelling, bruising, and limited range of motion in the affected area. In some cases, a palpable defect or muscle weakness may also be noted. Strains are classified by grade: Grade I (mild) includes minor stretching or microscopic tearing; Grade II (moderate) involves partial muscle tearing; and Grade III (severe) includes complete rupture.

Diagnosis typically involves a detailed history and physical examination. Imaging, such as ultrasound or MRI, may be used to assess the extent of the injury, especially in moderate to severe cases. Identifying the specific muscle group involved is essential for targeted management.

Treatment focuses on reducing pain and inflammation, promoting healing, and restoring function. Initial management follows the RICE protocol, which consists of rest, ice, compression, and elevation. Nonsteroidal anti-inflammatory drugs (NSAIDs) may be used to alleviate pain. Physical therapy plays a key role in rehabilitation, helping to restore strength and flexibility. In rare cases, surgical repair may be necessary for complete muscle ruptures.

Synonyms include

Muscle pull
Muscle tear
Muscle sprain
Muscular injury
Muscle overexertion

Commonly asked questions

Use a muscle strain ICD-10-CM code when a patient presents with symptoms such as pain, tenderness, swelling, or limited motion due to overstretching or tearing of muscle, fascia, or tendon. These codes are appropriate during the initial evaluation, subsequent treatment, or sequela management of a documented strain injury.

Common treatments include rest, ice, compression, and elevation (RICE), nonsteroidal anti-inflammatory drugs (NSAIDs), and physical therapy to improve strength and flexibility. Severe strains may require temporary immobilization or referral to orthopedics or sports medicine specialists for advanced care.

A diagnosis code for muscle strain indicates the location, severity, and encounter type of the injury, such as initial or follow-up care for strained muscle, fascia, or tendon. It helps clinicians document the injury and guides billing, treatment planning, and insurance reimbursement.

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