In simple words: A pulled muscle in the lower back, involving the muscle, fascia, and tendon. It's an overstretching or tearing that causes pain and weakness. This code is used for the first visit for this injury.

Overstretching or tearing of muscle, fascia, and tendon in the lumbar region causing pain and debility. This code applies to the initial encounter.

Example 1: A patient presents to the ER after lifting a heavy box, complaining of sudden lower back pain. Examination reveals muscle spasm and limited range of motion. Imaging confirms a muscle strain without fracture, and the patient is diagnosed with a strain of muscle, fascia, and tendon of the lower back., A weekend warrior playing basketball experiences a sharp pain in their lower back after a sudden movement. They present to their physician with pain and limited mobility. After examination and imaging, a diagnosis of a lumbar muscle strain is made., A pregnant woman in her third trimester experiences increasing lower back pain. Her physician determines it is a muscle strain due to the added weight and stress on her back.

Documentation should include details of the injury mechanism, location and severity of pain, physical exam findings (e.g., muscle spasm, tenderness, range of motion), and results of imaging studies.

** Excludes2: sprain of joints and ligaments of lumbar spine and pelvis (S33.-). Code also: any associated open wound (S31.-).