http://upload.orthobullets.com/topic/3055/images/Clinical photo - colorado_moved.jpg
http://upload.orthobullets.com/topic/3055/images/throwing phases.jpg
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http://upload.orthobullets.com/topic/3055/images/retroverted glenoid.jpg
http://upload.orthobullets.com/topic/3055/images/aber.005.jpg
http://upload.orthobullets.com/topic/3055/images/mri labral tear.jpg
Introduction
  • A condition resulting in the loss of internal rotation of the glenohumeral joint as compared to the contralateral side  
  • Epidemiology
    • occurs primarily in overhead athletes
      • often seen in baseball pitchers
  • Mechanism 
    • caused by repetitive throwing
      • thought to occur during the late cocking and early acceleration phase 
  • Pathoanatomy
    • glenohumeral joint kinematics are altered by a posterosuperior shift in humeral head 
    • the posterior capsule becomes tightened
    • the anterior capsule is stretched/lengthened
  • Associated conditions  
    • glenohumeral instability 
    • internal impingement 
      • abutment of the greater tuberosity against the posterosuperior glenoid during abduction and external rotation 
    • SLAP lesion 
      • throwers with GIRD are 25% more likely to have a SLAP lesion
Anatomy
  • Glenohumeral joint 
Presentation
  • Symptoms
    • vague shoulder pain
    • sometimes painless
    • may report a decrease in throwing performance
  • Physical exam
    • range of motion of the glenohumeral joint is altered
      • excessive external rotation is present at the expense of decreased internal rotation 
      • decrease in internal rotation is usually greater than a 25 degree difference as compared to non-throwing shoulder  
      • must stabilize scapula to get true measure of glenohumeral rotation
Imaging
  • Radiographs
    • recommended views
      • AP and lateral of glenohumeral joint
    • findings
      • usually normal
  • CT
    • may show increased glenoid retroversion 
  • MRI
    • ABER view on MRI can show associated lesions
Treatment
  • Nonoperative
    • rest from throwing and physical therapy for 6 months
      • indications
        • first line of treatment 
      • physical therapy 
        • posterior capsule stretching 
          • sleeper stretch      
            • performed with internal rotation stretch at 90 degrees abduction with scapular stabilization   
          • cross-body adduction stretch
        • pectoralis minor stretching 
        • rotator cuff and periscapular strengthening
  • Operative
    • posterior capsule release vs. anterior stabilization
      • indications
        • only indicated if extensive PT fails
Techniques
  • Posterior capsule release vs. anterior stabilization
    • technique is controversial
    • some advocate posterior capsule release while others advocate anterior stabilization
    • repair thinned rotator cuff if significantly thinned (transcuff or takedown and repair)
 

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Questions (7)

(OBQ11.82) Posterior shoulder tightness can lead to a glenohumeral internal rotation deficit (GIRD). This has been linked most closely to which of the following shoulder pathologies? Review Topic

QID:3505
1

Internal impingement

88%

(1418/1617)

2

Humeral avulsion of the glenohumeral ligament

6%

(91/1617)

3

Subacromial impingement

3%

(46/1617)

4

Bicep tendinitis

2%

(27/1617)

5

Hill-Sachs lesion

2%

(32/1617)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

Repetitive overhead throwing can lead to posterior capsular stiffness and relative loss of internal rotation (GIRD). This may shift the contact point posterior and superior on the glenoid, leading to internal impingement where the greater tuberosity impinges on the posterosuperior labrum and posterior rotator cuff when the arm is abducted and externally rotated. Initial treatment involves posterior capsular stretching.

Myers et al evaluated two groups of throwing athletes, one with a diagnosis of internal impingement and one without, to compare the degree of GIRD/posterior capsular tightness and its correlation with increased external rotation gain. They found that throwing athletes with internal impingement demonstrated significantly greater GIRD and posterior shoulder tightness, and that management should include stretching to restore flexibility to the posterior shoulder.

Tyler et al sought to determine if improvements in GIRD and/or decreased posterior shoulder tightness were associated with a resolution of symptoms in 22 patients with internal impingement. After an average of 7 weeks of physical therapy, they found that resolution of symptoms was related to correction of posterior shoulder tightness but not correction of GIRD.


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(OBQ09.58) A 31-year-old professional baseball pitcher has increased external rotation and a 30 degree deficit on internal rotation on his throwing shoulder compared to his non-dominant side. Motion analysis of the glenohumeral joint will show what abnormal movement of the humerus in relation to the glenoid during the cocking phase of throwing? Review Topic

QID:2871
1

Posterosuperior

54%

(485/899)

2

Posteroinferior

12%

(105/899)

3

Anteroinferior

12%

(107/899)

4

Anterosuperior

19%

(171/899)

5

Directly anterior

3%

(28/899)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

The clinical presentation is consistent for a glenohumeral internal rotation deficit (GIRD), typically caused by a posterior cuff and capsular contracture. Biomechanical studies have shown that the humerus is translated in a posterosuperior direction during the cocking phase of throwing in the setting of a posterior capsular contracture.

GIRD is a common finding in pitchers and other throwing athletes. While it is not necessarily a painful condition, it has been shown to to alter the mechanics of the shoulder during throwing and may lead to injury of the superior labrum and articular side of the rotator cuff. Physical exam is significant for increased external rotation and loss of internal rotation compared to the contralateral shoulder. Tests for a SLAP tear may also be positive. In this condition, radiographs and MRI are often be normal.

Grossman et al in a cadaveric study simulating GIRD by creating a posterior capsular contracture showed that the humerus moves in a posterosuperior direction during the cocking phase of throwing (external rotation in 90 degrees of abduction).

Lintner et al report "therapy is directed at posterior capsular stretching to prevent loss of internal rotation and to protect the superior labrum and posterior rotator cuff". They also report that increased external rotation may be attributable to increased humeral retroversion, while the internal rotation deficit is caused by soft tissue adaptations.

Illustration A shows an algorithm for clinical reasoning in the examination of impingement related shoulder pain.

ILLUSTRATIONS:

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(OBQ08.230) Which of the following shoulder motions is characteristically decreased in the throwing arm of athletes when compared to the nondominant side? Review Topic

QID:616
1

Internal rotation

90%

(445/494)

2

External rotation

7%

(35/494)

3

Abduction

1%

(4/494)

4

Adduction

1%

(3/494)

5

Forward elevation

1%

(7/494)

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PREFERRED RESPONSE 1

The throwing shoulder in pitchers frequently exhibits excessive external rotation at the expense of decreased internal rotation. The cited study by Crockett et al is a CT study of athletes and nonathletes that showed that athletes had a significant increase in dominant shoulder humeral head retroversion, glenoid retroversion, external rotation at 90 degrees, and external rotation in the scapular plane when compared to the nondominant shoulder. Internal rotation was decreased in the dominant shoulder of athletes. These differences were not present in the dominant shoulders on nonathletes.


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(SBQ07.1) A college baseball pitcher has posterior-superior and anterior pain in his throwing shoulder. On exam, he has a 30 degree loss of internal rotation on the affected side and a positive O'Brien's test. Radiographs and MRI are normal. While all of the following may be helpful, which of the following exercises should be emphasized most in this patient's rehabilitation program? Review Topic

QID:1386
1

Sleeper stretches, cross-body stretches, periscapular strengthening

72%

(317/443)

2

Sleeper stretches and subscapularis stengthening

17%

(74/443)

3

External rotation stretches with cuff strengthening

4%

(18/443)

4

External rotation stretches and periscapular strengthening

4%

(18/443)

5

Altering his arm slot and improving pitching mechanics

2%

(11/443)

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PREFERRED RESPONSE 1

The clinical presentation is consistent with GIRD which is treated with aggressive rehabilitation consisting of posterior capsular and cuff stretching.

GIRD (glenohumeral internal rotation deficit) is now commonly recognized in throwing shoulders. Posterior cuff and capsular tightness can cause decreased internal rotation which may cause pain and is implicated in SLAP and articular-sided rotator cuff tears. Radiographs and MRI are often normal.

Kibler et al reviews scapular dyskinesis and its relation to shoulder pain. They report treatment of scapular dyskinesis is directed at managing underlying causes and restoring normal scapular muscle activation patterns by kinetic chain-based rehabilitation protocols.

Burkhart et al developed the acronym "SICK" to refer to the findings one sees in this syndrome (Scapular malposition, Inferior medial border prominence, Coracoid pain and malposition, and dysKinesis of scapular movement). This overuse muscular fatigue syndrome is yet another cause of shoulder pain in the throwing athlete.


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(SBQ05.83) A 24-year-old minor league baseball pitcher presents with shoulder pain. On exam, his strength is normal. At 90 degrees of abduction, he has a total arc of motion of 150 degrees and a loss of internal rotation of 30 degrees. His scapula hangs lower than on the non-throwing shoulder. Initial management should consist of Review Topic

QID:1868
1

shoulder arthroscopy and SLAP repair

1%

(7/971)

2

shoulder arthroscopy and a capsular release

1%

(5/971)

3

intra-articular cortisone injection, rest and a pitching program

2%

(21/971)

4

diagnostic arthrosopy and subacromial decompression with coracoacromial ligament resection

0%

(4/971)

5

aggressive physical therapy involving posterior capsular stretching and scapular strengthening

96%

(932/971)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

Initial management in throwing athletes with shoulder pain includes rest from throwing with rehabilitaion to improve motion and strength, regardless of the pathology. This patient has glenohumeral internal rotation deficit (GIRD) with external rotation gain (ERG), which is often seen in asymptomatic throwers. However, the total arc of motion should equal 180 degrees, according to the total motion concept. Burkhart et al discuss the typical Type II SLAP tear seen in pitchers, indicating that posterior capsule tightness increases the risk of this injury. They advocate stretching the posterior capsule and strengthening the entire kinetic chain, including the scapular stabilizers. Braun et al arrive at similar conclusions, and maintain that injections and surgery should be reserved for patients who fail to respond to rest and rehabilitation, with few exceptions.


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(OBQ05.225) A 22-year-old minor league baseball pitcher is being treated for shoulder pain with a focused rehabilitation program. Figures A and B display rehabilitation manuevers that are critical in the treatment of his shoulder pathology. What is the most likely diagnosis in this athlete? Review Topic

QID:1111
FIGURES:
1

Long head of the biceps tendonosis

1%

(10/1785)

2

Glenohumeral internal rotation deficit (GIRD)

94%

(1676/1785)

3

Subscapularis rupture

3%

(55/1785)

4

Superior labral anterior posterior (SLAP) tear

2%

(32/1785)

5

Bankart lesion

0%

(5/1785)

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PREFERRED RESPONSE 2

Figure A shows a sleeper stretch and Figure B shows a prone internal rotation stretch with scapular stabilization which are both forms of posterior capsular stretching. Baseball pitchers often have excessive external rotation and diminished internal rotation on their throwing shoulder. A rehabilitation program that includes posterior capsular stretching is essential for the treatment of GIRD.

According to the review article by Braun et al, GIRD is a posterior shift in the total arc of motion and is thought to be a physiological adaptation of the shoulder joint to throwing. The treatment of loss of internal rotation is stretching of the posterior capsule.

The Level 3 article by Crockett et al reviewed shoulder CT scans and shoulder range of motion in 25 pitchers and 25 non-throwers. The pitcher group demonstrated a significant increase in humeral head retroversion by CT scan, external rotation at 90°, external rotation in the scapular plane, and total range of motion compared to the non-pitchers.


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Question COMMENTS (1)

(SBQ04.83) A 22-year-old collegiate pitcher is having pain and decreased velocity with throwing. He is examined in the office and is diagnosed with Glenohumeral Internal Rotation Deficit (GIRD). He is prescribed a therapy regimen that involves internal rotation stretching at 90 degrees of forward flexion with the scapula stabilized. This will stretch which region of the shoulder joint? Review Topic

QID:2168
1

Anterior capsule

2%

(9/400)

2

Posterior capsule

90%

(358/400)

3

Antero-inferior capsule

5%

(19/400)

4

Rotator interval

1%

(4/400)

5

MGHL

2%

(10/400)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

The "sleeper stretch", or internal rotation stretch with the arm flexed 90-degrees and the scapula stabilized, stretches the posterior capsule preferentially as shown in Illustration A. Posterior capsular tightness is felt to be a cause of decreased internal rotation (GIRD) often seen in baseball pitchers. The other capsular areas are not significantly addressed by this stretch.

Kibler et al provide a comprehensive discussion of shoulder rehabilitation, including principles of following a proximal-to-distal activation pathway, integrating various shoulder functions together in the rehab protocol, and emphasizing scapular control coupled with rotator cuff activation.

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