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Updated: Jun 5 2022

Glenohumeral Internal Rotation Deficit (GIRD)

Images photo - colorado_moved.jpg stretch_moved.jpg phases.jpg glenoid.jpg labral tear.jpg
  • summary
    • Glenohumeral internal rotation deficit (GIRD) is a condition resulting in the loss of internal rotation of the glenohumeral joint as compared to the contralateral shoulder, most commonly seen in the throwing athlete.
    • Diagnosis is made clinically with a decrease in internal rotation, increase in external rotation, with a decrease in total arc of rotation compared to the contralateral shoulder. 
    • Treatment consists of physical therapy with a focus on posteroinferior capsular stretching.  
  • Epidemiology
    • Demographics
      • occurs primarily in overhead athletes
        • often seen in baseball pitchers
  • Etiology
    • Pathophysiology
      • mechanism
        • caused by repetitive throwing
          • thought to occur during the late cocking and early acceleration phase
      • pathoanatomy
        • tightening of posterior capsule or posteroinferior capsule leads to translation of humeral head (capsular constraint mechanism)
        • translation of humeral head is in the OPPOSITE direction from area of capsular tightening
        • posterior capsular tightness leads to anterosuperior translation of humeral head in flexion
        • posterorinferior capsular tightness leads to posterosuperior translation of humeral head in ABER
        • anterior capsule is stretched
    • Associated conditions
      • glenohumeral instability
      • internal impingement
        • abutment of the greater tuberosity against the posterosuperior glenoid during abduction and external rotation leads to pinching of posterosuperior rotator cuff
      • articular-sided partial rotator cuff tears
        • tensile failure in excessive rotation
        • internal impingement
      • SLAP lesion
        • throwers with GIRD are 25% more likely to have a SLAP lesion
        • peel-back mechanism (biceps anchor and postero superior labrum peels back) during late cocking
          • because of posterosuperior translation of humeral head and change in biceps vector force posteriorly
  • Anatomy
    • Glenohumeral joint
  • Presentation
    • Symptoms
      • vague shoulder pain
      • sometimes painless
      • may report a decrease in throwing performance
    • Physical exam
      • stabilize the scapula to obtain true measure of glenohumeral rotation
      • increased sulcus sign
        • due to stretching of anterior structures that resist external rotation (coracohumeral ligament, rotator interval)
      • characterized by altered glenohumeral range of motion
        • decrease in internal rotation and increase in external rotation
          • if the GIRD (loss of internal rotation) is less than external rotation gain (ERG), the shoulder maintains normal kinematics
          • if the GIRD exceeds external rotation gain (ERG), this leads to deranged kinematics
            • decrease in internal rotation is usually greater than a 25° difference as compared to non-throwing shoulder
  • 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
          • posteroinferior capsule stretching
              • performed with internal rotation stretch at 90 degrees abduction with scapular stabilization
            • roll-over sleeper stretch
              • arm flexed 60° and body rolled forward 30°
            • doorway stretch
            • cross-body adduction stretch
          • pectoralis minor stretching
          • rotator cuff and periscapular strengthening
        • outcomes
          • 90% of young throwers respond to sleeper stretches/PT
          • 10% of older throwers do not respond, and will need arthroscopic release eventually
    • Operative
      • posteroinferior capsule release vs. anterior stabilization
        • indications
          • only indicated if extensive PT fails
  • Techniques
    • Posterior capsule release vs. anterior stabilization
      • some advocate posterior capsule release while others advocate anterior stabilization
      • repair thinned rotator cuff if significantly thinned (transcuff or takedown and repair)
      • technique controversial
        • for throwing athlete with posteroinferior capsular contracture, release posterior inferior capsule and posterior band of IGHL
        • electrocautery inserted through posterior portal, camera from anterior portal
        • from 9 to 6 o'clock position
        • at level of glenoid rim
        • until rotator cuff fibers (behind the capsule) can be seen from within joint
        • insert arthroscopic shaver to widen gap in capsule (prevents recurrence)
        • gentle manipulation at the end completes release of any remaining fibers, maximizes IR and flexion
      • results
        • will immediately gain 65° of internal rotation postop
  • Complications
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