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Introduction
  • Definition
    • 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
  • 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 
          • sleeper stretch      
            • 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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