Glenohumeral Internal Rotation Deficit (GIRD)

Topic updated on 09/26/13 1:32pm
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   
        • pectoralis minor stretching 
        • subscapularis and serratus (anterior) 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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Qbank (4 Questions)

TAG
(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? Topic Review Topic

1. Sleeper stretches, cross-body stretches, periscapular strengthening
2. Sleeper stretches and subscapularis stengthening
3. External rotation stretches with cuff strengthening
4. External rotation stretches and periscapular strengthening
5. Altering his arm slot and improving pitching mechanics

PREFERRED RESPONSE ▶
TAG
(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 Topic Review Topic

1. shoulder arthroscopy and SLAP repair
2. shoulder arthroscopy and a capsular release
3. intra-articular cortisone injection, rest and a pitching program
4. diagnostic arthrosopy and subacromial decompression with coracoacromial ligament resection
5. aggressive physical therapy involving posterior capsular stretching and scapular strengthening

PREFERRED RESPONSE ▶
TAG
(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? Topic Review Topic

1. Anterior capsule
2. Posterior capsule
3. Antero-inferior capsule
4. Rotator interval
5. MGHL

PREFERRED RESPONSE ▶
TAG
(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? Topic Review Topic

1. Internal impingement
2. Humeral avulsion of the glenohumeral ligament
3. Subacromial impingement
4. Bicep tendinitis
5. Hill-Sachs lesion

PREFERRED RESPONSE ▶
TAG
(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? Topic Review Topic

1. Posterosuperior
2. Posteroinferior
3. Anteroinferior
4. Anterosuperior
5. Directly anterior

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

1. Internal rotation
2. External rotation
3. Abduction
4. Adduction
5. Forward elevation

PREFERRED RESPONSE ▶
TAG
(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? Topic Review Topic
FIGURES: A   B        

1. Long head of the biceps tendonosis
2. Glenohumeral internal rotation deficit (GIRD)
3. Supscapularis rupture
4. Superior labral anterior posterior (SLAP) tear
5. Bankart lesion

PREFERRED RESPONSE ▶



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The proper way to do the "SLEEPER STRETCH" to stretch the posterior capsule of t...
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Braun S, Kokmeyer D, Millett PJ
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Crockett HC, Gross LB, Wilk KE, Schwartz ML, Reed J, O'Mara J, Reilly MT, Dugas JR, Meister K, Lyman S, Andrews JR
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