Updated: 6/16/2019

Glenohumeral Internal Rotation Deficit (GIRD)

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https://upload.orthobullets.com/topic/3055/images/Clinical photo - colorado_moved.jpg
https://upload.orthobullets.com/topic/3055/images/throwing phases.jpg
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https://upload.orthobullets.com/topic/3055/images/retroverted glenoid.jpg
https://upload.orthobullets.com/topic/3055/images/aber.005.jpg
https://upload.orthobullets.com/topic/3055/images/mri labral tear.jpg
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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Questions (21)
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(SAE08UE.116) A 22-year-old female collegiate javelin thrower has shoulder pain. She notes that her pain is primarily located in the posterior aspect of her shoulder, is exacerbated with throwing, and she experiences maximal tenderness in the extreme cocking phase of the throwing cycle. On examination, she reports deep posterior shoulder pain when the arm is abducted 90 degrees and maximally externally rotated to 110 degrees. This reproduces her symptoms precisely. Shoulder radiographs are normal. What is the most likely diagnosis? Review Topic

QID: 6678
1

Anterior shoulder instability

10%

(6/59)

2

Early adhesive capsulitis

2%

(1/59)

3

Internal impingement

78%

(46/59)

4

Subacromial impingement

10%

(6/59)

5

Full-thickness rotator cuff tear

0%

(0/59)

ML 2

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(SBQ04SM.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

1%

(12/827)

2

Posterior capsule

91%

(751/827)

3

Antero-inferior capsule

4%

(35/827)

4

Rotator interval

1%

(10/827)

5

MGHL

2%

(14/827)

ML 1

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PREFERRED RESPONSE 2

(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

57%

(870/1530)

2

Posteroinferior

9%

(145/1530)

3

Anteroinferior

12%

(180/1530)

4

Anterosuperior

18%

(283/1530)

5

Directly anterior

3%

(46/1530)

ML 4

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PREFERRED RESPONSE 1

(SBQ07SM.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%

(483/674)

2

Sleeper stretches and subscapularis stengthening

16%

(108/674)

3

External rotation stretches with cuff strengthening

4%

(29/674)

4

External rotation stretches and periscapular strengthening

4%

(30/674)

5

Altering his arm slot and improving pitching mechanics

2%

(16/674)

ML 2

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PREFERRED RESPONSE 1

(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%

(11/2015)

2

Glenohumeral internal rotation deficit (GIRD)

93%

(1878/2015)

3

Subscapularis rupture

4%

(73/2015)

4

Superior labral anterior posterior (SLAP) tear

2%

(36/2015)

5

Bankart lesion

0%

(7/2015)

ML 1

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PREFERRED RESPONSE 2

(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

87%

(1866/2152)

2

Humeral avulsion of the glenohumeral ligament

6%

(132/2152)

3

Subacromial impingement

3%

(64/2152)

4

Bicep tendinitis

2%

(37/2152)

5

Hill-Sachs lesion

2%

(45/2152)

ML 1

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PREFERRED RESPONSE 1

(SBQ05UE.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%

(14/1696)

2

shoulder arthroscopy and a capsular release

1%

(12/1696)

3

intra-articular cortisone injection, rest and a pitching program

1%

(23/1696)

4

diagnostic arthrosopy and subacromial decompression with coracoacromial ligament resection

1%

(12/1696)

5

aggressive physical therapy involving posterior capsular stretching and scapular strengthening

96%

(1626/1696)

ML 1

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PREFERRED RESPONSE 5

(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

91%

(755/828)

2

External rotation

6%

(50/828)

3

Abduction

1%

(8/828)

4

Adduction

0%

(4/828)

5

Forward elevation

1%

(11/828)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 1
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