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 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
QUESTIONS 1 of 23 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Previous Next (OBQ18.137) A 20-year-old male college-level thrower complains of chronic right shoulder pain and has been prescribed formal physical therapy with stretches consisting of laying in the lateral position on the affected side with your arm forward flexed 90°, elbow flexed 90°, and pushing the ipsilateral forearm towards the table. What is the correct diagnosis and the associated physical examination finding? QID: 213033 Type & Select Correct Answer 1 Adhesive capsulitis; > 25° decrease in affected shoulder internal rotation compared to contralateral shoulder 2% (36/1979) 2 Glenohumeral internal rotation deficit (GIRD); > 25° decrease in affected shoulder internal rotation compared to contralateral shoulder 84% (1672/1979) 3 Posterior labral tear; < 15° decrease in affected shoulder internal rotation compared to contralateral shoulder 3% (61/1979) 4 Adhesive capsulitis; < 15° decrease in affected shoulder internal rotation compared to contralateral shoulder 1% (20/1979) 5 GIRD; < 15° decrease in affected shoulder internal rotation compared to contralateral shoulder 8% (164/1979) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (OBQ18.103) A 19-year-old right hand dominant collegiate pitcher presents for worsening right shoulder pain and decreased velocity. On physical exam, he has decreased internal rotation but increased external rotation on his right compared to left side. He has pain and tenderness over his coracoid. An MRI arthrogram is performed and is normal. Which of the following is the next best step in management? QID: 212999 Type & Select Correct Answer 1 Weighted ball throwing program 3% (46/1819) 2 Subacromial steroid injection 1% (26/1819) 3 Arthroscopic biceps tenodesis and subacromial decompression 2% (30/1819) 4 Arthoscopic capsular release 3% (53/1819) 5 Pectoralis minor stretching and sleeper stretches 91% (1653/1819) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? QID: 3505 Type & Select Correct Answer 1 Internal impingement 87% (2547/2936) 2 Humeral avulsion of the glenohumeral ligament 6% (166/2936) 3 Subacromial impingement 3% (98/2936) 4 Bicep tendinitis 2% (50/2936) 5 Hill-Sachs lesion 2% (58/2936) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? QID: 2871 Type & Select Correct Answer 1 Posterosuperior 55% (1287/2350) 2 Posteroinferior 10% (243/2350) 3 Anteroinferior 12% (273/2350) 4 Anterosuperior 20% (466/2350) 5 Directly anterior 3% (70/2350) L 4 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic This is an AAOS Self Assessment Exam (SAE) question. Orthobullets was not involved in the editorial process and does not have the ability to alter the question. If you prefer to hide SAE questions, simply turn them off in your Learning Goals. (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? QID: 6678 Type & Select Correct Answer 1 Anterior shoulder instability 10% (61/607) 2 Early adhesive capsulitis 2% (12/607) 3 Internal impingement 77% (468/607) 4 Subacromial impingement 9% (55/607) 5 Full-thickness rotator cuff tear 2% (10/607) L 2 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ08.230) Which of the following shoulder motions is characteristically decreased in the throwing arm of athletes when compared to the nondominant side? QID: 616 Type & Select Correct Answer 1 Internal rotation 92% (1474/1610) 2 External rotation 5% (83/1610) 3 Abduction 1% (12/1610) 4 Adduction 1% (13/1610) 5 Forward elevation 2% (25/1610) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (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? QID: 1386 Type & Select Correct Answer 1 Sleeper stretches, cross-body stretches, periscapular strengthening 74% (1019/1384) 2 Sleeper stretches and subscapularis stengthening 15% (201/1384) 3 External rotation stretches with cuff strengthening 5% (75/1384) 4 External rotation stretches and periscapular strengthening 4% (50/1384) 5 Altering his arm slot and improving pitching mechanics 2% (22/1384) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (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? QID: 1111 FIGURES: A B Type & Select Correct Answer 1 Long head of the biceps tendonosis 0% (12/2557) 2 Glenohumeral internal rotation deficit (GIRD) 93% (2368/2557) 3 Subscapularis rupture 4% (106/2557) 4 Superior labral anterior posterior (SLAP) tear 2% (52/2557) 5 Bankart lesion 0% (9/2557) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (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 QID: 1868 Type & Select Correct Answer 1 shoulder arthroscopy and SLAP repair 1% (27/2310) 2 shoulder arthroscopy and a capsular release 1% (19/2310) 3 intra-articular cortisone injection, rest and a pitching program 2% (39/2310) 4 diagnostic arthrosopy and subacromial decompression with coracoacromial ligament resection 1% (26/2310) 5 aggressive physical therapy involving posterior capsular stretching and scapular strengthening 95% (2191/2310) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (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? QID: 2168 Type & Select Correct Answer 1 Anterior capsule 2% (26/1437) 2 Posterior capsule 91% (1305/1437) 3 Antero-inferior capsule 4% (55/1437) 4 Rotator interval 1% (20/1437) 5 MGHL 2% (26/1437) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic
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