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
QUESTIONS 1 of 20 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Previous Next 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 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 (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% (11/754) 2 Posterior capsule 91% (683/754) 3 Antero-inferior capsule 5% (34/754) 4 Rotator interval 1% (9/754) 5 MGHL 2% (12/754) ML 1 Select Answer to see Preferred Response 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 56% (811/1436) 2 Posteroinferior 10% (139/1436) 3 Anteroinferior 12% (171/1436) 4 Anterosuperior 18% (263/1436) 5 Directly anterior 3% (46/1436) ML 4 Select Answer to see Preferred Response 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 71% (441/620) 2 Sleeper stretches and subscapularis stengthening 16% (100/620) 3 External rotation stretches with cuff strengthening 5% (28/620) 4 External rotation stretches and periscapular strengthening 4% (27/620) 5 Altering his arm slot and improving pitching mechanics 3% (16/620) ML 2 Select Answer to see Preferred Response 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: A B 1 Long head of the biceps tendonosis 1% (10/1995) 2 Glenohumeral internal rotation deficit (GIRD) 93% (1861/1995) 3 Subscapularis rupture 4% (71/1995) 4 Superior labral anterior posterior (SLAP) tear 2% (36/1995) 5 Bankart lesion 0% (7/1995) ML 1 Select Answer to see Preferred Response 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 86% (1752/2027) 2 Humeral avulsion of the glenohumeral ligament 6% (125/2027) 3 Subacromial impingement 3% (60/2027) 4 Bicep tendinitis 2% (37/2027) 5 Hill-Sachs lesion 2% (45/2027) ML 1 Select Answer to see Preferred Response 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% (14/1622) 2 shoulder arthroscopy and a capsular release 1% (11/1622) 3 intra-articular cortisone injection, rest and a pitching program 1% (21/1622) 4 diagnostic arthrosopy and subacromial decompression with coracoacromial ligament resection 1% (12/1622) 5 aggressive physical therapy involving posterior capsular stretching and scapular strengthening 96% (1555/1622) ML 1 Select Answer to see Preferred Response 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% (692/760) 2 External rotation 6% (48/760) 3 Abduction 1% (6/760) 4 Adduction 1% (4/760) 5 Forward elevation 1% (10/760) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 1
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