Skip to main content

Advertisement

SpringerLink
Log in

Glenohumeral Internal Rotation Deficit: Prime Suspect or Innocent Bystander?

  • Injuries in Overhead Athletes (J Dines and C Camp, Section Editors)
  • Published:
Current Reviews in Musculoskeletal Medicine Aims and scope Submit manuscript

Abstract

Purpose of Review

Glenohumeral internal rotation deficit (GIRD) is a term used in the literature to describe the physiological adaptation that occurs in the dominant arm of the overhead-throwing athlete. The meaning of this term and the clinical significance and the rationale for its treatment have all been described with some ambiguity within the literature. GIRD as a measurement is multivariate. There is an adaptive bony component in humeral retroversion (HR) and muscular contributions in the form of thixotropy which can confound the capsular component of GIRD. Emerging diagnostic tools such as ultrasound can help differentiate between the bony and soft tissue contributions as well as provide a dynamic assessment in the throwing shoulder. The purpose of this review is to describe and differentiate between anatomical GIRD (aGIRD) and pathological GIRD (pGIRD), discuss the clinical significance of pGIRD and values reported within the literature, and describe its measurement and clinical treatment.

Recent Findings

Recent literature has demonstrated that GIRD alone is not associated with injury risk of the upper extremity in the overhead athlete. Although past literature has demonstrated pGIRD as increasing injury risk, other variables such as external rotation (ER) deficit, horizontal adduction deficit, and shoulder flexion deficit have been associated with injury of the upper extremity while GIRD did not. Further, an appreciation for the difference between adaptive GIRD and pathologic GIRD has recently been emphasized to ensure optimal treatment addresses the pathologic portion of GIRD. The recent focus on early treatment approaches to pGIRD may play a role in its diminished risk association.

Summary

This review offers the term humeral retroversion (HR) Corrected GIRD as a more clinically sensitive value that may provide the clinician a more precise rationale for the treatment of pGIRD. Currently, diagnostic ultrasound is a reliable and valid method for measuring HR in the overhead-throwing athlete. Future research that validates clinical methods for assessing HR could provide utility for clinical decision-making in the absence of diagnostic ultrasound.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. King JW, Brelsford HJ, Tullos HS. Analysis of the pitching arm of the professional baseball pitcher. Clinical Orthopedic Related Research. Nov-Dec; (1969) 67:116-23. PMID: 5361189.

  2. Chandler JT, Kibler BW, Uhl TL, Wooten B, Kiser A, Stone E. Flexibility comparisons of junior elite tennis players to other athletes. Am J Sports Med. 1990;18(2):134–6.

    CAS  PubMed  Google Scholar 

  3. Brown LP, Niehues SL, Harrah A, Yavorsky P, Hirshman HP. Upper extremity range of motion and isokinetic strength of the internal and external rotators in major league pitchers. Am J Sports Med. 1988;16:577–85.

    CAS  PubMed  Google Scholar 

  4. Bigliani LU, Codd TP, Connor PM, Levine WN, Littlefield MA, Hershon SJ. Shoulder motion and laxity in the professional baseball player. Am J Sports Med. 1997;25:609–13.

    CAS  PubMed  Google Scholar 

  5. Johnson L. Patterns of shoulder flexibility among college baseball players. J Athl Train. 1992;27:44–9.

    CAS  PubMed  PubMed Central  Google Scholar 

  6. Litner D, Mayol M, Uzodinma O, Jones R, Labossiere. Glenohumeral internal rotation deficits in professional pitchers enrolled in an internal rotation stretching program. Am J Sports Med. 2007;35(4):617–21.

    Google Scholar 

  7. Ellenbecker TS, Roetert EP, Piorkowski PA, Schulz DA. Glenohumeral joint internal and external rotation range of motion in elite junior tennis players. J Orthop Sports Phys Ther. 1996;24(6):336–41.

    CAS  PubMed  Google Scholar 

  8. Ellenbecker TS, Roetert EP, Bailie DS, Davies GJ, Brown SW. Glenohumeral joint Total range of motion in elite tennis players and baseball pitchers. Med Sci Sports Exerc. 2009;34:2052–6.

    Google Scholar 

  9. Torres RR, Gomes JL. Measurement of Glenohumeral internal rotation in asymptomatic tennis players and swimmers. Am J Sports Med. 2009;37(5):1017–23.

    PubMed  Google Scholar 

  10. Shanley E, Raugh MJ, Michener LA, Ellenbecker TS, Garrison JC, Thigpen CA. Shoulder range of motion measures as risk factors for shoulder and elbow injuries in high school soft ball and baseball players. Am J Sports Med. 2011;39:1997–2006.

    PubMed  Google Scholar 

  11. Kibler WB, Kuhn JE, Wilk K, Sciascia A, Moore S, Laudner K, Ellenbecker T, Thigpen C, Uhl T The disabled throwing shoulder: spectrum of pathology—10-year update. Arthroscopy: The Journal of Arthroscopic & Related Surgery.(2013). doi: 0.1016/j.arthro.2012.10.009.

  12. Manske RC, Grant-Nierman M, Lucas B. Clinical commentary: shoulder posterior internal impingement in the overhead athlete. Int J Sports Phys Ther. 2013;8(2):194–204.

    PubMed  PubMed Central  Google Scholar 

  13. Wilk KE, Macrina LC, Fleisig GS, Porterfield R, Simpson CD, Harker P, et al. Correlation of glenohumeral internal rotation deficit and total rotational motion to shoulder injuries in professional baseball pitchers. Am J Sports Med. 2010;39:329–35.

    PubMed  Google Scholar 

  14. Wilk KE, Reinold MM, Macrina LC, Porterfield R, Devine KM, Suarez K, et al. Glenohumeral internal rotation measurements differ depending on stabilization techniques. Sports Health. 2009;1:131–6.

    PubMed  PubMed Central  Google Scholar 

  15. Manske R, Ellenbecker T. Invited clinical commentary: current concepts in shoulder examination of the overhead athlete. Int J Sports Phys Ther. 2013;8(5):554–78.

    PubMed  PubMed Central  Google Scholar 

  16. •• MH MG, Vrla M, Wang D, Camp CL, Zajac JM, Pearson D, et al. Shoulder and Elbow Range of Motion Can Be Maintained in Major League Baseball Pitchers Over the Course of the Season, Regardless of Pitching Workload. Orthop J Sports Med. 2019:7–232596711882506 Over the course of one major league baseball season ER, TROM and HA increased over the course of the season while IR deficit did not in a group of pitchers who performed in-season treatment programs. These results were independent of workload. In addition, the article provides a reliable method for assessing shoulder ROM and GIRD in an overhead athlete.

  17. •• Correll S, Field J, Hutchinson H, Mickevicius G, Fitzsimmons A, Smoot B. Reliability and validity of the halo digital goniometer for shoulder range of motion in healthy subjects. Int J Sports Phy Ther. 2018;13:707–14 This evidence suggests a HALO digital goniometer can be used as a reliable and valid tool for measuring shoulder ROM but should not be interchanged with other means of measurements when measuring one patient over a given time period.

    Google Scholar 

  18. Awan R, Smith J, Boon AJ. Measuring shoulder internal rotation range of motion: a comparison of 3 techniques. Arch Phys Med Rehabil. 2002;83:1229–34.

    PubMed  Google Scholar 

  19. Boon AJ, Smith J. Manual scapular stabilization: It’s effect on shoulder rotational range of motion. Arch Phys Med Rehabil. 2000;81:978–83.

    CAS  PubMed  Google Scholar 

  20. Reinold MM, Wilk KE, Macrina LC, et al. Changes in shoulder and elbow passive range of motion after pitching in professional baseball players. Am J Sports Med. 2008;36(3):523–7.

    PubMed  Google Scholar 

  21. Kibler WB, Sciascia AD, Moore AD. An acute throwing episode decreases shoulder internal rotation. Clin Orthop Relat Res. 2012;470:1545–51.

    PubMed  Google Scholar 

  22. •• Yamauchi T, Hasegawa S, Nakamura M, Nishishita S, Yanase K, Fujita K, et al. Effects of Two Stretching Methods on Shoulder Range of Motion and Muscle Stiffness in Baseball Players with Posterior Shoulder Tightness: a Randomized Controlled Trial. J Elbow Surg. 2016;25:1395–403 Diagnostic ultrasound provides a reliable method for assessing posterior shoulder stiffness. The article also provided evidence for the use of the modified sleeper stretch and modified cross-body stretch to improve D side shoulder IR and horizontal adduction in college baseball players over a 4-week period supporting the long term effects of a consistent stretching program.

    Google Scholar 

  23. •• Reuther KE, Sheridan S, Thomas SJ. Differentiation of bony and soft-tissue adaptations of the shoulder in professional baseball pitchers. J Shoulder Elb Surg. 2018;27:1491–6 Diagnostic ultrasound provides a reliable means for accurately measuring HR and provides a basis for a HR-corrected GIRD value (GIRD + HR difference). This value may provide a more accurate value related to non-bony changes providing improved treatment rationale.

    Google Scholar 

  24. Mullaney MJ, Mchugh MP, Johnson CP, Tyler TF. Reliability of shoulder range of motion comparing a goniometer to a digital level. Physiother Theory Pract. 2010;26:327–33.

    PubMed  Google Scholar 

  25. Wilk KE, Meister K, Andrews JR. Current concepts in the rehabilitation of the overhead throwing athlete. Am J Sports Med. 2002;30(1):136–51.

    PubMed  Google Scholar 

  26. Myers JB, Laudner KG, Pasquale MR, Bradley JB, Lephart SM. Glenohumeral range of motion deficits and posterior shoulder tightness in thrower’s with pathological internal impingement. Am J Sports Med. 2006;34:385–91.

    PubMed  Google Scholar 

  27. Verna. Shoulder flexibility to reduce impingement. Presented at professional baseball athletic trainer society meeting. AZ: Mesa; 1991.

    Google Scholar 

  28. Burkhart SS, Morgan CD, Kibler W. The disabled throwing shoulder: spectrum of pathology part I: Pathoanatomy and biomechanics. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2003;19:404–20.

    Google Scholar 

  29. Tokish JM, Curtin MS, Kim YK, Hawkins RJ, Torry MR. Glenohumeral internal rotation deficit in the asymptomatic professional pitcher and its relationship to humeral retroversion. 4 shoulder injuries in professional baseball pitchers. Am J Sports Med. 2008;39:329–35.

    Google Scholar 

  30. Wilk KE, Macrina LC, Fleisig GS, et al. Loss of internal rotation and the correlation to shoulder injuries in professional baseball pitchers. Am J Sports Med. 2011;39(2):329–35.

    PubMed  Google Scholar 

  31. Wilk KE, Macrina LC, Arrigo C. Passive range of motion characteristics in the overhead baseball pitcher and their implications for rehabilitation. Clin Orthop Relat Res. 2012;470:1586–94.

    PubMed  PubMed Central  Google Scholar 

  32. Reagan KM, Meister K, Horodyski MB, Werner DW, Carruthers C, Wilk K. Humeral retroversion and its relationship to glenohumeral rotation in the shoulder of college baseball players. Am J Sports Med. 2002;30(2):354–60.

    CAS  PubMed  Google Scholar 

  33. Myers JB, Oyama S, Goerger BM, Rucinski TJ, Blackburn JT, Creighton RA. Influence of humeral torsion on interpretation of posterior shoulder tightness measures in overhead athletes. Clin J Sport Med. 2009;19:366–71.

    PubMed  Google Scholar 

  34. Thomas SJ, Swanik CB, Kaminski TW, Higginson JS, Swanik KA, Bartolozzi AR, et al. Humeral retroversion and its association with posterior capsule thickness in collegiate baseball players. J Shoulder Elb Surg. 2012;21:910–6.

    Google Scholar 

  35. Myers JB, Laudner KG, Pasquale MR, Bradley JP, Lephart SM. Glenohumeral range of motion deficits and posterior shoulder tightness in throwers with pathologic internal impingement. Am J Sports Med. 2006;34:385–91.

    PubMed  Google Scholar 

  36. Thomas SJ, Swanik CB, Higginson JS, Kaminski TW, Swanik KA, Bartolozzi AR, et al. A bilateral comparison of posterior capsule thickness and its correlation with glenohumeral range of motion and scapular upward rotation in collegiate baseball players. J Shoulder Elb Surg. 2011;20:708–16.

    Google Scholar 

  37. Proske U, Morgan DL. Muscle damage from eccentric exercise: mechanism, mechanical signs, adaptation and clinical applications. J Physiol. 2001;537:333–45.

    CAS  PubMed  PubMed Central  Google Scholar 

  38. Shanley E, Thigpen CA, Clark J, Wyland DJ, Hawkins RJ, Noonan TJ, et al. Changes in passive range of motion and development of glenohumeral internal rotation deficit (GIRD) in the professional pitching shoulder between spring training in two consecutive years. J Shoulder Elb Surg. 2012;21:1605–12.

    Google Scholar 

  39. • Noonan TJ, Thigpen CA, Bailey LB, Wyland DJ, Kissenberth MJ, Hawkins RJ, et al. Humeral Torsion as a Risk Factor for Shoulder and Elbow Injury in Professional Baseball Pitchers. Orthopaedic Journal of Sports Medicine. 2016. https://doi.org/10.1177/2325967115s00080Diagnostic ultrasound is a reliable method for measuring HR in professional baseball players. Players who sustained shoulder injuries had 4° less HR than non-injured players and players who sustained an elbow injured displayed 5° more HR than non-injured players. Increased HR appears to be protective of shoulder injuries but a risk factor for elbow injuries.

    Google Scholar 

  40. Johansen RI, Callis M, Potts J, Shall LM. A modified internal rotation stretching technique for overhead and throwing athletes. J Orthop Sports Phys Ther. 1995;21:216–9.

    CAS  PubMed  Google Scholar 

  41. Aldridge R, Guffey JS, Whitehead MT, Head P. The effects of a daily stretching protocol on passive glenohumeral internal rotation in overhead throwing collegiate athletes. Int J Sports Phys Ther. 2012;7(4):365–71.

    PubMed  PubMed Central  Google Scholar 

  42. Wilk KE, Hooks TR, Macrina LC. The modified sleeper stretch and modified cross-body stretch to increase shoulder internal rotation range of motion in the overhead throwing athlete. J Orthop Sports Phys Ther. 2013;43:891–4.

    PubMed  Google Scholar 

  43. Reinold MM, Gill TJ, Wilk KE, Andrews JR. Current concepts in the evaluation and treatment of the shoulder in overhead throwing athletes, part 2: injury prevention and treatment. Sports Health. 2010;2:101–15.

    PubMed  PubMed Central  Google Scholar 

  44. Cools AM, Johansson FR, Borms D, Maenhout A. Prevention of shoulder injuries in overhead athletes: a science-based approach. Braz J Phys Ther. 2015;19:331–9.

    PubMed  PubMed Central  Google Scholar 

  45. •• Fairall RR, Cabell L, Boergers RJ, Battaglia F. Acute effects of self-myofascial release and stretching in overhead athletes with GIRD. J Bodyw Mov Ther. 2017;21:648–52.

    PubMed  Google Scholar 

  46. Heinecke ML, Thuesen ST, Stow RC. Graston technique on shoulder motion in overhead athletes. Journal of Undergraduate Kinesiology Research. 2014;10(1):27–39 Instrument assisted soft tissue massage specifically Graston Technique was reported as providing evidence for its use in combination with a dynamic stretching program to prevent ROM loss over a 4 week period.

    Google Scholar 

  47. •• Romano V, Romano J, Gilbert GE Sacroiliac Stretching Improves Glenohumeral Internal Rotation Deficit of the Opposite Shoulder in Baseball Players in a Randomized Control Trial. JAAOS: Global Research and Reviews. (2018). doi: https://doi.org/10.5435/jaaosglobal-d-18-00060. This study reported that a treatment of contralateral SI joint stretching program resulted in improved GIRD compared to a sleeper stretch program. Results were based on the acute effects (same day) of the given treatment programs.

    Google Scholar 

  48. Robey JH, Boyle KL. Bilateral functional thoracic outlet syndrome in a collegiate football player. N Am J Sports Phys Ther. 2009;4(4):170–18.

    PubMed  PubMed Central  Google Scholar 

  49. •• Stone MA, Jalali O, Alluri RK, Diaz PR, Omid R, Gamradt SC, et al. Nonoperative Treatment for Injuries To The In-Season Throwing Shoulder: A Current Concepts Review With Clinical Commentary. International Journal of Sports Physical Therapy. 2018;13:306–20 This article provides and example of an alternative stretching techniques for posterior capsular contracture and an example of a modified sleeper stretch. Treatments were a part of an in-season non-operative shoulder injury program.

    PubMed  PubMed Central  Google Scholar 

  50. •• Fairall RR, Cabell L, Boergers RJ, Battaglia F. Acute effects of self-myofascial release and stretching in overhead athletes with GIRD. J Bodyw Mov Ther. 2017;21:648–52 Evidence suggests the addition of self-myofascial release to a static stretching program can improve GIRD ROM in the short term given enough preparation time.

    PubMed  Google Scholar 

  51. Manske RC, Meschke M, Porter A, Smith B, Reiman M. A randomized controlled single-blinded comparison of stretching versus stretching and joint mobilization for posterior shoulder tightness measured by internal rotation motion loss. Sports Health: A Multidisciplinary Approach. 2010;2(2):94–100.

    Google Scholar 

  52. Laudner KG, Sipes RC, Wilson JT. The acute effects of sleeper stretches on shoulder range of motion. J Athl Train. 2008;43(4):359–63.

    PubMed  PubMed Central  Google Scholar 

  53. Scher S, Anderson K, Weber N, Bajorek J, Rand K, Bey MJ. Associations among hip and shoulder range of motion and shoulder injury in professional baseball players. J Athl Train. 2010;45:191–7.

    PubMed  PubMed Central  Google Scholar 

  54. Shanley E, Rauh MJ, Michener LA, Ellenbecker TS, Garrison JC, Thigpen CA. Shoulder range of motion measures as risk factors for shoulder and elbow injuries in high school softball and baseball players. Am J Sports Med. 2011;39:1997–2006.

    PubMed  Google Scholar 

  55. Shanley E, Kissenberth MJ, Thigpen CA, Bailey LB, Hawkins RJ, Michener LA, et al. Preseason shoulder range of motion screening as a predictor of injury among youth and adolescent baseball pitchers. J Shoulder Elb Surg. 2015;24:1005–13.

    Google Scholar 

  56. Shitara H, Kobayashi T, Yamamoto A, Shimoyama D, Ichinose T, Tajika T, et al. Prospective multifactorial analysis of preseason risk factors for shoulder and elbow injuries in high school baseball pitchers. Knee Surg Sports Traumatol Arthrosc. 2015;25:3303–10.

    PubMed  Google Scholar 

  57. Garrison JC, Cole MA, Conway JE, Macko MJ, Thigpen C, Shanley E. Shoulder range of motion deficits in baseball players with an ulnar collateral ligament tear. Am J Sports Med. 2012;40:2597–603.

    PubMed  Google Scholar 

  58. Wilk KE, Macrina LC, Fleisig GS, Aune KT, Porterfield RA, Harker P, et al. Deficits in Glenohumeral passive range of motion increase risk of elbow injury in professional baseball pitchers. Am J Sports Med. 2014;42(9):2075–81.

    PubMed  Google Scholar 

  59. • Wilk KE, Macrina LC, Fleisig GS, Aune KT, Porterfield RA, Harker P, et al. Deficits in Glenohumeral Passive Range of Motion Increase Risk of Shoulder Injury in Professional Baseball Pitchers: A Prospective Study. Am J Sports Med. 2015;43:2379–85 Professional baseball pitchers who demonstrated < 5° greater ER on D side compared to ND side were 2.2 times more likely to be placed on the disabled list for a shoulder injury and 4 times more likely to require shoulder surgery. This article supports evidence for measurements other than GIRD as being possible indicators for injury.

    PubMed  Google Scholar 

  60. •• Camp CL, Zajac JM, Pearson DB, Sinatro AM, Spiker AM, Werner BC, et al. Decreased Shoulder External Rotation and Flexion Are Greater Predictors of Injury Than Internal Rotation Deficits: Analysis of 132 Pitcher-Seasons in Professional Baseball. Arthroscopy. 2017;33:1629–36 Over a 6 season period for one professional Major League baseball team, a shoulder flexion deficit > 5° and an ER deficit > 5° on the pitchers’ throwing shoulders increased a players risk for an elbow injury. No measurements were correlated with shoulder injuries and GIRD (> 20°) was not associated as an increased risk for shoulder or elbow injury.

    PubMed  Google Scholar 

  61. •• Keller RA, AFD G, Neumann JA, Limpisvasti O, Tibone JE. Glenohumeral Internal Rotation Deficit and Risk of Upper Extremity Injury in Overhead Athletes: A Meta-Analysis and Systematic Review. Sports Health: A Multidisciplinary Approach. 2018;10:125–32 This 2018 meta-analysis provided a tendency for shoulder injury with overhead athletes presenting with GIRD while a TROM increase correlated to no injury and a decrease in TROM provided a tendency for injury. All results were not statistically significant.

    Google Scholar 

  62. •• Johnson JE, Fullmer JA, Nielsen CM, Johnson JK, Moorman CT. Glenohumeral internal rotation deficit and injuries: a systematic review and meta-analysis. Orthopaedic Journal of Sports Medicine. 2018:6–232596711877332 This 2018 meta-analysis provided evidence that the GIRD values of injured athletes were greater than non-injured in both adult and adolescent groups. The adolescent group value was less providing evidence for the need for age related GIRD values as criterion for injury.

  63. •• Moreno-Pérez V, López-Samanes Á, Domínguez R, Fernández-Elías VE, González-Frutos P, Fernández-Ruiz V, Pérez-López A, Fernández-Fernández J Acute effects of a single tennis match on passive shoulder rotation range of motion, isometric strength and serve speed in professional tennis players. Plos One.(2019). doi: https://doi.org/10.1371/journal.pone.0215015. This article provided evidence of an acute loss of D side IR ROM and ER strength in a group of professional tennis players immediately after a competitive tennis match. The evidence provided supports the growing need for up to date recovery methods for restoring measures to pre-match levels assisting in player readiness profile.

    PubMed  PubMed Central  Google Scholar 

  64. Reinold MM, Gill TJ. Current concepts in the evaluation and treatment of the shoulder in overhead-throwing athletes, part 1: physical characteristics and clinical examination. Sports Health: A Multidisciplinary Approach. 2009;2:39–50.

    Google Scholar 

  65. Hibberd EE, Oyama S, Myers JB. Increase in humeral retrotorsion accounts for age-related increase in glenohumeral internal rotation deficit in youth and adolescent baseball players. Am J Sports Med. 2014;42:851–8.

    PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Mayo Clinic Tempe Sports Medicine, 63 S. Rockford Drive, Tempe, AZ, 85281, USA

    John M. Zajac & John M. Tokish

Authors
  1. John M. Zajac
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. John M. Tokish
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to John M. Zajac.

Ethics declarations

Conflict of Interest

John Zajac, DPT, and John M Tokish, MD, declare no conflicts of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is part of the Topical Collection on Injuries in Overhead Athletes

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Zajac, J.M., Tokish, J.M. Glenohumeral Internal Rotation Deficit: Prime Suspect or Innocent Bystander?. Curr Rev Musculoskelet Med 13, 86–95 (2020). https://doi.org/10.1007/s12178-020-09603-5

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12178-020-09603-5

Keywords

Search

Navigation