Wednesday, May 25, 2011

GIRD- Glenohumeral internal rotation deficit


Definition of GIRD:
GIRD is a 20° or greater loss of internal rotation of the dominant shoulder compared with the non-dominant shoulder.

Introduction:
Glenohumeral internal rotation deficit, often diagnosed in players of overhead sports, has been associated with the development of secondary shoulder lesions. Conditions such as labral and rotator cuff injuries have been linked with decreases in glenohumeral internal-rotation and increases in external-rotation motion. This group also shows a loss of horizontal or cross-body adduction in the throwing shoulder when compared with the non-throwing shoulder. GIRD is also strongly associated with scapular dyskinesis.

Tennis players, swimmers & athletes in throwing sports are commonly affected by GIRD. Deficit in dominant shoulder of tennis players is about twice the deficit found in swimmers. Data suggest that GIRD and scapular position change worsens as the level of competition increases in overhead sports. Pathologic conditions in the shoulder of a throwing athlete frequently represent a breakdown of multiple elements of the shoulder restraint system, both static and dynamic, and also a breakdown in the kinetic chain.

GIRD a structural adaptation for good or bad
Altered shoulder mobility reported in overhead athletes and is thought to develop secondary to adaptive structural changes resulting from the extreme physiological demands of overhead activity. Debate continues as to whether these altered mobility patterns arise from soft-tissue or osseous adaptations within and around the shoulder.

People who support the onset through osseous adaptations argue humeral retroversion are thought to develop over time in young pre-adolescent throwers when the proximal humeral epiphysis is not yet completely fused. Retroversion is thought to account for changes in the rotational ROM in overhead athletes. This may lead to superimposition of soft tissue adaptations i.e. capsulo-ligamentous adaptations such as anterior-inferior stretching (accountable for increased ER) or posterior-inferior contracture (accountable for increased IR) upon the osseous changes. This may ultimately lead to pathological manifestations such as secondary impingement, type II superior labrum from anterior to posterior (SLAP) lesions and/or internal (glenoid) impingement.

Internal impingement & GIRD
GIRD and posterior shoulder tightness (capsule, rotator cuff) have been linked to internal impingement. Increased posterior shoulder tightness and glenohumeral internal rotation deficit that exceeds the accompanying external rotation gain, are suggested contributors to throwing-related shoulder injuries such as pathologic internal impingement. On the contrary Mayers et al found throwing athletes with internal impingement demonstrated significantly greater glenohumeral internal rotation deficit and posterior shoulder tightness in the absence of significant differences in external rotation gain.

However it is very clear now that repetitive forces in overhead sports cause adaptive soft tissue and bone changes that initially improve performance but ultimately may lead to shoulder pathologies.

The cardinal lesions of internal impingement, articular-sided rotator cuff tears and posterosuperior labral lesions, have been shown to occur in association with a number of other findings, most importantly GIRD and SICK scapula syndrome, but also with posterior humeral head lesions, posterior glenoid bony injury and, rarely, with Bankart and inferior glenohumeral ligament lesions.

GIRD is difficult to treat by physiotherapy
Physical therapy and rehabilitation should be, with only a few exceptions, the primary treatment for throwing athletes before operative treatment is considered. According to Myers JB shoulder internal impingement management should include stretching to restore flexibility to the posterior shoulder. However Tyler TF et al reported resolution of symptoms after physical therapy treatment for internal impingement is due to correction of posterior shoulder tightness but not correction of GIRD. But Braun S et al reported throwing athletes who have a glenohumeral internal rotation deficit have a good response, in most cases, to stretching of the posteroinferior aspect of the capsule.

Wilk KE reported compared with pitchers without GIRD, pitchers with GIRD appear to be at a higher risk for injury and shoulder surgery.

References:
1. Wilk KE et al; Am J Sports Med. 2011 Feb;39(2):329-35. Epub 2010 Dec 4.
2. Torres RR et al; Am J Sports Med. 2009 May;37(5):1017-23. Epub 2009 Mar 4.
3. Thomas SJ et al; J Athl Train. 2010 Jan-Feb;45(1):44-50.
4. Tyler TF et al; Am J Sports Med. 2010 Jan;38(1):114-9. Epub 2009 Dec 4.
5. Myers JB et al; Am J Sports Med. 2006 Mar;34(3):385-91. Epub 2005 Nov 22.
6. Braun S et al; J Bone Joint Surg Am. 2009 Apr;91(4):966-78.
7. Kirchhoff C et al; Int Orthop. 2010 Oct;34(7):1049-58. Epub 2010 May 19.
8. Borsa PA et al; Sports Med. 2008;38(1):17-36.



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