Considerations in Elbow Rehabilitation and Athletic Performance Enhancement Training: Glenohumeral Internal Rotation Deficit (G.I.R.D.), It Effects More Than Just the Shoulder

Today’s guest-post is an excellent article from Rob Panariello, a regular guest contributor to my blog. Enjoy!

“Considerations in Elbow Rehabilitation and Athletic Performance Enhancement Training: Glenohumeral Internal Rotation Deficit (G.I.R.D.), It Effects More Than Just the Shoulder”

Robert A. Panariello MS, PT, ATC, CSCS
Professional Orthopedic and Sports Physical Therapy
Professional Athletic Performance Center
New York, New York

Scientific investigations performed over the past few decades have recognized that the overhead throwing motion (i.e. pitching), as well as other high angular velocity overhead activities generates tremendous demands upon the glenohumeral (GH) joint of the shoulder. What should also be taken into consideration are the associated stresses that occur at the elbow joint, and more specifically at the medial aspect of this joint during the performance of these high velocity activities. The act of pitching, and particularly the internal rotation of the shoulder that occurs during the high velocity pitching motion is the fastest human movement recorded with speeds exceeding 7250 degrees per second. It has been well documented that participation in the sport of baseball may result in an upper extremity injury resulting in the consequential loss of significant playing time with the pitcher being the most commonly injured player.

Inquiries of the source(s) of various “overhead” throwing type shoulder injuries have lead to multiple scientific investigations from numerous clinicians and professionals. The findings of many of these professionals have established a discrepancy in the measured shoulder internal rotation (IR) range of motion (ROM) of the dominant (throwing) shoulder when compared to that of the non-dominant (non-throwing) shoulder. This phenomenon has been referred to in the literature as GIRD (Glenohumeral Internal Rotation Deficit) and has been substantiated as one probable cause of various dominant upper extremity pathologies.

The work of my good friend Kevin Wilk and his associates has recognized the “Total Rotational Motion” (TRM) concept of the shoulder. This TRM concept proposes that the passive range of motion (PROM) of the shoulder is measured for both IR and external rotation (ER) at 90 degrees of shoulder abduction (with the scapula stabilized). These two ROM measurements are then added together to determine the shoulder TRM. These measurements are performed for both dominant and non-dominate shoulders and compared for any ROM discrepancies.

In review of Wilk’s research as well as our years of telephone and dinner conversations discussing various topics including the issue of GIRD, Kevin proposes, as substantiated by his research, when comparing the dominant (throwing shoulder) to the non-dominate (non-throwing) shoulder, the IR ROM deficit should not be greater than 15 degrees and the TRM should not exceed more than 5 degrees of the total (IR + ER) shoulder motion. Dominate throwing shoulder IR and/or TRM deficits of greater than 15 degrees or 5 degrees respectively; demonstrate significantly higher shoulder injury rates resulting in a loss of playing time.

The Effect of GIRD upon the Throwing Elbow

Participation in the activity of pitching or other overhead throwing type motions (i.e. javelin, etc.) subjects the elbow joint, much like the GH joint of the shoulder, to tremendous stress forces. Approximately 26% of all injuries to major league baseball pitchers involve the elbow joint. During the overhead pitching motion the elbow extends at speeds greater than 2300 degrees per second, and has both a medial shear force of 300 N and a compressive force of 900N respectively. In addition, a (elbow) valgus stress force of 64 Nm is produced during the acceleration phase of throwing, a force that exceeds the tensile strength of the Ulnar Collateral Ligament (UCL). To “counteract” these high stresses, the elbow joint is reliant on both bony (the ulno-humeral articulation) and soft tissue restraints (UCL) in an effort to preserve appropriate joint stability. The repetitive high valgus stresses that occur during throwing type activities may cause ulnohumeral chrondral and ligamentous overload (UCLO) resulting in such consequences as UCL pathology/insufficiency, osteophytosis, chondral damage (chrondromalacia), disabling elbow pain, and the incapacity to effectively throw at pre-injury performance levels.

It has also been substantiated that during the throwing motion, active shoulder IR establishes a physiologic (varus) counter to the valgus load/torque generated during the late cocking and acceleration phases providing a principal protective influence against valgus loads at the elbow during throwing (pitching) type activities.

The Rehabilitation and Performance Enhancement Training of the UCL Post-operative or Injured Athlete

The rehabilitation of the post-operative or injured UCL of the elbow patient will eventually progress the athlete to the initiation of a staged throwing program during the concluding phases of the elbow rehabilitation process. This throwing program may or may not be supervised by the rehabilitation professional. Often times limitations in health care benefits may influence the athlete to seek other professionals such as their athletic performance training professional and/or pitching coach to guide and/or supervise them through the “throwing program” portion phase of their elbow rehabilitation.

Mike Reinold and his associates have investigated and described that following a pitching performance a pitcher exhibits decreases in dominate shoulder IR of 9.5 degrees as well as decreases in TRM of 10.7 degrees. These documented shoulder IR and TRM variations remain for approximately a 24 hour period of time. The athlete’s throwing efforts during the initiation of a rehabilitation throwing program may not produce the shoulder and elbow joint forces seen during maximal pitching efforts from a mound during game day competition, but perhaps those athletes that initiate and progress with their rehabilitation (repetitive) throwing program would both mimic and reinforce these shoulder IR ROM deficits found upon the conclusion of a pitching performance. Therefore, establishing and/or maintaining acceptable throwing shoulder IR and TRM are paramount in reducing stress not only to the athlete’s shoulder but to the elbow as well.

The Rehabilitation and Strength and Conditioning Professional should be aware and place caution upon those athletes that present with GIRD. GIRD does not only provide increased risk of pathology at the throwing shoulder, but may significantly affect the anatomical structures of the elbow joint as well.

References

1. Altchek, DA, Attending Orthopedic Surgeon, Co-Chief Sports Medicine and Shoulder Service, Hospital for Special Surgery, New York, NY. Medical Director New York Mets, personal conversation

2. Dines JS, Frank JB, Akerman M, and Yocum LA. Glenohumeral Internal Rotation Deficits in Baseball Players with Ulnar Collateral Ligament Insufficiency. Am J Sports Med. 2009; 37(3): 566-570.

3. McFarland EG, and Wasik M. Epidemiology of Collegiate Baseball Injuries, Clin J Sports Med. 1998; 8(1): 10-13.

4. Osbahr DC, Dines JS, Breazeale NM, Deng X, and Altchek DA. Ulnohumeral Chondral and Ligamentous Overload. Am J sports Med. 2010; 38(12): 2535-2541.

5. Reinold MM, Wilk KE, Macrina LC, Sheheane C, Dun S, Fleisig GS, Crenshaw K, and Andrews JR. Changes in Shoulder and Elbow Passive Range of Motion After Pitching in Professional Baseball Players. Am J Sports Med. 2008; 36(3): 523-527.

6. Wilk KE, Macrina LC, Fleisig GS, Porterfield R, Simpson II CD, Harker P, Paparesta N, and Andrews JR. Correlation of Glenohumeral Internal Rotation Deficit and Total Rotational Motion to Shoulder Injuries in Professional Baseball Pitchers. Am J Sports Med. 2011; 39(2): 329-335.

7. Wilk, KE. Associate Clinical Director, Champion Sports Medicine, Director of Rehabilitative Research ASMI, Birmingham, Alabama personal conversation

8 thoughts on “Considerations in Elbow Rehabilitation and Athletic Performance Enhancement Training: Glenohumeral Internal Rotation Deficit (G.I.R.D.), It Effects More Than Just the Shoulder

  1. Steve Hammond

    Rob, thanks for your thoughts, and nice article. As a professional pitcher, I agree that ‘GIRD’ is an interesting and important subject to analyze. I have found that it is a difficult thing to quantify though for two reasons. One is that its very tricky to accurately and consistently measure IR and ER properly. For example, how much do you ‘pack’ down the scapula to stabilize before you test? Also, its easy for the subject to slightly arch his back to enable more range of motion… Second, the test assumes that the thrower has a ‘normal’ range of motion in his non-throwing arm. Many people will have limitations in that arm, which will affect the test. I, for example, always sleep on my non-throwing side and it has led to poor ER in that arm. I don’t necessarily worry about my non-throwing arm, because I have enough to deal with in regards to maintaining mobility and strength in my throwing arm.

    Another thing I would like to note is that I have found that performing IR stretches in my throwing arm after pitching has tended to improve my recovery. I agree that there is a significant loss in ROM after an intense throwing or pitching session. To counteract that, I either have a trainer perform IR stretches post-throwing, or do them myself, usually using a strong band attached to a pole.

    Reply
    1. Rob Panariello

      Steve,

      We are a physical therapy company in the NY metro area presently with 13 facilities and a 20,000 square foot state of the art athletic performance training center. Our Performance Center is really our “5th Avenue” facility as we have a physical therapy facility inside it and a baseball academy (not owned by us) right next door. Our good relationship with this baseball academy allows us access to utilize their indoor pitching mounds and batting cages for the baseball athletes we both rehab and train. This is especially beneficial during the NY winter months. We rehab a significant number of high school (we provide athletic trainers to 18 local high schools), college, and Pro baseball pitchers who have had Tommy John surgery and whom also upon the completion of their rehab, train with us. We also have a number of Tommy John athletes whom have completed their rehab via an expiration of their health care benefits or were DC’d from their elbow rehab at other facilities and come to our performance center to either (a) initiate/continue their throwing program and/or (b) have us train them for their up coming season. A number of these post-op Tommy John athletes present with GIRD, and if they do present with GIRD we hold off with their throwing program until this is resolved for the reasons mentioned in this post. This is my reason for my posting of this article, for those in similar situations i.e. rehab professionals, S&C coaches, etc… to be aware of these circumstances if presented to them.

      As far as your questions, I am of the opinion that the testing for IR and TRM is fairly easy and reliable. The athlete is placed in supine so that the table surface along with body weight (compressive loading) assists to stabilize the scapula. The scapula is further stabilized as the testing is performed with the hand placed on the shoulder so that the thumb is on the coracoid process and the fingers are placed over the body of the scapula as described by Kevin Wilk. Thus movement by either the scapula or any body segment i.e. arching of the back will be felt by the stabilizing hand.

      To answer your second question it is well documented that pitchers, especially if the initiation of pitching started at a young age, will gain increases in shoulder external rotation i.e. the development of humeral retroversion with corresponding changes occurring at the glenoid, and a loss of shoulder IR. Although IR of dominant vs. non-dominate throwing shoulder ROM differences exist and have been substantiated in the literature, it is also important to recognize the TRM concept as the TRM will be very similar when comparing both upper extremities with either ER or IR shoulder ROM differences. Wilk’s research reviewing Pro baseball pitching injuries those whom were outside the 5 deg TRM acceptable difference range exhibited a 2.5-times greater risk of sustaining a shoulder injury.

      Thanks for your post.

      Reply
  2. Greg Lehman

    Thanks for this Bret and Robert.

    Apologies in advance for the poop sandwich that follows. This post is a good review of GIRD and how it is influenced in throwers. It then has a good intro into the mechanics at the elbow joint during throwing. BUT (and here is the poop) where is the link between GIRD and elbow dysfunction? There is a one paragraph that kind of touches on it:

    “it has also been substantiated that during the throwing motion, active shoulder IR establishes a physiologic (varus) counter to the valgus load/torque generated during the late cocking and acceleration phases providing a principal protective influence against valgus loads at the elbow during throwing (pitching) type activities”

    …but this paragraph only tells us that the braking motion during shoulder internal rotation is important to influence the valgus loads at the elbow. It doesn’t saying anything about how a deficit in Internal Rotation at the shoulder would influence Valgus loads. Even if you are lacking 15 degrees of IR you are still internal rotating at the shoulder and I assume still have a protective effect at the shoulder. Is more better. Is there any biomechanical or epidemiological research linking deficits in shoulder IR with increased load at the elbow.

    The title of this post was such a tease :). Good post regardless I was just hoping for more in terms of injury biomechanics or some sort of mechanical rationale.

    Maybe in a future post?

    Respectfully,

    Greg Lehman

    Reply
    1. Rob Panariello

      Greg,

      We know that specific deficits in specific joint ROM may produce pathologies at that specific joint. For instance one of the main factors, if not the MAIN factor, for successful knee rehabilitation is for the patient to achieve full knee extension. Without it we are looking for trouble. During the gait cycle we require full knee extension at heel strike and lacking the ability to achieve full knee extension can lead to significant problems at the knee during the rehabilitation process.
      We know that shoulder IR is a physiologic counter to valgus stress at the elbow, therefore we need a certain amount of shoulder IR to establish this “counter force”. If we lack the required shoulder IR (as well as the TRM), much like the knee example above we certainly can set ourselves up for shoulder pathology. In my opinion, based on the literature the IR acceptable difference is 15 degrees. A greater shoulder IR deficit has been documented to result in shoulder pathology.

      I will also state that I attend 3 “Grand Rounds” at 3 different medical institutions per week, including 1 institution that provides the team physicians for most of the NY Pro sports teams. I also see patients and observe O.R surgery numerous times a month with various physicians including these pro team physicians. Our company is also the team physical therapists for the NHL NY Islanders and I speak with our team (sport) physicians as well. For what it is worth, none of these Sports Medicine physicians would ever allow any Tommy John athlete to throw with an associated GIRD at the shoulder, especially during the concluding phases of rehab when a “throwing program” is initiated. This also includes my friend Dr. David Altchek whom is a world renowned shoulder and elbow surgeon. That also speaks volumes to me.

      If you are interested in documented research on this topic my suggestion would be to begin with the Kevin Wilk and Josh Dines articles that I have included in my references.

      Sorry to have only “teased” you, that certainly was not my intention. Thank you for your post

      Reply
  3. Rob Panariello

    Greg,

    Greg,
    I just realized that the last sentence of the 1st paragraph should have stated “….result in shoulder and elbow pathology”. I apologize for initially omitting the word “elbow”. Thank you once again for your comments.

    Rob

    Reply
  4. Carl

    Rob and Greg,

    I don’t want to second guess the researchers but GIRD is often talked about but I am seeing the same problems with pitchers getting injured despite knowing about range of motion loss.

    Reply
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