7/29/2019 Glenohumeral Internal Rotation Deficit Rehab | Sports Medicine Orthopedic Surgeon - Houston, TX

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Houston, TX Dr. David Lintner, M.D.

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Glenohumeral Internal Rotation Deficit Rehab

GIRD
Glenohumeral Internal Rotation Deficit

Dr. Lintner
Matt Holland, PT

The throwing shoulder must be mobile enough to allow the extremes of external rotation needed to throw a
ball, but it is a delicate balance between mobility and stability that is needed to perform the demands of the
overhead throwing motion without undue strain on the other structures of the shoulder joint.

Increased external rotation with a loss of internal rotation ROM is a natural adaptation in the thrower’s
shoulder. Multiple theories exist as to how the adaptations occur including changes in humeral retroversion
and repetitive microtrauma to the posterior capsule leading to thickening and contracture of the posture
capsule of the shoulder. When this loss of internal rotation exceeds 20-25 degrees from the non throwing side
excessive strain on the structures of the shoulder may result in further problems and shoulder pathology
including superior labral tears (SLAP tears), biceps tendonitis, rotator cuff tendonitis or tears, and pain with
throwing will occur. When the arm is in the cocked position the posterior capsule moves under the humeral
head and if the posterior capsule is too tight it is like a hammock that is strung too tight pushing the humeral
head upward and resulting in increased strain and shear on the labrum, rotator cuff, and biceps tendon. As the
shoulder moves from a cocked position forward during acceleration this posterior capsule tightness creates
increased shear that will damage these structures over time.

For many years we have worked diligently on stretching the posterior capsule to improve internal rotation
ROM and decrease pain and injury in the thrower’s shoulder. We have primarily focused on stretching
internal rotation with the “Sleeper’s Stretch” position. Recently in following up with these athletes we have
noticed that their internal ROM in abduction at 90 degrees improves, but many are still exhibiting tightness
of the posterior shoulder into horizontal adduction across the body. Therefore we have begun to focus not
only on internal rotation stretching with the Sleeper stretch, but also working on cross body adduction.
Having good flexibility and ROM across the body is of particular importance during the follow through
phase of throwing.

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Studies show that approximately 90 percent of all athletes with GIRD will gain ROM in internal rotation
when they are enrolled in a consistent program focusing on the posterior capsule.

Capsular stretching should be done consistently and it is important to remember that the capsule is best
stretched with a low load and prolonged duration of stretching and done on a daily basis. It is also important
for the therapist, coach, and athletic trainer to remind the athlete that the capsule is highly innervated and
overstretching of the capsule will result in a great deal of pain. Resolving IR deficits often happens very
quickly and will result in substantial reduction of pain with throwing. It is critical for the athlete to maintain
ROM and be consistent and compliant with the internal rotation stretching program throughout the season.

Below is our protocol for internal rotation stretching.

Sleeper Stretch
3 sets of 15-30 sec holds

Side Lying Cross Body Adduction

3 sets of 15-30 sec holds

Laying on affected side to block scapular motion
Use unaffected side to prevent arm from drifting into external rotation

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Make sure athlete stays rolled toward the affected side to prevent compensation

For shoulders that are more difficult to gain ROM the therapist and athletic trainer can use the following
manual therapy techniques to gain ROM. Perform manual techniques at least 3 times per week.

Manual Passive IR Stretching

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Joint Mobilization
Posterior capsule mob with the arm in external rotation (remember in external rotation the posterior capsule
is inferior to the humeral head) Direction of mobilization: inferior and posterior

Supine Cross Body adduction with the scapula blocked

Scapula can be blocked with one hand or one hand on each scap to hold the athletes body still. Athlete then
pulls arm across the body using the nonthrowing elbow on top of the throwing hand to prevent the arm from
drifting into external rotation. As an alternative, the therapist can stabilize the scapula while pushing the arm
across body. They key is to keep the forearm parallel to the shoulders. The shoulder will try to rotate

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externally as you push cross body. Check the video.

Prone internal rotation stretching with the scapula blocked.

Use one of your hands to hold the scap down and then gently using your forearm push the athletes elbow
toward the floor. CAUTION: THIS IS AN AGGRESSIVE STRETCH AND YOU WILL ONLY NEED
MINIMAL FORCE. LET OFF SLOWLY OR THE ATHLETE WILL HAVE A GREAT DEAL OF PAIN!

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Dr. David Lintner

Dr. David Lintner specializes in arthroscopic surgery of the knee and shoulder and is active in teaching
orthopedic surgeons the latest techniques. He also specializes in injuries to throwers’ shoulders and elbows,
having written more than thirty scientific articles about ACL injuries, thrower’s injuries, and other sports
medicine issues.

Dr. Lintner is proud to partner with Kirby Surgical Center and provide high quality care and personal
attention to our patients. Find more information about Kirby Surgical Center here.

Read more about Dr. David Lintner

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Dr. David Lintner
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Shoulder Rehab Protocols

Anterior Capsular Shift Rehab
Biceps Tenodesis Rehab Protocol
Accelerated Program (Overhead Athelete) Rehab
Arthroscopic or Open Bankart Procedure, Latarjet Procedure
Anterior Shoulder Dislocation/Subluxation (Conservative Rehab)
Arthroscopic Subacromial Decompression Rehab
Glenohumeral Internal Rotation Deficit Rehab
Posterior Shoulder Dislocation/Subluxation (Conservative Rehab)
Rotator Cuff Repair Rehab (Updated 10/13) includes DS2 Platform exercises
SLAP Repair Rehab (Updated 8/25/11) includes DS2 Platform exercises
Miscellaneous Protocols
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Links and Resources

American Association of Orthopedic Surgeons

DS2 Rehab Systems (The DS2 Platform)
Journal of the American Academy of Orthopaedic Surgeons
The American Journal of Sports Medicine
The American Orthopaedic Society For Sports Medicine
The National Athletic Trainers' Association
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Sports Links
Information on Throwing Injuries

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Baytown Office: (832) 556-0880 (map)

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Dr. David Lintner is an orthopedic sports medicine specialist practicing in Houston, TX, as well as team
doctor to many of the professional teams in the Houston area.

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