Is GIRD in Asymptomatic

Athletes a Risk Factor for

Shoulder Injury?
- A prospective collegiate study at Kean University

Nicholas Belasco DO
What Goes Up Must Come Down

• Tremendous force on the arm during

throwing: Late cocking through
acceleration
• Leads to Capsular Damage:
• Stretching
• Contractures
• Labral Damage:
• SLAP Lesions
• We see this in all overhead athletes:
• Tennis
• Baseball
• Volleyball
• Swimmers
Historical Perspective
• Very Controversial – “dead arm syndrome”
• Andrews et al. AJSM – 1985
• Postulates that the deceleration phase of
throwing causes the injuries
• Jobe et al. J Shoulder/Elbow Surg – 1995
• Internal impingement issue caused by/related
to capsular laxity in ant capsule
• Burkhart et al. Arthroscopy – 1998
• “peel-back” lesion: leading to capsular
contractures

• Really unknown what was causing all these

shoulders to fail
Trying to Explain Injury: The
Thrower’s Paradox
• The overhead athlete’s
shoulder must be:
• Lax enough to allow
excessive external
rotation to
accommodate power
generation
• Stable enough to
prevent injury
Shoulder ROM Adaptations
• Athletes gain ER at expense of IR

• Physiologic adaptation to maintain the 180

degree arc

• Humeral head retroversion additional

adaptation
• Asymptomatic pitchers have more
humeral retroversion
The Effect of GIRD:
• As arthroscopy becomes more
common place SLAP lesions are
discovered more easily (esp type
2)
• Numerous research papers
showing a retrospective correlation
between painful shoulders/SLAP
tears/restricted posterior capsule
etc. and existence of GIRD
The Effect of GIRD:
• Why does GIRD = SLAP?
• Thought to be due to increased
posterior/superior instability secondary
to posterior/inferior capsule contraction
• Grossman et al. JBJS 2005
• Concluded that a shift posterior/inferior
of the capsule forces the humeral head
posterior/superior which could explain
the etiology of SLAP lesions
GIRD Defined
• Internal rotation reduction accompanies external rotation
increase
• GIRD-
• According to Burkhart et al. (Burkhart et al.,
2003b),GIRD is “the loss in degrees of glenohumeral
internal rotation of the throwing shoulder compared
with the non-throwing shoulder”.

1. an internal rotation loss that exceeds the

external rotation gain in the dominant arm (“true”
GIRD)

2. a loss of internal rotation with a loss of total arc of

motion in the pitching arm

3. a loss of greater than 25° of internal rotation

 Is all GIRD Bad?
• Asymptomatic vs.
Symptomatic?
• “true” GIRD vs. “false”
GIRD?
• The answer lays with
prospective study
• Identify risk factors
and modifiers
• This is a true
prevention model
First Prospective Studies
• Donley et al. 1999-2002
• Rotational data on 430 professional
pitchers
• Compared GIRD with injury data and
on field performance data
• Found GIRD of 10-12 degrees
optimal for eliminating shoulder
injury
• Clear need to reproduce and expand on
this investigational data
Is GIRD in Asymptomatic Athletes a
Risk Factor for Shoulder Injury?

• A prospective study to evaluate a number

of factors related to GIRD in asymptomatic
collegiate athletes:
• Baseball/Volleyball/Softball
• Questions:
• Role of degree of GIRD on injury risk
• Role of Rate of Change on injury risk
• Role of “False” vs. “True” GIRD
Methods
• Athletes from Kean University (Div III)
Volleyball, Baseball and Softball teams
(~60 participants)
• Athletes answered survey during pre-
season and post-season
• Demographics
• Shoulder injury history
• Athletic participation history
• Penn shoulder scores for:
• Pain
• Function
• Satisfaction
 Methods
• Clinical measures taken
during pre-season and
repeated post-season
• Validated method chosen
after literature search
• All exams preformed by
same team physician and
ATCs
-Athlete lays with shoulder stabilized and is • Bilateral measures taken of
passively moved into internal and external
rotation both IR and ER
--Measure taken when motion at scapula felt
by examiner
--Measures are in (+) degrees away from 90
degrees (the 0 point)
Pre-season Data
• Of 13 Volleyball players:
• 5 had mild symptoms at rest
• All athletes had some degree
of GIRD (total rotation deficit)
• Not related to years
playing, age, shoulder
symptom score
Post-Season Data
• On-going study:
• Volleyball arm complete
• No injuries during season but
symptomatic changes seen in Penn
Shoulder Score
• Not statistically significant
• Development of symptoms appears
unrelated to degree of GIRD or rate of
change
• Participants had an increase in
external rotation without
corresponding change in internal
rotation that was statistically
significant
 Pre-Season Post-Season p-value*

•A total of 13 right-arm
female volleyball players
N Mean SD N Mean SD
were included in the study,
with average age of 19 years
[SD = 0.71]. Distribution of
ROM Internal - Left 9 49.44 9.95 9 49.33 4.95 0.97 race was: 69% White, 23%
Hispanic and 8% Asian.
Average experience was 7.2
ROM External - Left 9 90.78 15.56 9 93.33 14.19 0.62 years [SD = 2.03]. Two
players (15%) had history of
injury and none of the
ROM Total - Left 9 140.22 10.71 9 142.67 12.67 0.61
players (0%) had any history
of surgery.
The results in Table 1 showed
ROM Internal - Right 9 39.89 7.66 9 40.56 4.85 0.81 statistically significant difference
between pre season and post-
season in terms of ROM External
– right [average Rom External –
ROM External - Right 9 94.44 10.98 9 105.00 12.60 0.009
right was 94.44 pre-season vs.
105.00 post-season; p = 0.009]
and ROM Total – right [average
ROM Total - Right 9 134.33 6.40 9 145.56 13.45 0.011 ROM Total – right was 134.33
pre-season vs. 145.56 post-
season; p = 0.011].

Penn Score - Pain 9 29.67 0.71 9 29.89 0.33 0.45 No statistically significant
difference was observed
between pre season and post-
season in terms of any of the
Penn Score - Function 9 59.56 0.73 9 59.56 0.73 1.00 other measures listed in the table
(p >0.05).
Discussion
• Tremendous variability in degree of
pre-season ROM with large ranges
and large standard deviation
• Confirms that using GIRD as
sole marker of shoulder
dysfunction is at best
speculative

• Many athletes had clinically defined

GIRD without progression to
symptoms
• Much greater number then
previously thought
• Should all these athletes be put
on aggressive stretching
programs?
Discussion
• Subset of “true” GIRD deserves greater
focus
• Working to consensus of the definition
of GIRD should be based on clinical
consensus of pathological impact

Each new study on asymptomatic athletes

highlights these same problems
Conclusion
• Study must run to completion
• Initial results should impact treatment
• Without clear and modifiable risk
factors – primary prevention cannot be
undertaken
• Therapy programs designed to reduce
GIRD do work (to reduce GIRD) effect on
outcomes less certain