GIRD-Not Just For the Pros

At least once a week I have a conversation with a young up and coming baseball or softball player about GIRD (Glenohumeral Internal Rotation Deficit).  This diagnosis is not just for pitchers; honestly it is really not limited to throwers as we see it in many overhead athletes.  So what the heck is it?

GIRD is a change in total range of motion (Arc) comparing the throwing shoulder to the non dominate side.  More specifically internal rotation decreases. ROM is usually measured as an arc, approximately 180 degrees with the elbow at shoulder level.  When the elbow is pivoted back we call it external rotation and when it goes forward internal rotation.  These two measurements should equal roughly 180. (example = ER 130 +IR 50 = 180 degrees of total motion).   Many throwers will have a slightly different arc of motion from one shoulder to another,  usually the ER on the throwing shoulder is increased and the IR decreased. This shift in motion in and of itself is not pathological, as long as the total ROM of the shoulder remains the same (approx 180).  What does cause issues is when the IR is decreased and the change in external rotation cannot compensate causing an overall loss in motion from the usual 180 degrees.

Examples of Arc of motion that can equal 180 and be different from shoulder to shoulder.

The shoulder joint is surrounded by joint capsule, or a thick layer of tissue filled with a tiny amount of fluid that lubricates the joint similar to an oiled ball bearing.  One of the described causes of GIRD is capsule tightness.  The posteriorinferior (back side) of the capsule becomes tight which puts abnormal stress on the humerus bone in the shoulder during motion.  This tightness may actually be in response to forces on the opposite side of the shoulder joint (Anteriorsuperior)  becoming impinged or squeezed.  These anterior structures are the rotator cuff and biceps tendon.   Unfortunately over time the increase in posterior tightness places more stress on the anterior structures and a loss of internal rotation can occur along with pain and decreased velocity.   This can become a vicious cycle to break.

Forces in the back of the shoulder tighten and can change the central pivot point of the shoulder joint. (+ sign here) this shifts the whole joint upward and cause impingement and difficulty with throwing.

Fixing true GIRD can involve many steps.

1. Resting the affected joint from the overhead sport for a short period of time.
2. Anti-inflammatory medication whether it be by mouth or injection.
3. Physical therapy by an upper extremity specialist working on capsule stretching and shoulder stabilization.
4. Occasionally, we perform MRI scans to rule out other pathology that could be causing pain or lack of range of motion.
5. Lastly, a slow interval return to play for the overhead sport.

Rarely does GIRD require surgery but if needed a capsule release can place small slits in the capsule to relieve the tightness in the area.  This is only reserved as a last resort and is seen more in postoperative loss of motion.
With persistence GIRD can be eliminated and athletes can return to their given sport to compete.  However it is important that they continue the stretching routine to prevent a recurrence over the course of their careers.

We see GIRD in a variety of overhead athletes including volleyball

Sources:
Orthobullets
Mike Reinold Blog

ACL Rehab Why Does It Take So Long to Heal?

We perform close to 100 ACL reconstructions a year here at the Grossteam. Our patient population can vary from weekend warriors to high level collegiate athletes and everyone in between. However, no matter what level of sport or career a patient is trying to get back to I find myself answering similar questions everyday. When can I get back to activities? When will I be healed? Will it ever be the same? So here is my summary of ACL reconstruction and why the heck it takes so darn long to recover.


First lets review the structure of the ACL. (I do have a previous BLOG that goes into great detail about ACL tears/surgery if you need more review) The ACL attaches to the femur and tibia and is often torn with a twisting or hyperextension force to the knee. Reconstructing the ACL consists of removing the old ACL and forming a new ligament from either patient or cadaver tissue. This new ligament is then inserted into tunnels drilled in the bone in the previous ACL footprint and anchored with hardware. In our case metal buttons.



Now is when the rehabilitation begins. Any tissue placed to make a new graft has been essentially cut off from its previous blood supply and will require a new blood supply to heal. This healing process will first begin at the bone graft interface and inside the bone tunnels. The graft tunnel healing occurs at 3 months post op. Then will continue to travel down the graft toward the center of the graft in the knee over the entire first year. (Did you hear me say that?) There is no healing of the graft at all until 3 months post op? Yes! That is why we consider patients at the highest risk of graft failure from 6-16 weeks post op. During this time their graft is at its weakest and their postoperative pain has worn off. This is the time period when I usually see kids jump off diving boards, attempt gym class, and pickup basketball games all against orders. It is also when we see the most re-tears of ACL grafts, which should now come as no surprise.

I know by now I may have you a bit freaked out by the whole notion of rehabilitating an ACL. Do not worry there is a lot of science on our side. We have a very organized and strict rehab program that we have developed to make sure our patients are as ready as possible to return to sport/work. First, we have a list of the best physical therapists in town; many we have worked closely with for years. Ask us for a recommendation before you rehab! Next, we use a testing based program to make sure you are ready to advance to the next step of the protocol. For instance not all patients are at the same step at the same time, it would be foolish to think they would all achieve goals at the same rate. We perform a test called a Biodex around 4 months post op to check the strength of the hamstrings and quadriceps in their operative verse nonoperative leg. If their strength is similar they may begin jogging and light plyometric activity, if not they continue strengthening and try again in a few weeks.



Once a patient passes a Biodex test and is performing jogging and plyometrics without difficulty they may wish to pursue more advance activities. In this population we recommend more in depth testing with an advance movement screen called a Dorsavi. This test is a computer and sensor based test that can capture weakness and muscle imbalance during movement resembling athletic activity. The sensors are similar to those in cell phones in that they can tell where your body is in space. These are attached to the core and the legs and a process of repetitive planking, squatting, and jumping is performed. The sensors can tell if the patient is off balance, if the knee is out of alignment, and give the therapist information as to what muscle groups need strength. Then the patient is given a strength program tailored to their specific needs. Our patients usually take a Dorsavi test if needed between 8-10 months post op. Once they pass this test they return to their given sport.



ACL rehabilitation can seem daunting, however with our new advanced testing and surgical techniques we are able to return patients to the workplace and the field more safely. Our patients can be confident that their knee has been tested and they have achieved the necessary strength for return to play with less complication. After all its hard enough to play a sport at a high level, you shouldn't have to worry about your knee too!