Glenohumeral Internal Rotation Deficit
Introduction
Glenohumeral internal rotation deficit (GIRD) affects many overhead throwing athletes due to the repetitive nature and extreme positioning of throwing.[1] GIRD refers to a loss of 20° or more internal rotation as compared to the contralateral shoulder.[1] A more clinically relevant assessment also includes the total rotational motion (TRM).[2] A TRM difference of 5° or greater difference between shoulders is considered a more clinically meaningful indicator of pathological GIRD.[3][4]
It is common for overhead throwing athletes to have an increased external rotation as compared to internal rotation in their throwing arm.[4] As such, the presence of decreased glenohumeral internal rotation is not always pathologic. However, the presence of GIRD does lead to increased injury rates and a potential for decreased performance, so it is important to assess when treating athletes.[1][5]
Clinically Relevant Anatomy
The glenohumeral joint is a ball and socket joint with a large range of motion. While this range of motion allows for a variety of movements, it is also dynamic and can change based on the stressors placed upon it.[6]
The glenohumeral joint is stabilised by both static and dynamic stabilisers. Static stabilisers consist of structures such as the joint capsule, labrum, and glenohumeral ligaments while dynamic stabilisers are muscles, such as the rotator cuff, deltoid, and biceps.[1][5][6]
There are three main glenohumeral ligaments - superior, middle, and inferior. The posterior inferior glenohumeral ligament and the posterior joint capsule are affected with GIRD. This can result in a superior and posterior shift of the humeral head, which can lead to a bony adaptation in young athletes in the form of increased humeral retroversion.[1]
Mechanism of Injury / Pathological Process
GIRD is common in overhead throwing athletes due to the repetitive nature of the throwing motion.[1][7] The repetitive microtrauma that is caused during the late cocking phase of throwing, where the athlete is in excessive external rotation, places high stress on the posterior joint capsule as well as the surrounding soft tissues of the glenohumeral joint.[2][5] Over time, this repetitive microtrauma can lead to tightening of the posterior capsule and rotator cuff, which in turn leads to a loss of internal rotation range of motion and an increase in external rotation range of motion.[2][4][5] Especially in young athletes, repetitive overhead throwing with posterior structure tightening can lead to humeral and glenoid retroversion.[1] [3][8] Tightening of the posterior joint capsule and bony retroversion leads to altered shoulder biomechanics and in turn, increases stress on the rotator cuff, labrum, and other surrounding structures.[3][8] This can cause athletes with GIRD to have a higher risk of secondary shoulder pathology as well as decreased performance.[4][5]
Clinical Presentation
Key complaints with GIRD are posterior shoulder pain and shoulder tightness.[5][9][10] Posterior shoulder pain is typically reported to be during the late cocking phase of throwing.[1] Pain is also present with palpation of posterior shoulder structures.[1]
Shoulder rotation range of motion should be assessed with the patient in supine with the shoulder at 90° abduction with the scapula stabilised.[2][5][8] A difference of 20° or greater in shoulder internal rotation as compared to the contralateral shoulder is considered positive for GIRD.[1][6] When assessing range of motion, it is also important to look at the total rotational motion (TRM), or the total arc of motion from maximum external rotation to maximum internal rotation.[2] [6] A decrease of more than 5° of TRM as compared to the contralateral shoulder is significant for increased injury risk.[2][8] Assessing changes in ROM and TRM as compared to the contralateral arm is the best way to assess for GIRD in the clinic. [1][2]
It is important to check bilateral range of motion as it is common for overhead throwing athletes to have increased external rotation range of motion on their throwing arm as compared to their non-throwing arm.[5] [6] Greater external rotation range of motion is not considered as problematic if the TRM is consistent on each shoulder.[5]
Diagnostic Procedures
In the clinic, GIRD is diagnosed with a combination of subjective and objective measures, including posterior shoulder pain and tightness as well as changes in bilateral internal rotation range of motion and TRM.
With imaging, plain film radiographs cannot diagnose GIRD but can detect the presence of Bennett's lesion, an osteophyte that develops on the posterior rim of the glenoid from repeated stress.[1] An MRI is the imaging modality of choice for identifying associated soft tissue pathologies and ruling out other potential impairments. [1]
Differential Diagnosis
GIRD is most commonly reported as posterior shoulder pain and tightness. It is important to rule out other pathologies to appropriately treat the patient. Other common shoulder pathologies in throwing athletes are as follows:
Outcome Measures
Management / Interventions
Non-operative management is the preferred treatment for GIRD.[1] This begins with physiotherapy focusing on stretching and strengthening with the goal of increasing internal rotation and the TRM.
Stretching
A daily stretching program of the posterior and posteroinferior aspect of the shoulder is recommended to decrease tightness and increase internal rotation range of motion. Some recommended stretches include:[1][2][9][10][7]
- Sleeper stretch
- Cross-body adduction stretch
- All-fours posterior stretch
Manual Techniques
Manual techniques, such as instrument assisted soft tissue mobilisation (IASTM), can also be utilised to improve tissue mobility by stimulating a local tissue inflammatory response.[1] Some evidence has shown that IASTM combined with stretching had improved results with tightness and range of motion than stretching alone, but more studies are needed.[1][10]
Anterior-posterior (AP) glenohumeral joint mobilisations can help to improve mobility of the posterior capsule to improve humeral head positioning as well as rotational range of motion.[9][10]
Neuromuscular Re-education
Muscle energy techniques (METs) have also been shown to improve shoulder function. For GIRD, METs utilise post-isometric relaxation to lengthen soft tissues in order to improve internal rotation range of motion.[1][6][7][14]
Proprioceptive neuromuscular facilitation (PNF) techniques such as hold-relax are also helpful to improve range of motion in those with GIRD.[1] This technique places the joint at its maximal range of motion and then an isometric contraction is applied to improve range of motion.[1]
Exercise Interventions
An appropriate strengthening program based on their acuity and their unique deficits is also important to rehabilitating an athlete. The Thrower's Ten is a program designed to bringing overhead throwing athletes back to sport.[15] It emphasises strengthening the scapular stabilisers, rotator cuff, and forearm musculature.[15] It has been shown to be effective in rehabilitation as well as an injury risk reducer and performance improver in throwing athletes.[15]
Return to Sport
Return to sport decisions should be made through a constellation of clinical signs. The athlete should have minimal to no difference in their TRM side to side along with decreased difference in their shoulder internal rotation range of motion.[2] Their rotator cuff strength should be appropriate and they should be able to demonstrate pain-free throwing prior to returning to sport.[2]
Summary
GIRD is a common problem in overhead throwing athletes due to the repetitive, high stress motion of throwing.[1] When assessing a throwing athlete with posterior shoulder pain and tightness, properly evaluating their shoulder internal and external rotation range of motion as well as their TRM will help to make the most appropriate diagnosis and plan of care.[2] It is important to remember when evaluating a throwing athlete that decreased internal rotation is not always pathological and to look at the TRM to make an evidence based decision on their care.[2] [4] GIRD is treated with a combination of daily stretching, manual therapy, neuromuscular re-education techniques, and strengthening in order to return the athlete to their sport.[1] [2][6][15]
References
- ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 1.20 1.21 Fares MY, Lawand J, Daher M, Suarez JD, Kayepkian T, Koa J, Geagea E, Abboud JA. Glenohumeral internal rotation deficit: insights into pathologic, clinical, diagnostic, and therapeutic characteristics. Clinics in Shoulder and Elbow. 2024 Apr 4;27(4):505.
- ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 Kibler WB, Sciascia A, Thomas SJ. Glenohumeral internal rotation deficit: pathogenesis and response to acute throwing. Sports medicine and arthroscopy review. 2012 Mar 1;20(1):34-8.
- ↑ 3.0 3.1 3.2 Johnson JE, Fullmer JA, Nielsen CM, Johnson JK, Moorman III CT. Glenohumeral internal rotation deficit and injuries: a systematic review and meta-analysis. Orthopaedic journal of sports medicine. 2018 May 15;6(5):2325967118773322.
- ↑ 4.0 4.1 4.2 4.3 4.4 Kirsch JM, Bakshi NK, Ayeni OR, Khan M, Bedi A. Clinical outcomes and quality of literature addressing glenohumeral internal rotation deficit: a systematic review. HSS Journal®. 2020 Oct;16(3):233-41.
- ↑ 5.0 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 Rose MB, Noonan T. Glenohumeral internal rotation deficit in throwing athletes: current perspectives. Open access journal of sports medicine. 2018 Mar 19:69-78.
- ↑ 6.0 6.1 6.2 6.3 6.4 6.5 6.6 Sehgal S, Sen S, Dhawan A. Effects of muscle energy technique in increasing range of motion and strength of glenohumeral internal rotator, in athletes with glenohumeral internal rotation deficit. Am J Sport Sci. 2016 Mar 28;4(2):43-8.
- ↑ 7.0 7.1 7.2 Mine K, Nakayama T, Milanese S, Grimmer K. Effectiveness of stretching on posterior shoulder tightness and glenohumeral internal-rotation deficit: a systematic review of randomized controlled trials. Journal of Sport Rehabilitation. 2017 Jul 1;26(4):294-305.
- ↑ 8.0 8.1 8.2 8.3 Zajac JM, Tokish JM. Glenohumeral internal rotation deficit: prime suspect or innocent bystander?. Current reviews in musculoskeletal medicine. 2020 Feb;13(1):86-95.
- ↑ 9.0 9.1 9.2 Swanson BT, Hagenbruch M, Lapaan B, Skipalskiy K. Combined Effects of Glenohumeral Mobilization, Stretching, and Thoracic Manipulation on Shoulder Internal Rotation Range of Motion. International Journal of Sports Physical Therapy. 2024 Apr 1;19(4):394.
- ↑ 10.0 10.1 10.2 10.3 Minhaj S, Afridi ZK, Rubab S, Qazi Z, Siddiqui M. Glenohumeral internal rotation deficit and risk of upper extremity injury in overhead athletes: systematic review. Archives of Physical Medicine and Rehabilitation. 2025 Jan 1;106(1):91-7.
- ↑ Baptist Health. Sleepers Stretch. Available from: https://www.youtube.com/watch?v=D0ERSobj6_I [last accessed 5/21/2026]
- ↑ Prehab. How to Properly Perform The Cross Body Stretch - Have You Been Doing It Wrong This WHOLE Time?. Available from: swvXpKN832E [last accessed 5/21/2026]
- ↑ Prehab. Posterior Shoulder Stretch. Available from: https://www.youtube.com/watch?v=Jg8dJidCqp4 [last accessed 5/21/2026]
- ↑ Pıçak GŞ, Yesılyaprak SS. Effectiveness of muscle energy techniques on glenohumeral internal rotation deficit in overhead athletes: a systematic review. Türk Fizyoterapi Ve Rehabilitasyon Dergisi. 2023;34(2):273-82.
- ↑ 15.0 15.1 15.2 15.3 Bera P, Bhura P, Bhura C, Shah SF. Effects of Advanced Throwers Ten programme to measure strength, power and endurance in overhead athletes. Int J Sports Health Phys Educ. 2025;7:94-100.