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Measuring and Preventing Glenohumeral Internal Rotation Deficit (GIRD) in Pitchers

Several studies show that the dominant arm in baseball throwers have increased external rotation and decreased internal rotation compared with their non-dominant arm.  (4,5)  This loss of internal rotation on the throwing arm compared to non-throwing arm is defined as GIRD, or glenohumeral internal rotation deficit.

For measurements of glenohumeral internal rotation, the athlete is placed in the supine position with the humerus abducted to 90 degrees.  A towel roll was placed under the distal aspect of the humerus maintaining the humerus parallel to floor.  The elbow is flexed to 90 degrees and the humerus is internally rotated until the coracoid begins to move.  The measurements are made using a goniometer with a bubble level indicator.  Please consult with a qualified medical professional in order to obtain results from this objective test (Figure 1).

There is a big debate in the sports medicine field regarding GIRD and it being caused by capsular, muscular, and osseous (bony adaptation) or a combination of all three adaptations.  Due to these stresses placed on the shoulder during the throwing motion, previous studies have revealed that adaptive changes occur within the humerus know as humeral retroversion.  This allows for greater shoulder external rotation and less internal rotation as compared to the non-throwing shoulder. (8)

We, as athletic trainers/physical therapists, can affect motion if caused by either capsular or muscular tightness.  Some believe that a posterior inferior capsular contracture.gunnertechnetwork.comelops due to repetitive distraction causing micro-trauma in tension during the follow-through phase of throwing.  This occurs due to Wolf’s law, the SAID principle, as glenohumeral distraction force is equal to or greater than the pitcher’s body weight. (6)  Others believe that due to the high eccentric activity of the posterior cuff during the follow-through phase of throwing, this may cause a rise in muscular tension and an associated loss of internal rotation range of motion.  (7)  Competitive overhead throwing athletes perform at the extremes of glenohumeral motion and place tremendous repetitive stresses on the shoulder.

Regardless of what causes this deficit, this contracture produces altered glenohumeral kinematics that may lead to injury.  There is also debate on how the humeral head is altered due to GIRD.  One theory, due to the posterior shoulder tightness, the humeral head translates anteriorly during end range cocking phase applying stress to the posterior rotator cuff.  This may also place increased stress on the anterior capsule causing symptomatic anterior instability.  In contrast, others believe the posterior capsular contracture with decreased internal rotation does not allow the humeral head to rotate externally into its normal postero-inferior position in the late cocking phase of throwing.  The decreased internal rotation caused by this posterior capsular contracture causes a posterior superior obligate migration of the humeral head in maximum external rotation.  The posterior superior shift causes the SLAP lesion via the peel back mechanism.  This may predispose the thrower to an internal impingement type injury.  Continued internal impingement leads to deepening of the tear and extension of delamination.  Further microtrauma, or continued throwing, may produce a full thickness rotator cuff tear.  (1)

What we, the San Francisco Giants Medical Staff are doing are measuring all athletes at the beginning of spring training as well as the end of the season.  If athletes have a GIRD of 20 degrees or more (Figure 2), we mandate them receiving hands-on stretching at the beginning and the end of each day.  If an athlete has a GIRD of 18-20 degrees, we have them perform the sleeper stretch regularly and then re-measure in 3 weeks time.  If their GIRD is less than 18 degrees (Figure 3), they are no longer required to stretch regularly, just perform the self sleeper stretch.  Over the past 2 years, our organization has decreased our shoulder surgeries by 76% by implementing a more regimented, required stretching program.

We have noticed that new draftees signing with the Giants organization, from either college or high school, have increased GIRD measurements.  A regimented stretching program for baseball players with greater than 18 degrees of GIRD to be stretched prior to throwing as well as after throwing at the collegiate and high school level may prove to decrease career ending injuries to the shoulder.  It is our goal to not allow an athlete to throw until his GIRD measurement is less than 18 degrees.

A recent study published in the American Journal of Sports Medicine, notes that GIRD maybe associated with elbow valgus instability as well.  That being said, an internal rotation stretching program at the high school and collegiate levels may also assist in preventing the epidemic of ulnar collateral ligament injuries.  Their has been a big push by sports medicine specialists limiting pitch counts, not allowing curve balls to be thrown at the little league level, etc.  I would like to see a shoulder internal rotation stretching program at every high school and college training room in order to allow our young athletes to stay healthy and dream big.  O

 

 

More Information Please!

Please email Ben Potenziano with any questions at bpotenziano@sfgiants.com.

 

References

  1. Lintner, David, Mayol, Magdiel, Uzodinma, Obinna, Jones, Rex, and Labossiere, David.  Glenohumeral Internal Rotation Deficits in Profressional Pitchers Enrolled in an Internal Rotation Stretching ProgramThe American Journal of Sports Medicine.  2007; volume 35, No. 4: 617-621.
  2. Dines, Joshua S., Frank, Joshua B., Akerman, Meredith, and Yocum, Lewis A.  Glenohumeral Internal Rotation Deficits in Baseball Players with Ulnar Collateral Ligament Insufficiency.  The American Journal of Sports Medicine.  2009; Volume 37, No. 3: 566-570.
  3. Reinold, MM, Wilk, KE, Macrina, LC, et al.  Changes in Shoulder and Elbow Passive Range of Motion After Pitching in Profressional Baseball PlayersThe American Journal of Sports Medicine.  2008; Volume 36: 523-527.
  4. Crocket, HC, Gross, LB, Wilk, KE, et al.  Osseous Adaptation and Range of Motion at the Glenohumeral Joint in Profressional Baseball Pitchers.  The American Journal of Sports Medicine.  2002; Volume 30: 20-26
  5. Reagan, KM, Meister, K, Horodyski, MB, Werner, DW, Carruthers, C, Wilk, K.  Humeral Retroversion and its Relationship to Glenohumeral Rotation in the Shoulder of College Baseball PlayersThe American Journal of Sports Medicine.  2002; Volume 30: 354-360.
  6. Morgan, Craig.  Presentation at ASMI Injuries in Baseball course 2003.
  7. Reinold, MM, Wilk, KE, Macrina, LC, Sheheane, C, Shouchen, D, Flesig, GS, Crenshaw, K and Andrews, JR.  Changes in Shoulder and Elbow Passive Rom of Motion After Pitching in Profressional Baseball PlayersThe American Journal of Sports Medicine.  2008.  Volume: 36; 523-527.
  8. Crockett, HC, Gross, LB, Wilk, KE, Schwartz, ML, Reed, J, O’Mara, J, Reilly, MT, Dugas, JR, Meister, K, Lyman, S, and Andrews, JR.  Osseous Adaptation and Range of Motion at the Glenohumeral Joint in Profressional Baseball PitchersThe American Journal of Sports Medicine.  2002.  Volume: 30; 20-26.

 

What to do with GIRD information?

 

The previous overview provides coaches, players and athletic trainers with more information on how they can assist their players. The coaches should assist their players with an intervention plan of sleeper stretches as well hands on stretching if an Athletic Trainer is available.

The San Francisco Giants stretch all their players that are red flagged. These players are stretched by the Athletic Trainer or Physical Therapist on staff. Those players that have been noted as being tight are taught how to perform the sleeper stretches on their own. We advise them to stretch prior to stretching and after their session. The sleep stretch in our opinion is a valuable component of our overall shoulder program. We have seen a decrease in shoulder injuries since implementing the program throughout the system. The Giants medical staff believes this is an important part of a throwing program for a high school athlete to a professional baseball player.

There are several stretches that we perform and the Internal Rotation Sleeper Stretch will be the first that is shown. The athlete performs this stretch while he/she are lying on their dominant throwing side. Let’s assume this player is right handed. They would lay on their right side with their arm at 90 degree with their body over their shoulder. They would push their wrist downward. Be sure to hold the stretch for a minimum of 20 seconds and a minimum of 5 times/day.  The athlete should feel the stretch in the posterior shoulder. I have included the photos so you can see exactly how these stretches are performed.

The other stretches that have been added are the Pectorals Minor and Major stretch. We also include an elbow stretch which you will see in the final two pictures.  They are Elbow Extension stretch which can be done with a bat and a dumbbell. The dumbbell stretch should be done with a towel under the elbow. The dumbbell should not weigh more than 5-10 lbs.

The San Francisco Giants Medical Staff has been applying these stretching methods throughout our system and have seen significant gains.

We recommend an Athletic Trainer or Physical Therapist perform these stretches.

 

 

If you were told you have tight internal rotation of your shoulder, perform the following stretches and follow-up with us for new measurements in 2 weeks to track your progress.  If you have any questions regarding proper form, please ask a trainer to assist.

 

Internal Rotation Sleeper Stretch   In side lying position with arm up in range of 75 -110 degrees with elbow bent to 90 degrees with body leaning over shoulder, push wrist down with opposite hand.   Hold stretch for 20 seconds and perform minimum of 5 times/day.  (Especially important to perform before and after each throwing session)

 

 

 

 

Pectoralis Minor stretch   Place half foam roll on table, line up foam roll with spine and lay on top allowing your shoulders to wrap around roll.  Lay there for 5-10 minutes every day.

 

Pectoralis Major Stretch   Stand in doorway and place front of shoulder and inside of bent arm on surface of wall.  Position bent elbow around the same height of shoulder, lean into wall allowing shoulder to be pushed back.  Hold stretch for 20 seconds and perform minimum of 3 times/day

If you were told you have limited elbow extension, perform the following stretches and follow-up with us for new measurements in 2 weeks to track your progress.  If you have any questions regarding proper form, please ask a trainer to assist.

 

Elbow Extension Stretch   In sitting position with towel roll just above elbow joint, grasp end of bat and push into elbow extension with other hand holding opposite end of bat.  A variation of this stretch would be to hold a 5-10 lbs weight and allow to extend elbow.  Hold stretch for 20 seconds and perform minimum of 3 times/day.

 

Ben Potenziano, M.Ed, ATC, CES Strength and Conditioning Coach

 Ben Potenziano has been with the San Francisco Giants for 6 seasons. This is his fifth as the team’s strength and conditioning coach. Currently in his second stint with the Giants organization, he had spent five seasons overall in the club’s minor league system. He has previously served as head athletic trainer in the San Francisco system at short-season, single-A, double-A and the club’s affiliate in the Arizona Rookie League. He is a member of the Professional Baseball Athletic Trainers Society and National Strength and Conditioning Association and the National Athletic Trainers Association. Ben is a graduate of the University of Maine at Farmington with a bachelor’s degree in Community Health Education and a Masters of Physical Education with a concentration in Exercise Science from the University of Maine at Orono.

 

Article provided by Performance Conditioning Baseball/Softball www.performancecondition.com/baseballsoftball the Official Publication of the Professional Baseball Strength and Conditioning Coaches Society

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The Range of Motion and Length/Tension Relationship: A New Way to Look at Flexibility and Dysfunction in Baseball and Softball Athletes

Nate Shaw, ATC, CSCS, Major League Strength and Conditioning Coordinator, Arizona Diamondbacks

Nate Shaw joined the Diamondbacks in 2005, after a three-year stint in the Tampa Bay Devil Rays organization, the last two as their minor league strength and conditioning coordinator. He spent his first season in the Rays’ chain as their New York Penn League athletic trainer and strength coach. While with the Devil Rays, Shaw was responsible for implementing data-based research to further.gunnertechnetwork.comelop programs and procedures in accordance with injury prevention and performance enhancement.

Nate started his work in professional sports by spending two years (2001-2002) with the Toronto Blue Jays during their spring training sessions in Dunedin, FL. He also co-founded the GHFC Sports Performance Program, implementing all key facets of the operation including marketing, sales and program design.

Shaw, 33, graduated from the University of Florida in 2001 with a Bachelors Degree in Exercise and Sport Sciences.

One of the major concerns of strength and conditioning coaches at the MLB level is to make sure everything is working properly. It is important to have flexibility in the right areas before one starts creating unnecessary tightening of the muscles with poor exercise choices. Baseball places a tremendous amount of force on the bones, muscles and tendons in the body. It is important that all of the length/tension relationships are as close to equilibrium as possible before making muscle groups that are “baseball unnecessary” even larger and tighter.

The term flexibility is vastly misunderstood in sports. In the past the term flexibility was a catchall term to identify the way a person could move based on a specific sport.    Flexibility conjures up all different types of concepts and ideas. For example, it is generally accepted that if one can touch his toes, he is flexible; however, what does this really mean? The athlete’s hamstrings might be flexible if he can touch his toes, when in fact the athlete might have a tight hamstrings and a tremendously flexible lumbar region.  For baseball and softball, a program’s focus is on the length/tension relationship and how the agonist and antagonist interact, which is much more important than how “flexible” or “inflexible” a player is.  Muscles cross joints and have a specific action they perform. When a muscle contracts it shortens and brings its bone attachments closer to each other. If the agonist or antagonist is short or “inflexible”, their motion can be inadequate and the length and tension inappropriate. For our population equilibrium of the length and tension relationships is the most important aspect of flexibility.  Length tension discussion focuses on an individual’s normal range of motion. Having the appropriate available motion allows the proper distance for force generated and then dissipated.

When the athlete calls on the system to generate force the amount of distance is imperative.  More motion= more distance for acceleration.   The same is true for deceleration.  Having enough “braking” distance allows the musculoskeletal system to properly absorb the force.  As long as the length and tension of opposing muscle groups is close to equilibrium, the appropriate motion will be available to properly and safely decelerate over the proper distance.

 

Key Length/Tension Relationships

In baseball and softball the shoulder is the most critical joint and one that players can do a lot to damage it, or do a lot to strengthen and make the area injury resilient.

The humerus (upper arm bone) can be put out to the side at a 90-degree angle to the body and twisted up and down, which is called internal and external rotation. When compared bilaterally the degrees of motion should be equal.  If on one side an athlete can’t go into much internal or external rotation as the other side, which means the length and tension of the muscles surrounding that joint are off. What has been found with most throwers is that the total range of motion available (internal rotation plus external rotation) equals about one hundred and eighty degrees. On the dominant side, a thrower may only be able to internally rotate down to about 45 degrees whereas on the non-throwing side, the internal rotation is 90 degrees and all the way back to the table.

In an ideal situation, we find the length/tension relationship in the order of 180 degrees. The dominant arm’s motion is the same, but it is skewed towards external rotation.  This is considered a sports-specific adaptation and may make players good at what they do.

In a study at the University of Florida, Dr. Keith Meister revealed this adaptation is a result of the cumulative effects of throwing over many years. So as long as the length/tension relationship is good, meaning there’s 180 degrees of total motion.

A length tension relationship problem occurs when there is asymmetry in the sum total of rotation.  180 degrees is ideal. If one side is 220 degrees and the other 180 degrees, then there may be a problem in the length/tension relationship and there may be a greater chance for injury.

Historically players with a profound lack of internal rotation were treated and stretched to increase Internal Rotation.  This was a general rule based on a uniform standard.  Unfortunately when looking in retrospect it is possible that those athletes may not have needed to be stretched, a decrease in IROT with a subsequent increase in EROT may have been a normal adaptation to throwing.  If the non dominant side would have been measured, clinicians may have found bilateral symmetry thus negating the stretch component of the program.

The 180-degree rule presented is not etched in concrete. There are variations from individual to individual but what we are looking for is symmetry on both the right and left. It’s all a matter of balance.  For coaches application of the length/tension relationship is a relatively new undertaking—research is only now coming out on it. Consequently, application of this concept is a process of education. The intent of this article is to make coaches aware of the concept, and to consider and.gunnertechnetwork.comeloping more of an understanding.

Course of Action Based on Right Arm/Left Arm Internal/External Range of Motion

It is relatively easy to make a course of action when comparing bilateral range of motion.  Motion will either be the same, or motion will be less.   An athlete’s injury history is probably the best indicator of risk injury.  The ideal set of shoulders will be injury free and have symmetry. Symmetry could be defined as within 20 degrees.  If one side is 185 and the other 191 degrees, that is not a cause for concern. But if one side is 180 and the other 220, there may be cause for concern.  If a player’s throwing arm is looser and the young athlete has a history of injury, then it must be addressed immediately. On the other hand, if his measurements are asymmetrical and there is no injury history then it may be OK; however, this needs to be looked at from an injury prevention standpoint. Typically the athlete has less motion on the throwing side. After the athlete throws, the external rotators get fatigued and tighten, therefore causing a loss of internal rotation. Therefore, the question becomes, does this individual need to do soft tissue work, strengthening work, Stretching, or maybe some PNF, etc.? The answer is simple; probably all of the above.  We need to train the neurological system and the muscular system to act together so they have a “normal range of motion.”

Length/Tension Relationships in the Hips

Our population does not escape with only one major hot spot for injury.  In spring training I screen all of our athletes for length tension discrepancies.  Shoulders are crucial, but hips are close second.  Our screening process over the last 5 years has revealed tight hip flexors and IT bands on a regular basis.  This is probably because of the rotational component in baseball. The Hip joint mirrors the shoulder—weak muscles are weak because tight muscles are tight. So, if one wants to increase the range of motion, or maybe correct an injury caused by this lack of range of motion, a few changes are required.

If it is determined that the hip flexors need lengthening my recommend is to stretch the rectus femoris or quads (agonist) and strengthen the hip flexors or glutes (antagonists). We would approach this from two ways—stretch and strengthen. If there is a weak muscle, we wouldn’t just strengthen, we would strengthen and stretch. This way function can be restored to the system.  There is some debate about which is more important, but no one can dispute that they are both important and should both be addressed.

If an athlete has tight hamstrings, chances are the quads are weak. In that case, the quads and hip flexors would get strengthened while the hamstrings are lengthened. Also, the athlete would work on abdominal control. Many length/tension relationship problems start at the core muscles. There many contributing factors, and this is why an extensive evaluation is crucial.   A good place to start to gain hip functionality is the 4-way hip complex (see side bar for how-to do.)

Dysfunction Beyond Length/Tension Relationships

The body can respond to dysfunction in many ways and dysfunction can be manifested in many different ways in the sports of baseball and softball. It could be bad nutrition, excessive travel, overload by playing/training everyday, not enough sleep, etc. By the middle of the season everybody is tired although most become immune to it. The people that can regenerate, recover and perform without proper recovery are the ones that make it to the major leagues.

If a team played in all playoffs series to five and seven games, the total number of games played during the season would be 181. Therefore, as the season progresses the muscles get a little tighter and more fatigued. If one has tight hamstrings they will get tighter the more the athlete plays. Even in the minor leagues it’s the same thing only the number of games is less. What’s involved is a lot of time and volume.

In college they practice almost everyday with games midweek and on the weekends. If they play three or four days out of seven, that provides two days off and that’s a lot of time off compared to the major leagues where players are guaranteed one day off for every 21 worked. Volume and load are huge. In Major League Baseball, this is the biggest problem. Cumulative volumes and loads are unchanging. There is no recovery. At lower levels of play, there is more opportunity for recovery, which means the cumulative demands are lower and the strengthening volume and load can be higher. The high volume creates more dysfunction.

When an athlete has a chance to recover, the body is able to deal with the dysfunction by just saying, “OK I’m not going to beat myself down today. I’m going to rest and try to catch back up and get rid of some of the cumulative overload.” It’s like having a recovery bank account; rest is like making deposits or at least not withdrawing any money.  Working out and playing games is like shopping; you are spending your recovery.  It is important to realize that there is no overdraft protection for your body.  Injury is usually the result.

At the high school level, recovery is similar to college. But on the select team level and year round play, it’s a different situation. Young,.gunnertechnetwork.comeloping athletes just don’t get any rest because they are playing all the time. Years ago athletes would play a multitude of sports and blossom in the minor or major leagues. In years past there weren’t as many Tommy John surgeries or blown rotator cuffs. Pitch count and not being allowed to throw a curve ball are good things for young athletes and steps in the right direction. Nevertheless, there is still just too much volume at the various age levels.

Program Considerations

In writing exercise prescriptions and training plans one must be sure to understand volume and recovery. This year we had a rainout so we played a double header and then five games in a row, that’s six games in five days. The question became what can I do to help these athletes in a weight room? What they needed was recovery, but they didn’t get that because they had another game to play. So as a result why should I load the athletes up with heavy squats when I know they won’t have a chance to recover from the baseball games; never mind the demand of weightlifting?

That is why in college and high school one can do more strength training and the conditioning professional can invoke these length/tension relationships more effectively. In the Major Leagues you may have an entire workout.gunnertechnetwork.comoted to range of motion. In some cases this is all you have time for.  In MLB time is not a variable that can be manipulated.  Consequently we often do “recovery workouts” where the athletes come in and do some PNF stretching on the tight muscles, typically the rectus femoris, IT band, glutes and piriformis. It is important for the athlete to feel good. As far as resistance exercises are concerned we might work on the quads to get the hamstrings to loosen up and also do some manual stretching. The length/tension relationship plays a key role in the.gunnertechnetwork.comelopment of baseball and softball athletes. I hope I’ve effectively introduced you to this concept.

 

Article provided by Performance Conditioning Baseball/Softball www.performancecondition.com/baseballsoftball the Official Publication of the Professional Baseball Strength and Conditioning Coaches Society