Ok, so this isn't the Sporting Groin Part 3, instead this is a quick-ish piece on my favourite subject and area of the body, the shoulder and the debate that is going on around treating shoulder pain in those that do a lot of overhead activity or sports, my last groin article will be coming soon, I promise…
So recently in the physiotherapy world the identifying and treatment of posterior, or back of the shoulder stiffness has become more and more popular (and I include myself in this) for those patients with sub acromial compression type shoulder pain who do a lot of overhead activity, be it swimming, throwing, playing tennis, weight lifting or just generally lifting things up and down daily, and there has been some debate on how to identify and treat it, including just today a little twitter debate I had with @walkinphysio (well worth a follow) and its a topic I will now add my two penneth too!
So posterior shoulder tightness is sometimes termed G.I.R.D, which stands for a Glenoid Internal Rotational Deficit and it is thought to be caused via a phenomenon called 'Obligate Translation', where compression and irritation to the antero-superior (upper front) structures of the shoulder (i.e. the long head of biceps, supraspinatus tendon and bursa) causes a reactive stiffening to the postero-inferior (lower back) structures (ie the teres minor, infraspinatis and the capsule) in an effort to withdraw the humeral head away from the noxious irritation, think a bit like when you touch a snail or slugs head and you see it withdraw! I attempted a little drawing below to try and describe it better
Diagram of a shoulder demonstrating 'Obligate Translation'
This is thought to work for a while, helping to re center the humeral head and reduce the sub acromial compression and irritation, but then unfortunately the stiffening of the postero-inferior structures begins to cause its own problems and actually starts to cause a loss of humeral head centering that it originally reduced and so further compounds the original sub acromial compression and pain… go figure!!!
Effect of GIRD 'pushing' humeral head antero-superiorly
A GIRD can be spotted by checking one arm against another for the amount of internal rotation each has in a number of ways, if the painful side has less internal rotation then a diagnosis of posterior shoulder stiffness can possibly be made.
A common way a GIRD is checked is in what I call the 'scarecrow test' (my own term, but not my test) where you stand or sit upright (usually shoulder blades against a wall to avoid leaning forwards or backwards) elbows out to side, and then let hands 'dangle' underneath elbows, like a scarecrow! If painful side doesn't 'dangle' as much then you may have a GIRD, see the image below for an example
Scarecrow test for GIRD
Another test (and subsequent treatment) is the sleeper stretch, where you lie on your side arm out in front and push the hand down to the floor, see image below for an example, again if the painful shoulder has less movement, indicated by a reduced ability to get hand to the floor, you may have a GIRD.
Sleeper Stretch Test
Finally a simple measure of reduced internal rotation is by placing the hand up behind the back and again comparing to the other side, as shown below, but as this is a movement also relies on other shoulder and joint movements this has to be observed and interpreted carefully
Hand behind back test
Ok, so you think you have seen one shoulder having less internal rotation than the other, hopefully its the painful arm! BUT… before you start and jump on the treatment planning, some care needs to be used when interpreting these tests in isolation. There are some other factors that can masquerade as a GIRD.
First bony abnormalities such as humeral retroversion (a slight twist in the long upper bone in your arm) or even glenoid anteversion (a bony deformation of the angle of the socket of the shoulder) can mean that the shoulder has less internal rotation due to the bony alignment and shape and this cannot be addressed with any physio or any other therapy.
The other is just plain, simple asymmetry, no-one, I repeat no-one is symmetrical, nothing in nature is, so why do we (ie us physios) always use it as a measure of dysfunction? Yes we should look for gross asymmetries but fine subtle differences are, in my opinion, natural and normal!
So taking all the above into account a GIRD sign needs to 'help' inform with regards to a probable cause of shoulder pain, it isn't always the immediate problem nor is it always treatable. I think only through trial and error and clinical experience will a therapist be able to tell if a GIRD is present, if it is a consequence of the shoulder pathology and if it needs addressing and is rectifiable (a MRI and even CT scan also helps immensely but I do understand that these aren't always available).
Now again in my opinion there is no doubt that if there is a GIRD in a shoulder that you think is contributing to the pain then it has to be addressed and rectified. However we cant just assume its a capsule issue alone if we do we will probably not make much impact on it, we can't ignore the posterior cuff that overlies the capsule will also have shortening structural changes due too the loss of movement over time, so both need to be 'worked on', and both have different methods of doing this.
For the contractile more pliable and superficial cuff, then manual soft tissue release methods, MET techniques (a type of contracting/relaxing stretching) and massage can and must be to be used in and around the shoulder.
However for the deeper non contractile capsular tissue a different approach has to be used, usually in the form of glenohumeral joint mobilisations, glides and distractions (techniques that involves moving the joint surfaces into different planes and angles).
And then combine all these with a vigorous home stretching program, that will do most of the work and 'releasing'
I have a saying… rehab is like baking a cake, I'm the chef, the patient the ingredients, I provide the reciepe, the patient has to mix the ingredients together and bake the cake, and occasionally in a therapy session I'll add a cherry and some sprinkles on top ie mobs etc… Cheesy I know!
Now this is where the debate comes in as to what's the best techs and stretches to use when dealing with a GIRD, the excellent Mike Reinold on his site disputes the use of the Sleeper stretch as a treatment option, here, and I can see why, as it can place the shoulder into a risky 'impingement' position and so create more pain and irritation especially as most GIRDs have impingement like symptoms.
However I find that if the patient isn't side lying but is supine (lying on their back) then the arm is in a more frontal plane out to the side rather than in front of them it reduces the impingement risk (somewhat). The only trouble is they now can't do the stretch themselves as they cannot reach over with the other hand to apply the stretch, but this is where the therapist comes in to great affect, as this position does allow the therapist to apply joint mobilisations at the same time, so getting a double bonus effect, stretch and joint mobilisations so hitting both the contractile tissue and the capsule. The positions and angles of the arm, i.e. height of the elbow and inclination of the forearm can be changed slightly according to patient comfort and amount of stiffness as well as the amplitude of the glides can also be controlled, in all I think this is a great way to help reduce a GIRD.
McClure 2007 also highlighted that perhaps the Sleeper stretch isn't as good as another stretch called horizontal adduction (reaching across your body, see below) in reducing a GIRD and so can be further evidence against the use the sleeper stretch.
Horizontal adduction shoulder stretch
However, I do think the sleeper stretch has a place and a role in dealing with GIRDs, I think if taught correctly and the position (ie height of the elbow) is adjusted to the individual tightness and pain levels, then the sleeper stretch can be an effective method of reducing a GIRD, again Mike Reinold shows us how to do the sleeper stretch correctly and safely here
Finally and so, so importantly what should NEVER be forgotten is 'what caused the GIRD in the first place', no GIRD starts out of nowhere, there is always a trigger. This could be cuff weakness or imbalance, poor scapular positioning, over training or general overload, poor technique etc etc, but I will guarantee that if you just treat a GIRD in isolation yes the patients pain can reduce and they will go away happy, for a short while, but it wont be long before they start to get pain again due to the underlying cause not being identified and so will be back unhappy, or not be back at all, as they may go elsewhere even more unhappy.
So make sure you check for GIRDs but try and ascertain that it's not structural and is significant to be a factor and that it can be rectified. Then more importantly work on finding out why it occurred in the first place and address that with vigour.
As always thanks for ready