Glenohumeral Internal Rotation Deficit and Injuries: A Systematic Review and Meta-analysis

Jordan E Johnson, Joshua A Fullmer, Chaseton M Nielsen, Joshua K Johnson, Claude T Moorman 3rd, Jordan E Johnson, Joshua A Fullmer, Chaseton M Nielsen, Joshua K Johnson, Claude T Moorman 3rd

Abstract

Background: There is an association between throwing activity and glenohumeral internal rotation deficit (GIRD). An 18° to 20° deficit has been adopted as the standard definition of pathological GIRD, but specific findings as to how GIRD relates to an injury are inconsistent.

Purpose: To systematically review the literature to clarify the definition of GIRD diagnosis for adolescent and adult overhead athletes and to examine the association between GIRD and an increased risk of injuries in these athletes.

Study design: Systematic review; Level of evidence, 4.

Methods: A systematic review of the literature was performed. Observational studies comparing glenohumeral internal rotation range of motion (ROM) in injured and uninjured overhead athletes were included for the meta-analysis. Studies of adolescent and adult athletes were analyzed separately. ROM was compared for the injured and uninjured groups, and a weighted mean GIRD was estimated. To account for potential heterogeneity across studies, both fixed- and random-effects models were used to calculate a standardized mean difference (SMD).

Results: Nine studies of level 3 or 4 evidence were included. From these, 12 study groups (4 adolescent, 8 adult) comprising 819 overhead athletes (226 injured, 593 uninjured) were included in the meta-analysis. The estimated SMD in GIRD between the injured and uninjured groups was 0.46 (95% CI, 0.15-0.77; P < .01) for the overall sample. The between-group effect was larger for adults (SMD, 0.60 [95% CI, 0.18 to 1.02]; P < .01) than adolescents (SMD, 0.20 [95% CI, -0.24 to 0.63]; P = .13). The weighted mean GIRD for the injured and uninjured groups was 13.8° ± 5.6° and 9.6° ± 3.0°, respectively, which also differed by age group. Moderate study heterogeneity was observed (I2 = 69.0%).

Conclusion: Based on this systematic review, the current definition of pathological GIRD may be too conservative, and a distinct definition may be required for adolescent and adult athletes. While the results indicate a link between internal rotation deficits and upper extremity injuries in the overhead athlete, higher quality prospective research is needed to clarify the role that GIRD plays in future injuries to overhead athletes of various ages.

Keywords: GIRD; injury; overhead athlete; range of motion; shoulder.

Conflict of interest statement

One or more of the authors has declared the following potential conflict of interest or source of funding: This study was funded by the Jerry M. Wallace School of Osteopathic Medicine at Campbell University, the University of Utah, and the James R. Urbaniak, MD, Sports Sciences Institute at Duke University. J.E.J. has received compensation from ScholarRx in association with a publication unrelated to the current article. C.T.M. is a consultant for Smith & Nephew and has received hospitality payments from Smith & Nephew.

Figures

Figure 1.
Figure 1.
Right hand–dominant overhead athlete with glenohumeral internal rotation deficit.
Figure 2.
Figure 2.
PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flowchart of study selection.
Figure 3.
Figure 3.
Funnel plot (with pseudo–95% CIs) of the 12 groups contained in the 9 included studies.
Figure 4.
Figure 4.
Forest plot (sorted by age group, ascending for standardized mean difference [SMD]) comparing injured versus uninjured shoulders for the presence of glenohumeral internal rotation deficit (GIRD).

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