Deficits in the shoulder’s ability to rotate both internally and externally occur in patients with shoulder pain all of the time. Today we will be talking about internal rotation deficits. This is clinically referred to as “GIRD” (Glenohumeral Internal Rotational Deficit).
The following photos illustrate how GIRD presents. Note that with the patient’s attempt to bring the hand down to the floor, either the hand stops well before the normal range (pic #1), or the shoulder picks up off the floor to compensate for the movement of the hand (pic#2).
Photo #1: Hand stops well before normal range
Photo #2: Shoulder picks up off the floor to compensate for movement of the hand.
This phenomenon is seen frequently in overhead throwing athletes such as baseball pitchers and volleyball servers (which is a different topic of discussion).
Why does this happen to normal folks like us?
One plausible theory has to do with how the head of the humerus (the ball) fits into the glenoid fossa (the socket) of the shoulder joint. The unfortunate truth is that with most of us, the ball portion of the shoulder rests a bit too forward in the socket.
This may occur because of what we spend most of our time doing, namely sitting at a desk and reaching forward to operate a mouse pad or a keyboard. This forward reaching movement can draw the head of the humerus forward, and over time the body accommodates to this position to make us more efficient.
The muscles, ligaments, and capsule of the shoulder can become stiff posteriorly because the shoulder never rests back into the socket. We will also often see a more lax anterior portion of the shoulder because the humerus bone is resting in a forward position and stretching against the anterior structures.
Stay with me here.
In order for the shoulder to rotate inward, it needs to be able to glide back into the socket. If the head of the humerus is always sitting forward, the backwards glide is stiff.
How do we deal with this?
We need to slowly “un-stiffen” the back portion of the shoulder and encourage normal mechanical motion of the humerus. There are many manual things that can be done to encourage the posterior glide of the humerus such as massage to the posterior muscles of the shoulder and capsular stretching. A physical therapist can show you how these are done in a single visit. There are also exercises that you can start doing to encourage the correct gliding.
The following exercise is a good starting point in addressing GIRD. Pay particular attention to the towel placements in the video. They are incredibly important because they serve to block the head of the humerus from lurching forward.
It is also a good idea to strengthen other muscles that support the shoulder and the shoulder blade if they are weak. Once again, a quick assessment done by a professional can point you in the right direction.
If you have struggled with shoulder pain and notice that your shoulder will not rotate internally as in the photos, it is entirely possible that this deficit in rotation may be contributing to your problem.
Read More About Shoulder Issues
• What Does a Shoulder Labral Tear Feel Like?
• How Do I Stabilize an Unstable Shoulder?
• When Can I Start Working Out After Shoulder Surgery?
• How Do I Deal With A Shoulder Dislocation?
• Is Sleeping On My Side Bad For My Shoulder?
• Managing Expectations When Recovering from a Labral Repair
Image credits: Top photo © WavebreakmediaMicro/Fotolia
My daughter is 10 days out from labral tear surgery, she is 13 and since it doesn’t hurt anymore, and the sling is ugly, she wants to NOT wear it. I keep telling her, the labrum needs to heal more, but she is tired of being “babbied”…any advice or “scare” tactics to get this child of mine to understand what immobilization for 2 weeks means? Don’t really want to “scare” her, but at this age, she thinks she knows so much more than her mom, and we are not scheduled to meet with the doctor for 8 more days.
I think that scaring her or threatening her is a great idea lol. You do not want a repeat of that surgery. There must be articles or blogs out there that highlight the dismay of people who pushed their shoulders too soon and re-tore. Have her read one of those.
Hello doc I hope you can point me in the right direction
I am close to 14 months post surgery. Basically had a 360 tear of labrum that required 7 anchors (4 anterior 3 post), full thickness tear of supraspanatis and several bone spurs removed. I completed 55 sessions of PT and since then have been going 4-5 days a week to the gym religiously. Still do many stretching and strengthening of the shoulder, really target the 4 rc muscles with bands and 5lb weights. I am not doing any heavy lifting at all, for instance if I can’t do 10 reps I don’t lift the weight.
Just recently as in this week, I have been able to do incline bench press (bar only) with some discomfort. That exercise would be excruciating pain before this week, even trying to do only 5lb Dumbbells. My ROM is pretty good except for internal rotation. Trying to do what you do that in the video above….my rotation is stuck basically at the starting point, maybe a couple degrees. Externally rotating is pretty good considering. I still have some pain in my bicep, elbow, and side and back of shoulder.
Also my daughter plays softball so I am ONLY able to throw around maybe 20 throws from like 40-50 feet before my shoulder kills me and I have to ice. Doesn’t bother me throwing underhand.
So my questions would be
-why does incline presses give me discomforts?
-what can I do to help with internal rotation?
-should I be worried that my shoulder is still troublesome 14 months later?
-should I try and see a sports chiropractor
-when should I see a doc and discuss my issues
Thanks for your time
Incline press is likely causing some light impingement. The rotator cuff brushes up against the acromion shelf that lies above it. Indicative of weakness in some of the scapular support (usually). In terms of the internal rotation, it probably wouldn’t hurt to do that exercise through the range of motion that is available to you.
It also wouldn’t hurt to get a fresh set of eyes on the shoulder, a sports chiro might be helpful.
Given the amount of work that you had done on your shoulder, 14 months doesn’t sound that surprising to me.
Doc, I have had my dominant arm shoulder restricted for nearly two years. Its kind of a mystery as to what exactly happened but my theory is that I had a seizure in my sleep while on my stomach and my arms seized out overhead violently. There was never a definite of what happened or what is exactly wrong. X-rays were negative and an MRI did not seem very helpful either. My should cannot perform throwing motions and i am able to have someone else move my shoulder at different angles but if someone were to stretch it straight overhead, my shoulder will dip forward immediately and I would be unable to hold it in place once the person lets go of it. If I do shoulder raises, pushups, chest flyes, etc… I notice my right shoulder does not sit at the same level as my good shoulder.
Im only 34 and have a small child so I really want to get back to full motion and normal throwing motions so I can play baseball, basketball or football with my kid. I have done a lot of stretching on my own and it has gotten better but reaching top shelfs is even a task for me. Physical therapy helped some but just when it got close to normal, they did something that made it a lot worse about a year ago and it never got back to where it was. I appreciate any feedback I can get
A few of the things that you are describing sound to me like you might have torn one of your rotator cuff tendons? I would see a doc and ask him or her to test the “supraspinatus” tendon to see if it is functioning.
Dear Dr Baumstark
I’m having increasing pain in my left shoulder to such an extreme that I can’t even find a comfortable resting position for my arm when I sleep at night… The main movements that indicate pain (sharp, knife-like pain) are as follows: if I hold my arm straight in front of me and try to rotate my palm upwards; if I try to bend my arm behind me (i.e. scratching my back from below); and raised directly overhead (i.e. if I were to catch a ball).
I feel the pain in the back of the shoulder mainly, but also to the side / middle of the shoulder muscle.
I have tried to swim regularly and although it seems to help, when I stop for a few days the pain seems to be even worse. As such, I’m afraid that the swimming is actually damaging it further…
Any suggestions or likely causes?
Thanks, in advance. I sincerely appreciate whatever advice you may be able to offer.
I would guess that you at least have a rotator cuff impingement, or possibly a labral tear. Pain with turning your palm upwards when your arm is out in front of you is a provocation test for a labral tear. I think that a trip to the orthopedist is in order.
Hi Dan, I slipped on ice while jogging last March (2016) and suffered a posterior dislocation that resulted in a lesser tuberosity / subscapularis tendon avulsion fracture and posterior labral tear (2-4 oclock). I had arthroscopic surgery 8 days later, and then a revision ORIF surgery 5 days later due to a missed bone fragment. Despite tremendous physical therapy efforts I regained no external rotation and had arthroscopic capsular release done at the 8-month mark.
I am now 4-months post cap release, and STILL have virtually no external rotation at the side. I do however, have some rotation in 90degrees of abduction, but it is painful. I feel something very painful catching with grinding noises when I try to push my abducted arm backwards, and cannot do the bench press motion or breast stroke swimming without feeling pain. I was labeled with ‘frozen shoulder’ for the past year but have excellent ROM in all other directions which defies the typical scenario. Have you ever seen isolated loss of ER and do you have any suggestions? Having gone past the year-mark this week, I am getting very frustrated. I am 41 and very active.
I am sorry to hear about that Sheri, that injury sounds nasty to say the least. I can’t help but think that there is some type of boney block going on in there that is keeping the shoulder from externally rotating. A classic sign of a frozen shoulder is restricted / stiff external rotation, but there should also be restriction in other directions (but to a lesser degree). If there is no other restriction, I think that something else is being overlooked.
I would get a fresh set of eyes on the problem. Find another shoulder ortho and show him or her all of your diagnostic work and notes.
Mr. Baumstark,
Over the course of 6 months, I dislocated my shoulder (anterior) 3 times. After the first two dislocations, I had full ROM within 2 months. However, the third dislocation seemed to be the most traumatic, as my ability to externally rotate my shoulder has been severely limited ever since.
I finally had the stabilization surgery (hooks inserted to reattach the torn labrum back to the bone). After weeks of recovery, I still cannot externally rotate my shoulder fully.
What specifically do you think has caused my inability to externally rotate? Am I just impatient, as it will eventually heal (perhaps with PT)? Or do I need another surgery?
Thank you for reading. A response would be greatly appreciated.
– Nate
This will likely take several months (at least) to partially come around. External rotation of the shoulder is coupled with the anterior motion of the head of the humerus, so it would be expected for that range to be tighter. The surgeon probably made the anterior portion of the capsule a bit tighter on purpose to prevent against further dislocations. Having a small permanent loss of external range of motion might actually be a good idea. The doc should be able to tell you if that is what he or she did.
I was diagnosed with subcoracoid bursitis and underwent a surgery with three anchors being placed in my left shoulder. if i consider my hands down to be at zero degree, hands facing up to be 90 degree then my motion is restricted from 90 degree to 270 degrees. What should i do? Please help me with some solution as i am not being able to play football with a constant threat that if i fall on my left shoulder, it would be worse.
I’m 60. Played baseball & softball for 45 ys. Have lifted weights & done cardio for past 35 to varying degrees. Recently I have experienced pain in the frontof my shoulder (thinking possibly long head of bicep tendonitis)? Did rest for 2 wk. then PT ( excercises from Ortho) for 8wk. stretch – went back to light lifting & pain persisted. Rested again for 2 wks. – did 10 wks. of PT, pain never ‘totally’ went away…dulled down but was ‘there’. Back at gym regularly because I’ll blow up (weight-wise) if I don’t, plus I’m 60, an ex-jock & stubborn. Disrupting my sleep and I just can’t do shoulders work much other than light bands, light weights. Can rotate arm full circle ‘forward’ – very painful with a ‘click’ point going backwards. HELP? My Dr. just says live with it – you’re 60! Not a good answer for me.
Well, getting some sort of diagnostic test would shed some light on exactly what the pathology is. In terms of your weight routine, I have one word for you……modification. I would avoid overhead exercises at least for the short term. There is plenty that you should be able to do that is safe, external and internal rotation, rows, the reverse fly machine, etc.. I would get a comprehensive list from your PT.
The unfortunate truth is that the space under the acromion portion of the shoulder blade narrows as we age, causing more friction on the rotator cuff with overhead motions.
Enjoy your site. Hoping to pose a question for a response.
I had a one-time seizure years ago that resulted in a torn labrum and also the muscles detached from my rhomboid and trap area. I had a surgery to re-attach the muscles and generally view that as successful.
When I had the seizure, I had a compression fracture of the humeral head. Docs gave different opinions about whether I needed a bone graft, a cap, or if it was a small enough dent to not need it. One doc said he could tell when he did the surgery. He didn’t cap it or bone graft it and shortly after I was out of the sling I felt like a “tear” again. My labrum doesn’t sublex as much as before but it would if I did certain movements.
My question–With all of this, I have two “crunches” that go on all the time. When my shoulder rotates backward, same spot, there is a very deep/solid crunch. The other is in my bicep or tricep area and that happens when moving my shoulder. It clearly doesn’t glide well and something is crunching.
I’ve met with two shoulder docs and neither is recommending surgery because I am generally pain free. It’s just this very annoying daily and consistent crunching that is very audible and noticeable even to those around me.
One doc suggested muscle “laxity” and the other said it “could” be scar tissue but he isn’t sure.
I’ve been a PT obedient patient and done all exercised recommended. I hate to live with this the rest of my life (I’m in early 40s).
Any approach I’m not thinking of in terms of what to exercise? Or what to ask a doc?
I can’t believe they can’t tell me what structures are rubbing together to cause this crunching.
Thanks.
That is a very difficult question to answer via the internet. There are so very many structures that could possibly be implicated in this type of situation. If you want a definitive answer, I would find a very experienced PT and have him / her feel around the shoulder while shoulder movements are being performed that reproduce the crunching sounds. Finding the involved structures should point you in the right direction in regard to what exercises might be best. On the positive side, if these noises do not cause pain, this is a good thing!
doctor suffered a previous traumatic dislocation in the pullover barbell I was encouraged by a friend to increase the load and when I went down the pull over the shoulder line he moved forward that fact occurred to 2 months I recovered almost all the movements but I am with limitation in the external rotation feel pain and shoulder locks, another thing I noticed was that my shoulder is a little more “low” than the healthy shoulder the clávicula is up, did not have osseous lesions did only 2 x-ray and CT scans, the doctor said that it would be good to operate even if it is the 1 dislocation since I am a sports practitioner I would like to know about exercises and if I can recover the total mobility of the shoulder
I am guessing that there might be a concurrent labral tear due to the dislocation. This will likely take many more months to see maximal improvement of stability and mobility. I would focus on light resisted external and internal rotations along with perhaps some shoulder blade control exercises. Doing something as simple as sliding the arms up the wall and back while maintaining some pressure into the wall with the ulnar side of your hand is a good place to start (they are called “V” slides” and is shoulder exercise #25 in our shoulder section on the website). I am also a huge fan of the “body blade” for rotator cuff exercise. We use the body blade “CXT” here as PhysioDC. Realize that prior dislocations are a predictor of future dislocations, so I would definitely not place my shoulder in the end-range position that you dislocated in.
doctor I came back here to ask another question how do I know if my shoulder is back to correct anatomical position? I suffered a previous dislocation and I was sedated, today 2 months and 1 week of this dislocation and I can not perform the external rotation, I saw some videos of shoulder reductions and some patients are left with the normal movements even in the previous dislocation, which could cause this Shoulder locking? I still do not understand vi 3 videos of dislocation, 2 previous and was used practically the same technique makes an external rotation or make an external rotation + abduction and shoulder usually returns to the place, so in my case must have used another reduction with that of the sheet and as I mended my shoulder to it is lower than the healthy apparently the clávicula is higher and a bone in the back became prominent
If your shoulder was dislocated you would be in extreme pain and you would not be able to move your shoulder. Most shoulders dislocate in the anterior direction, which is the direction that external rotation needs in order to be accomplished. I would stay away from aggressively moving into external rotation because it may put you in a position where you can dislocate again.
awesome stuff… any recommendations in the philly area ? love your demeanor and approach. post surgical and general shoulder issues. trying to stay athletic in 40’s.
In terms of a PT to see…….ugh. I am not sure that I know anybody up there. Your best bet is to do some research on local PT’s and find one with at least ten (10) years of experience who has some training in manual therapy or osteopathy.
I never had surgery after i had an accident when I fractured my elbow and three bones in my shoulder that was in October 2018 on the mend at physiotherapy now but no matter how much excorsise i do my arm just goes. back to bring very stiff and i can’t sleep .
I would ask the doc about perhaps getting one of those “static progressive” elbow braces for elbow stretching. These tend to work well for stubborn stiffness.
Dr.
If I put my arm straight out at 180 degree horizontal from my body and then bend my forearm to the sky(vertcal) keeping my bicep part of my arm still horizontal. I can not rotate it down frontwards(internal) and it immediately locks my shoulder and starts to hurt.
Hmmm, maybe an impingement? There is part of the humerus bone that can rub up against the shelf with that type of motion. This could mean that your mechanics aren’t perfect and might improve with strengthening, or with time the space does tend to narrow a bit. A PT should be able to figure out which it is with an evaluation.