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awhile back I posted about son's shoulder injury. He got mri and had bicep strain, small tears nothing deemed worthy of surgery and has since had cortisone injection. 2 months later it wore off and hes in pain so went to a new ortho as his other one is out having surgery. Today he was diagnosed with Gird and was given prednisalone and told to do stretches. I found another post about Gird on here but does anyone have recent experience with it? He was going to pt for a long while with no relief. The only positive I see is that it doesn't effect him swinging the bat

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GIRD is a rather meaningless diagnosis for a pitcher.  Glenohumeral internal rotation deficit is present is pretty much every pitcher who has thrown a ball seriously.   It is a diagnosis of range of motion, not a finding of actual trauma.  Find an ortho who specializes in treating overhand athletes and shoulders in particular.  Your average ortho that sets broken bones from playground injuries is not going to have the experience or expertise to treat a throwing shoulder.

My son struggled with intermittent shoulder pain for a couple years in HS.  He was diagnosed a various times with bicep tendonitis and impingement.  He was told flexibility (GIRD) was a root cause.  He saw multiple orthos and physical therapists and was pretty religious about stretching but it would still flair up from time-to-time.

I am not a doctor but the approach we took was to NOT take any Advil or Aleve.  I wanted him to feel the symptoms and stop throwing if his shoulder was tight.  I don't think taking cortisone or prednisone would be a good idea because it could mask pain and lead to causing injury - just my opinion.

He got through it by finding a really good PT who understood shoulder physiology and regained the flexibility he needed.  I should add that both his HS and travel coaches were fully aware and always took him out when he told them he felt pain.  He now stretches regularly and added hanging to his regiment and hasn't had a problem in a couple years.

Smitty how long would the bouts with GIRD last? in other words if it flared up, would he miss a few days? weeks? This has been going on since July but the only thing that gave him temporary relief was a cortisone injection that lasted appx 2 months...he just started a medrol pack yesterday and was told to do a ton of sleeper stretches

@edcoach posted:

Smitty how long would the bouts with GIRD last? in other words if it flared up, would he miss a few days? weeks? This has been going on since July but the only thing that gave him temporary relief was a cortisone injection that lasted appx 2 months...he just started a medrol pack yesterday and was told to do a ton of sleeper stretches

I can’t stress this enough.  GIRD does not “flair up”. Your son’s shoulder pain is not GIRD.  GIRD is an adaptation of the shoulder range of motion.  As you increase your shoulder external range of motion, the layback throwers get when they throw, you lose internal rotation range of motion.  Here is an illustration that compares a typical thrower’s off hand and dominant hand.  Both arms have 180’ range of motion yet the throwing hand has greater ER and “deficit” of  IR.



2E414579-83FC-4E12-A0A2-99846BD4C0EB



I would encourage you to read Mike Reinold’s article to understand what a diagnosis of GIRD means.

https://mikereinold.com/gird-g...al-rotation-deficit/

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Last edited by 22and25
@edcoach posted:

the doctors hes been seeing seem qualified, ie doctors for the Olympic team, the local D1 Universities sports team as well as the local AAA baseball team...when I call a dr office should I specifically ask for a dr. that specializes in overhand sports and/or baseball? I think if I asked that they'd all say yes....

A quick google search found this guy in Oklahoma City:

Dr. Jimmy Conway is a leading expert in the treatment of throwing injuries for baseball and softball players.

http://jimmyconwaymd.com/staff/



A doctor’s bio is easy to find online.  They should list shoulders as a specialty or better if they mention a particular interest in throwing athletes.

Last edited by 22and25

Just to be clear, I know nothing about this particular doctor and I am not endorsing him in any way.  He was just an example of the ease with which you can find a shoulder specialist in your area who has an interest in baseball injuries.  

Please read the GIRD article I posted and go armed with good questions.  Being your own best advocate is important with any medical issue.  

edcoach - glad to see you getting aggressive with this and contacting a specialist.  My son suffered from this (looking at 22and25s diagram) and missed his whole junior season.....it was all about flexibility and range of motion on his pitching side.   He was supposed to start against UNC in the NCAA regionals in 2012.  It got to be so bad that he only pitched part of an inning in relief in the NCAA regional pool play....they had to shut him down immediately.

Prior too this episode, my wife and I knew nothing about it...he never complained.   He was absolutely devastated at how his season ended.  He worked his way back his senior year.   This isn't something to mess around with.

Good luck!

PS....great stuff 22and25

thanks fenwaysouth....im sorry about your son but glad he made it back....im definitely at my wits end and definitely not messing around...hopefully tomorrow answers are gained...its been almost 7 months..one common denominator so far is all 3 orthos have said no surgery required so I guess thats good...I think many may push surgeries but not so far.

@Smitty28 posted:

My son struggled with intermittent shoulder pain for a couple years in HS.  He was diagnosed a various times with bicep tendonitis and impingement.  He was told flexibility (GIRD) was a root cause.  He saw multiple orthos and physical therapists and was pretty religious about stretching but it would still flair up from time-to-time.

I am not a doctor but the approach we took was to NOT take any Advil or Aleve.  I wanted him to feel the symptoms and stop throwing if his shoulder was tight.  I don't think taking cortisone or prednisone would be a good idea because it could mask pain and lead to causing injury - just my opinion.

He got through it by finding a really good PT who understood shoulder physiology and regained the flexibility he needed.  I should add that both his HS and travel coaches were fully aware and always took him out when he told them he felt pain.  He now stretches regularly and added hanging to his regiment and hasn't had a problem in a couple years.

Excellent point about hanging (from a bar, a door or whatever). It is a must for keeping bicep muscles elongated and not near enough emphasis is put on it IMO.

@Fenwaysouth, I am not sure if you read the linked article but the point is that the pitcher in that diagram is not suffering from anything.  The problem with many GIRD diagnosis is this:

Pitcher presents to ortho with “shoulder pain”.

Ortho compares internal rotation of throwing shoulder and non throwing shoulder.  Notes IR deficit in throwing shoulder and declares a finding of GIRD.

Player with hurt shoulder reports to PT with prescription for stretching to correct GIRD.

Did the ortho compare external rotation?  Note a loss of total range of motion when adding ER and IR as compared to the non throwing shoulder?

In actuality, shoulder pain is likely caused by something completely unrelated to the loss of internal rotation.

ive literally gone from never hearing the word GIRD 24 hrs ago to knowing way more than I need to :-)     Im thinking my son's injury isnt GIRD for one because it happened (popped) on a long throw from the outfield.  I do agree he hasnt stretched appropriately or thoroughly before games for years...but GIRD seems to be incorrect...he swears the pain is when he ER's the shoulder not the IR

@edcoach posted:

Smitty how long would the bouts with GIRD last? in other words if it flared up, would he miss a few days? weeks? This has been going on since July but the only thing that gave him temporary relief was a cortisone injection that lasted appx 2 months...he just started a medrol pack yesterday and was told to do a ton of sleeper stretches

He would have to take it easy for a couple days then ease back into throwing, so he might have to DH or play OF for a game or two before going back behind the plate during HS season.  In the summer he had to skip a tournament a few times. He could go months with no pain and the BAM it flared up again.  It was always scary and I was convinced he must have a tear or something, but it always went away.  One piece of info we got from a very experienced ortho surgeon was that if he could throw at all without pain it's not a tear.

@edcoach posted:

the dr. Colby saw yesterday said no more deadlifts, hang cleans or really any olympic lifts...sound right?

I’m in the same court of opinion on this issue. IMO (and the opinion of many Ortho specialists) it’s a bad idea for baseball players to perform any Olympic lifts. The risk is too great for the reward. There are many safer ways for baseball players to get stronger.

Demands of overhand athletes are general in most senses and very specific in others.  I would love to hear the rationale behind the notion that deadlifts, front squats, split squats, etc are bad for baseball players.  If lifting heavy is bad for baseball players why does every college and professional clubhouse look like a Gold’s Gym?



3CE48D1D-551A-4821-9E3E-14076A36AED0

Why did the Yankees hire Eric Cressey?  

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Last edited by 22and25
@Smitty28 posted:

One piece of info we got from a very experienced ortho surgeon was that if he could throw at all without pain it's not a tear.

I'm not saying this statement is completely wrong but definitely not entirely true.  My son had a torn labrum which he rehabbed and continued to play with for a few months.  The first month or so he didn't have any pain.  It didn't feel 100%, but no shooting pain like he had before PT.  After a few months months he ended up having surgery and 4 anchors put into his shoulder.  

@edcoach posted:

awhile back I posted about son's shoulder injury. He got mri and had bicep strain, small tears nothing deemed worthy of surgery and has since had cortisone injection. 2 months later it wore off and hes in pain so went to a new ortho as his other one is out having surgery. Today he was diagnosed with Gird and was given prednisalone and told to do stretches. I found another post about Gird on here but does anyone have recent experience with it? He was going to pt for a long while with no relief. The only positive I see is that it doesn't effect him swinging the bat

I haven't read through this thread yet, just addressing the OP for now.

GIRD, or glenohumeral internal rotation deficit, isn't pathological. Meaning, "Okay you have a 10 degree difference between sides, you're now going to get injured!" or 19 degrees or 20.

Below I'll share with you some information I use on presentations regarding the shoulder.

There was limited evidence that a lack of external rotation (but no other shoulder joint range of motion measures) may be a risk factor for shoulder injuries in baseball pitchers. There was limited evidence for an increased risk of shoulder injury when training and match load in youth handball players increased >60% in the week before injury compared with the average load of the preceding 4 weeks or if youth baseball players participated in a high volume of training each week.

Since there is limited evidence for which potential risk factors to assess or what prevention strategy to employ, the main purpose of screening shoulder parameters in overhead sports should be to evaluate current shoulder status, measure improvements in performance or to serve as normative values to reach before return to play after injury.

What does that mean? It means there's some evidence that says if you have 93 degrees of ER on your throwing arm and 91 degrees of ER on your non throwing arm, you may want to try to get a couple more degrees (this is only seen in professional pitchers, not in high school pitchers). There's no other evidence that GIRD is causative of shoulder injuries, nor TROM (total range of motion, which is ER + IR).

https://bjsm.bmj.com/content/52/20/1312.long



Another study published in 2020, they included 15 prospective studies (meaning they follow them from the start before any injuries happen), and most studied included looked at baseball.

They concluded that there is limited evidence that preseason range of motion screening cannot predict shoulder or elbow injuries in volleyball, softball, tennis or handball athletes – aside from, perhaps, external rotation for professional pitchers (but not adolescents) or swimming athletes (Pozzi et al., 2020).

Their finding were that swimmers with less than 93 degrees of ER, or more than 100 may be susceptible to injury, and that professional baseball pitchers with less than a five-degree increase of external rotation on their throwing arm are also slightly at risk.

What does that mean? Again, the only thing that may be helpful is at least 5 degree of ER more in the throwing than non-throwing shoulder, but that's only for professional pitchers.

https://bjsm.bmj.com/content/54/17/1019

Long story short, GIRD isn't causative of shoulder injuries. It's not a mediating factor of recovery. And what we measure on the table isn't indicative of what happens while throwing. Prime example, study done on elite handball players looked at their ER on the table, ER while pulling as far as they could, and ER while throwing. What they measured had no association between the ER seen while throwing and velocity. The conclusion speaks volumes: It was concluded that ROM of the external rotation measured on the bench does not give any information about the maximal throwing performance or the external rotation angle during throwing and therefore cannot be used to identify potential fast throwers or injuries in elite team handball players.  

What does that mean? It means unless we have a lab we're probably not getting a ton of useful information through range of motion. Even then, the studies show there may be a benefit at having at least 5 degrees more of ER on your throwing arm compared to your non-throwing arm (but this result is only seen in professional pitchers). Total range of motion and GIRD are not causative of injury or increasing the likelihood of getting injured.

https://pubmed.ncbi.nlm.nih.gov/26902748/

And why is that, about GIRD? Well, this study that at high school-aged players and found that those who DID NOT HAVE an IR deficit were more likely to get injured. Those who had at least a 20 degree GIRD were protected from injury.

Now, would I use that above study to say everyone should lose 20 degrees? No, but it goes to show that, with the totality of evidence, GIRD isn't something that necessarily needs "fixing". Rather the physiotherapist should look at what the person in front of them is having difficulty with, and build them up from there. Stretching isn't going to prepare the tissues to handle throwing 70, 80, 90 MPH.

http://europepmc.org/article/MED/24893778

edcoach,

There is a physical therapist ( in Oklahoma City, i believe) that specializes in sports, by the name of Mark Brown. He is the physical therapist of choice for several highschool teams as well as the local Ballet Company. I've attended several of his On-line Continuing Education Seminars and the guy really knows his stuff. You can look him up on-line, and maybe give him a call. He showed me ( virtual) that there is always a big difference in external rotation/ internal rotation Range Of Motion, in Throwing shoulder vs non-throwing shoulder , of pitchers. This is normal and should not be construed as needing correction ( unless there are other factors). Stability is of prime concern for shoulders.

Xfactor, presented an excellent post and i looked up the referenced material -excellent resources. Thx for posting!

Best Of Luck!

I would focus on the portion of diagnosis concerning the scapula.  The scapular muscles play a critical role in shoulder stability, particularly in maintaining the position of the glenoid (this is the socket that the ball of the humerus rides in).  Without strong scapular muscles the biomechanics of the shoulder break down.

Here is a paper that explains the role of scapular stability in the throwing shoulder. The introduction will tell you all that you need to know but I would encourage you to click the link and digest as much as possible of the entire article.

“In normal upper quarter function, the scapula provides a stable base from which glenohumeral mobility occurs.1,2 Stability of the scapulothoracic joint depends on coordinated activity of the surrounding musculature. The scapular muscles must dynamically position the glenoid so that efficient glenohumeral movement can occur. When weakness or dysfunction of the scapular musculature is present, normal scapular positioning and mechanics may become altered.1,2 When the scapula fails to perform its stabilization role, shoulder complex function is inefficient, which can result not only in decreased neuromuscular performance but also may predispose the individual to injury of the glenohumeral joint.1,2

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3811730/

As for treatment, you won’t stretch your way to scapular stability. This will require some strength training.  I would find a PT or trainer with overhand athlete experience and have them write some training programming to help build those back of the shoulder muscles.

Last edited by 22and25
@edcoach posted:

Just got back from specialist. He said he has gird and said he has a sick scapula. Showed how much lower and weaker throwing side is than the other. Also got injection right into the joint  so will have that plus the medrol dose pack plus told him hes got to up the reps on stretches daily and showed him the stretches

I looked up SICK scapula since I don't recall ever hearing the term and sure enough it is very similar to how my son's shoulder posture looked when he first began having shoulder issues.  As I said early, this issue took a couple years to fully resolve itself, during which time he had periodic flare-ups followed by ortho visits and PT sessions.  As he learned how to stretch, warm up properly, ease into hard/long throws, and strengthen his shoulders and back muscles it no longer became a problem.  It's been about 3 years now since he's had an issue and his arm is stronger and more accurate than ever.

I point this out to suggest to you that there's probably not a quick fix to this.  It may take months or years but it can get better, and he can function if he prepares himself properly.  Forgive me if I'm overstepping here, but it concerns me that he's taken cortisone, prednisone and another injection, none of which would make me comfortable.  I am not a doctor but my doctor friends have always warned me against pain killers, particularly in young people, as they could mask conditions that could lead to serious injury.

thanks for the responses Guys.  22and25 I agree with the strengthening that will be needed...the ortho did say that and referred him to pt and said we need one with that experience in strengthening the back of the shoulder muscles but he said the guy he uses is out of business because he was bought out and has a no competition clause or something so im going to look hard for a trainer that can do this....Smitty...hes taking the Medrol pack and got the injection today..im assuming the injection was cortisone but im not sure.  He was throwing a ton of info at me that I was trying to digest.  He said he has worked with many many mlb players and was the team ortho for many oklahoma baseball and football teams and he focuses on the shoulder mainly...ive got to trust him as now in the last 2 days I basically have 2 guys telling me the same thing...rest, stretching, strengthening of the scapula, etc...

@edcoach posted:

Just got back from specialist. He said he has gird and said he has a sick scapula. Showed how much lower and weaker throwing side is than the other. Also got injection right into the joint  so will have that plus the medrol dose pack plus told him hes got to up the reps on stretches daily and showed him the stretches

I would venture to say that almost every ballplayer (I know mine does) with significant time playing the game will have a shoulder that is lower than the other side.  His throwing arm will also have greater ER and “deficit” of  IR as referenced in the images at the beginning of the post.  Neither of those mean you have or will get a should/arm injury.

As previously mentioned I would pay special attention to the scapula.  Focus on strengthening all the surrounding muscles in the shoulder.  My own personal opinion I would not use injections or pain killers.  

I think time, rest and PT are going to be your best friends for a while.  

The only thing about that SocalOG is that he's had time, rest and PT and things didn't improve. Trying to get him through feb-april and shut down throwing til August.  Are there strength trainers that could help the scapula and back shoulder muscles? I'm assuming yes obviously but didn't know if that's better than pt or not. He probably did 20 pt sessions yet the situation was not resolved

It’s as important to find a PT or trainer with shoulder expertise as it was to find a doctor with shoulder expertise.  And again, someone who works with overhand athletes in particular.  The shoulder is probably the most complex joint structure in the body.  Scapular issues can be caused by one or more of several different muscles.  You need a PT or a trainer who has the experience to observe your son’s movements, diagnose the specific deficiencies and write effective programming to strengthen the appropriate areas in a targeted way.  

Eric Cressey literally wrote the book (ok, a book🙂) on healthy shoulders in throwers.  If money and time were no object, I would put my kid on a plane to Florida and have Cressey asses him and start him on a program.

@edcoach posted:

The only thing about that SocalOG is that he's had time, rest and PT and things didn't improve. Trying to get him through feb-april and shut down throwing til August.  Are there strength trainers that could help the scapula and back shoulder muscles? I'm assuming yes obviously but didn't know if that's better than pt or not. He probably did 20 pt sessions yet the situation was not resolved

Sorry about that.  I know how frustrating it can all be.  Fortunately, for my son the diagnosis was really easy, a torn labrum.  At least we knew the exact issue and how to go about the healing process.  

Like 22and25 said, the shoulder is very complicated.  Everyones situation is different and there is not a 1 size fits all solution.  Be vigilant and keep looking for the solution that is best for your situation.  

Just curious, how many MRI's has he had?  Sometimes it takes a few to spot the issue.  

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