The American Journal of Sports

Medicine
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The Effect of Glenohumeral Internal Rotation Deficit Due to Posterior Capsular Contracture on
Passive Glenohumeral Joint Motion
Jeffrey J. Gates, Akash Gupta, Michelle H. McGarry, James E. Tibone and Thay Q. Lee
Am J Sports Med 2012 40: 2794 originally published online October 29, 2012
DOI: 10.1177/0363546512462012
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http://ajs.sagepub.com/content/40/12/2794

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The Effect of Glenohumeral Internal

Rotation Deficit Due to Posterior
Capsular Contracture on Passive
Glenohumeral Joint Motion
Jeffrey J. Gates,*y MD, Akash Gupta,* MD, Michelle H. McGarry,* MS,
James E. Tibone,y MD, and Thay Q. Lee,*z PhD
Investigation performed at Orthopaedic Biomechanics Laboratory,
Long Beach VA Healthcare System, Long Beach, California
Background: To date, no study has investigated the biomechanical consequences of glenohumeral internal rotation deficit
(GIRD) at values seen in symptomatic athletes.
Hypothesis/Purpose: The purpose of this study was to determine the biomechanical changes that occur with a full spectrum of
GIRD in a cadaveric model with passive loading. We hypothesized that there is a critical percentage of GIRD that will result in
a decrease in posterior glenohumeral translation and shift of the humeral head apex at the extreme ranges of motion.
Study Design: Controlled laboratory study.
Methods: Six specimens were tested using the following conditions: (1) native state (intact); (2) after external rotation (ER)
stretch (stretched); and (3) GIRD of 5%, 10%, 15%, and 20%. For each condition, maximum ER, maximum internal rotation
(IR), and total range of motion were measured. Kinematic data were obtained to determine the position of the humeral head
apex (HHA), the highest point on the articular surface of the humeral head, relative to the geometric center of the glenoid. The
amount of translation was measured in the anterior, posterior, superior, and inferior directions.
Results: External rotation significantly increased compared with the intact condition for the stretched and 5% GIRD states, and IR
decreased significantly beginning with 5% GIRD. At maximum ER, the HHA shifted significantly in the superior direction compared with the intact condition for all GIRD states, and at maximum IR, the HHA shifted significantly in the inferior direction compared with the intact and stretched conditions starting at 10% GIRD. The amount of posterior translation decreased significantly
starting at 10% GIRD, and the amount of inferior translation decreased significantly starting at 20% GIRD.
Conclusion: Biomechanical changes of passive glenohumeral joint motion occur in the glenohumeral joint with as little as 5%
GIRD.
Clinical Relevance: Biomechanical changes of passive glenohumeral joint motion are noted with as little as 5% GIRD in this
cadaveric model, and as the amount of GIRD increases, more substantial effects are noted.
Keywords: glenohumeral internal rotation deficit; throwers shoulder; biomechanics; cadaver study

Glenohumeral internal rotation deficit (GIRD) is a common

finding in overhead athletes. However, this loss of internal
rotation may or may not be pathological. In 2003, Burkhart
et al4 defined an acceptable amount of GIRD as less than
20 or less than 10% of the total rotation seen in the contralateral shoulder. Recent studies have reported that throwers with GIRD of greater than 20 compared with their
contralateral shoulder are at a greater risk for upper
extremity injury,29 and a 4-fold greater risk for injury
has been reported in players with greater than 25 GIRD
compared with those with smaller degrees of GIRD.24
Multiple studies have postulated that GIRD is associated with undersurface rotator cuff tears, posterosuperior
labral tears, and irreversible posterior capsular contracture.1,5,14 One clinical study found that there was a greater

Address correspondence to Thay Q. Lee, PhD, Orthopaedic Biomechanics Laboratory, VA Long Beach Healthcare System (09/151), 5901
East 7th Street, Long Beach, CA 90822 (email: tqlee@med.va.gov,
tqlee@uci.edu).
*Orthopaedic Biomechanics Laboratory, Long Beach VA Healthcare
System, Long Beach, California.
y
Department of Orthopaedic Surgery, University of Southern California, Los Angeles, California.
z
Department of Orthopaedic Surgery, University of California, Irvine,
Irvine, California.
One or more of the authors has declared the following potential conflict of interest or source of funding: Funding was provided by VA Rehabilitation Research and Development and Merit Review and the John C.
Griswold Foundation.

The American Journal of Sports Medicine, Vol. 40, No. 12

DOI: 10.1177/0363546512462012
2012 The Author(s)

2794
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Vol. 40, No. 12, 2012

Biomechanical Analysis of GIRD 2795

incidence of ulnar collateral ligament tears in overhead

athletes with significant amounts of GIRD.8 Specifically,
the investigators found that those athletes with ulnar collateral ligament tears had GIRD measuring 18.8% compared with GIRD of 8.8% in their asymptomatic
counterparts.8 Another clinical study showed greater
amounts of GIRD in patients with symptomatic internal
impingement (11%) compared with asymptomatic controls
(6.2%).19
Previous biomechanical studies have attempted to recreate GIRD in cadaveric models by creating a simulated posterior capsular contracture.10,12,15 However, none of these
studies created the degree of GIRD that is actually seen in
patients with the condition. More precisely, the study that
created the largest amount of GIRD in vitro achieved a value
of only 7.0 or 4.6% of the total range of motion for the normal shoulder.10 This value is considerably less than the
amount of GIRD in throwers with symptoms, which has
been reported as greater than 20 or 11% compared with
the nondominant contralateral shoulder.8,19,24,29
The purpose of this study was first, to create a cadaveric
model that could recreate values of GIRD seen in throwers
with pathologic conditions, and second, to test a full spectrum of glenohumeral internal rotation deficits to investigate what biomechanical changes occur. We hypothesized
that there is a critical percentage of GIRD that will result
in a decrease in posterior glenohumeral translation and
shift of the humeral head apex at the extreme ranges of
motion.

MATERIALS AND METHODS

Specimens
Six fresh-frozen cadaveric shoulder specimens (5 male, 1
female; average age, 66.3 years; range, 51-84 years) were
used for this experiment. All specimens were free of any
underlying lesions. Each specimen was dissected free of
all overlying soft tissue with the exception of the glenohumeral capsule, the coracoacromial ligament, and the
rotator cuff tendon attachments. The humerus was cut
2 cm below the deltoid tuberosity and mounted in a polyvinyl chloride pipe with plaster of Paris. The scapula was
also potted with plaster of Paris into a custom scapular
box with the glenoid oriented parallel to the surface of
the box. Three small screws were placed into both the scapula and the humerus to reproduce kinematic measurements throughout the trials. The 3 screws on the scapula
were placed on the coracoid, anterior acromion, and posterior acromion. The 3 screws on the humerus were placed in
line with the bicipital groove: 1 proximal, 1 distal, and 1
posterior to the second point.17 The specimens were then
mounted onto a custom shoulder testing system.

Shoulder Testing System

A custom shoulder testing system was created to measure
humeral rotational range of motion, the position of the
humeral head apex with rotational range of motion, and

Figure 1. Custom shoulder testing apparatus. AP, anteriorposterior; ML, medial-lateral; ROM, range of motion; SI,
superior-inferior.

glenohumeral translation (Figure 1). The specimens were

mounted in 60 of glenohumeral abduction (corresponding
to approximately 90 of humerothoracic abduction) in the
scapular plane.16 The system allowed the humerus to
rotate, and the humerus can be locked at varying degrees
of humeral rotation.
The base of the apparatus consisted of 2 translation plates
that allowed translation in both the anterior-posterior and
superior-inferior directions. Attached to these plates were
screws for attaching ropes that led to individual pulleys for
applying forces in the anterior, posterior, superior, and inferior directions. Before any testing, a 22-N compressive load
was applied to the glenohumeral joint through the linear
bearing system and lever arm attached to the top of the
translation plate. Joint compression of a 22-N load has
been shown to be an adequate force to consistently center
the humerus in the glenoid.7,12,15,23,25,28 The glenohumeral
joints were vented and lubricated with normal saline to be
certain each condition was performed with a vented joint
since the stretching or plication procedure may have vented
the joint. Each specimen was tested under sequential conditions of intact, stretched (to simulate increased external

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2796 Gates et al

The American Journal of Sports Medicine

rotation seen in throwers), and 5%, 10%, 15%, and 20%

GIRD.

adequate to translate the humeral head to its end point

as determined by the capsular laxity based on the amount
of compressive load applied.12,15,23

Glenohumeral Rotational Range of Motion

Before the total range of motion was measured of each
specimen, the neutral position was determined by drawing
a line 12 mm posterior to the bicipital groove and aligning
this line so that it was at the most lateral position relative
to the scapula.9 After the specimens were preconditioned
with 1.1 N
m of torque for 7 cycles in the external and
internal rotation directions, maximum external rotation
was measured using a torque wrench with 1.1 N
m of torque. This amount of torque was adequate to reproduce
a consistent end point of rotation while being small enough
not to cause capsular damage. In a similar manner, maximum internal rotation was then measured. Each measurement was repeated to ensure reproducibility within 2. The
values of maximum internal and external rotation were
then used to calculate the total intact range of motion of
the specimen.

Humeral Head Apex Position

The Microscribe 3DLX (Revware Inc, Raleigh, North Carolina) was used to take kinematic measurements by digitizing the positioning screws on both the scapula and
humerus as the humerus was rotated from maximum
external rotation to maximum internal rotation at 30
intervals. The entire process was repeated for a second
trial to confirm repeatability to a value of 1 mm. If the difference between the 2 trials was greater than 1 mm, a third
trial was repeated and the averages of the closest 2 trials
were used. To calculate the position of the humeral head
apex, the specimens were disarticulated after testing and
the articulating surfaces of both the glenoid and the
humerus were digitized relative to the kinematic measuring screws digitized throughout testing.17 Coordinate
transformations were then performed to calculate the
humeral head apex position relative to the geometric center of the glenoid during testing based on the position of
the 3 reference screws on the humerus and scapula.

Glenohumeral Translation
The humerus was then locked at neutral rotation to measure glenohumeral translation. After the specimen was
preconditioned 7 times in each direction with 10 N of translation force, the pulleys were used to apply a force of 10 N.
The amount of translation that occurred was recorded for 2
trials using the Microscribe 3DLX. The translation in each
direction was calculated as the difference from the
humeral head position with the humeral head centered
on the glenoid and the humeral head position with respect
to the glenoid with translational load applied in the anterior, posterior, superior, and inferior directions. The center
position was digitized before each translational loading.
The entire process was then repeated with a force of
15 N in each direction. These translational loads were

Increased External Rotation (Stretched Condition)

Because throwers shoulders commonly have an increase in
external rotation combined with a decrease in internal
rotation, the capsule was stretched in external rotation.
For calculation of the stretched condition, a value that
corresponded with a 30% increase in maximum external
rotation was determined.10,12,15 To create this condition,
the anterior capsule was stretched in external rotation
after the glenohumeral joint was placed in maximum
external rotation and the translation plates were locked.
The stretching protocol was based on previous studies in
our laboratory.10,12,15 Next, 3.3 N
m of torque was applied
for 1 minute, and then all torque was released for 30 seconds. Torque was increased by 1.1 N
m every minute until
the 30% goal or 75 N
m of torque was reached. Previous
studies have shown that increasing torque beyond this
point increases the possibility of rupturing the capsule.10,12,15 This final external rotation position was then
locked for 45 minutes. When the anterior capsule was
stretched to 30%, an increased torque above the measurement value (1.1 N
m) was required to achieve the stretch.
After the stretch was released and the range of motion
was measured with 1.1 N
m, the increase in external rotation was similar to that reported clinically in throwers.19,24,29 After release, the total rotational range of
motion, humeral head position, and glenohumeral translation were measured as described above for the intact
condition.

Glenohumeral Internal Rotation Deficit Conditions

The total range of motion measured for the intact specimen
before stretching was used to calculate the amount of internal rotation deficit needed for each GIRD condition. This
was specifically done by determining how many degrees
of rotation would need to be lost to decrease the total range
of motion by 5%, 10%, 15%, and 20%. The maximum internal rotation of the specimen was then subtracted by each of
these values to determine the new value of maximum
internal rotation needed for each GIRD condition.
Before the posteroinferior plication was performed, the
length and width of the glenoid face were measured with
digital calipers. This measurement was done by distracting
the glenohumeral joint so that the glenoid rim could be palpated. The measurements were taken extra-articularly so
that the thickness of the capsule was included in the measurement; however, since the goal was to determine the
midpoint of both the length and width, the capsular thickness would not have affected this measurement. Each measurement was then divided in half to determine what
would correspond to the 6-oclock and 9-oclock positions
on the glenoid face (in a right shoulder). These points
were then marked on the capsule at the glenoid edge
with a fine-tipped marker and served to define the limits

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Vol. 40, No. 12, 2012

Biomechanical Analysis of GIRD 2797

differences. Data are reported as mean 6 standard error

of the mean.

RESULTS
Rotational Range of Motion
There was a significant increase in maximum external
rotation after anterior stretching of 9.8 6 3.3 (7.4% of
intact total range of motion) compared with intact (P =
.002). This significant increase in external rotation was
maintained for the 5% GIRD condition (P = .049) but not
for the subsequent GIRD conditions. There was a decrease
in internal rotation of 8.2 6 1.2, 16.1 6 1.7, 23.1 6
2.3, and 30.1 6 2.6 for the 5%, 10%, 15%, and 20%
GIRD conditions, respectively.
Figure 2. Photograph demonstrating the posteroinferior glenohumeral capsule plication technique.
of the plication. A 0-monofilament suture was then placed
in a running fashion from the 6-oclock to the 9-oclock
position using 3 suture loops grasping the entire capsule
from the glenoid edge to its attachment on the humerus
(Figure 2). While this was done, some of the residual posterior rotator cuff attachment was included in the plication
because it could not feasibly be separated from the capsule
without compromising its integrity. The 2 ends of the
suture were then tied with a single surgeons knot that
could be held securely with an atraumatic hemostat clamp.
The suture was secured with the clamp at the position of
internal rotation achieved with a torque of 1.1 N
m that
corresponded with the desired GIRD condition. The maximum internal rotation was then measured to confirm the
correct amount of tensioning. If the internal rotation measurement was not at the desired level, the clamp was
released and the suture was retightened. After this, the
total rotational range of motion, humeral head position,
and glenohumeral translation were measured as described
above.
After completion of the 5% GIRD condition, the clamp
securing the plication stitch was released. The suture
was then tightened and secured with the clamp again after
the amount of internal rotation loss that corresponded with
the 10% GIRD condition was achieved. This technique was
used because pilot testing in which the specimens were
resutured after each GIRD condition resulted in variable
and inconsistent data. Using the same stitch with increasing levels of tightening resulted in consistently reproducible data. The biomechanical measurements described
above were then taken for this GIRD condition. The process was repeated in the exact manner for the 15% and
20% GIRD conditions.

Statistical Methods
A repeated-measures analysis of variance with a Tukey
post hoc test was used for statistical analysis. Significance
values were set with P \ .05 to classify any significant

Humeral Head Position

For humeral head apex position in maximum external
rotation, there was a significant superior shift of the
apex beginning at 5% GIRD of 1.8 6 0.3 mm compared
with the intact condition (P = .028) (Figure 3). In maximum
internal rotation, there was a significant inferior shift of
the humeral head apex compared with both the intact
and stretched conditions beginning at 10% GIRD (3.1 6
0.6 mm from intact; P \ .001) (Figure 3). In maximum
internal rotation, there was also a significant medial shift
of the humeral head apex compared with the intact condition of 2.1 6 0.3 mm starting at 10% GIRD (P \ .001) and
compared with the stretched condition starting at 5%
GIRD (P = .028) (Figure 4). Glenohumeral internal rotation
deficit due to posterior plication caused statistically significant shifts of the humeral head apex in the end range of
motion, specifically inferior-medial in internal rotation
and superior in external rotation, beginning with 5%
GIRD.

Glenohumeral Translation
There was significantly less posterior translation compared with the intact and stretched conditions beginning
with 10% GIRD for both the 10-N and 15-N forces (4.4 6
1.6 mm [P = .013] and 3.9 6 1.6 mm [P = .036], respectively, vs intact) (Figure 5). There was no significant
change in anterior translation for any GIRD value or any
force. In the superior-inferior direction, there was significantly less inferior translation starting with 20% GIRD
compared with both the intact and stretched conditions
for both the 10-N and 15-N forces (6.0 6 2.6 mm [P =
.015] and 5.1 6 2.4 mm [P = .027], respectively, vs intact)
(Figure 6). There was no difference in superior translation
for any condition. Similarly, there was no difference in
translation in any direction when the intact condition
was compared with the stretched condition, with the largest increase being in the anterior direction an average of
1.8 6 1.2 mm (P = .13 and P = .17 for 10 and 15 N, respectively). Glenohumeral internal rotation deficit due to posterior capsule contracture decreased posterior translation

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2798 Gates et al

The American Journal of Sports Medicine

25
Anterior

5
mm

mm

15
10

Posterior

4
6
8

20

*#
MaxIR

10
15

*#

20
10N A

30IR

30ER

MaxER

5% Plication

15% Plication

10N P
Intact

Humeral Rotation Position

Stretch

*#

25
15N A

Stretched

10% Plication

15N P

5% Plication

15% Plication

20% Plication

10% Plication
20% Plication

Figure 5. Anterior (A) and posterior (P) translations for each

condition.

Figure 3. Superior-inferior shift of the humeral head apex

compared with the intact condition at each humeral rotation
position and condition. ER, external rotation; IR, internal rotation. *P \ .05 vs intact; #P \ .05 vs stretched.

Inferior mm Superior

4
2

mm

0
2
4

6
8

5
10

15

20
10N S

*
#

MaxIR

Intact
30IR

30ER

10N I
Stretched

15N S
5% Plication

15% Plication

MaxER

15N I
10% Plication

20% Plication

Humeral Rotation Position

Stretch

5% Plication

15% Plication

10% Plication

20% Plication

Figure 4. Medial-lateral shift of the humeral head apex compared with the intact condition at each humeral rotation position and condition. ER, external rotation; IR, internal rotation.
*P \ .05 vs intact; #P \ .05 vs stretched.
beginning with 10% GIRD and inferior translation with
20% GIRD.

DISCUSSION
This study demonstrates that biomechanical changes occur
in the glenohumeral joint with as little as 5% GIRD due to
posterior capsule contracture. As the amount of GIRD is
increased, more biomechanical changes become apparent.
Specifically, the humeral head apex position shifted in
the end range of motion and posterior and inferior translation decreased with increasing values of GIRD.

Figure 6. Superior (S) and inferior (I) translation for each

condition.
Multiple studies have shown that overhead athletes
have a shift in their overall rotational range of motion compared with their nondominant arm.2,8,19 Specifically, there
is an increase of maximum external rotation with a corresponding decrease in maximum internal rotation. It is for
this reason that the stretched condition (to increase external rotation) was included in this experiment. Interestingly, the 5% GIRD condition in this experiment
replicated the exact phenomenon where the maximum
external rotation was increased, the maximum internal
rotation was decreased, and the overall total range of
motion was similar to intact. When this state was compared with the other GIRD conditions, there were biomechanical changes starting at 15% GIRD. Therefore, if one
believes that the usual shift of motion in throwers is a normal adaptation, then the clinician may be concerned when
the athlete is demonstrating 15% or greater GIRD.
It is uncertain whether this changed rotational range of
motion profile is due to soft tissue changes, bony adaptations,

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Vol. 40, No. 12, 2012

Biomechanical Analysis of GIRD 2799

or some combination thereof.2 Multiple magnetic resonance

imaging studies have shown that symptomatic throwers
have anatomic changes, such as thicker labrums, shallower
capsular recesses, and thicker posteroinferior capsules.26,27
Throwers have also been shown to have osseous adaptations
that contribute to the shift in throwing arc.6,20,21,30 Recent
findings have suggested that if differences in humeral torsion
are accounted for, minimal differences exist between the
rotational arc in healthy shoulders.20 Several studies have
shown that internal rotation stretching or even arthroscopic
posterior capsular release31 can decrease the amount of internal rotation deficit seen in throwers, giving evidence that the
soft tissues are the main culprit behind GIRD.3,18 Considering these observations, we thought that a plication of the
soft tissues would be a reasonable model of recreating GIRD.
Previous studies have attempted to replicate internal
rotation deficits in cadaveric models, but the amount of
GIRD that was created was well below what is seen clinically even in asymptomatic throwers.10,12,15 Several biomechanical studies have shown changes in translations of the
humeral head with selective tightening of the posterior
capsule. Harryman et al13 found that operative tightening
of the posterior capsule led to superior translation of the
humeral head with flexion of the glenohumeral joint.
Gerber et al11 found that creating a plication of the entire
posteroinferior capsule resulted in reductions in internal
rotation at all angles of abduction but did not affect external rotation. However, these studies tested only 1 posterior
capsule plication condition and did not look at multiple plications in the same specimen.
There are several limitations to our study. First, as with
most cadaveric studies, individual muscles about the shoulder were not loaded during this experiment. Therefore, the
effect of the GIRD conditions may have been magnified
because the potential protective effect of muscle loading
was not reproduced. Also muscular changes have been
reported with repetitive loading, specifically increasing
cross-sectional area of the infraspinatus with external
rotator contractions, that could affect range of motion measurement.22 Second, our plication technique, which encompassed the posteroinferior capsule from 6-oclock to
9-oclock, may also simulate a more generous area of posterior capsule contracture than actually occurs in vivo. Future
studies may attempt to plicate just the posterior band of the
inferior glenohumeral ligament. Third, since our posterior
capsule plication involved the inferior capsule, we also
saw decreases in external rotation; however, the maximum
external rotation was larger than intact for each condition
even though it was only statistically higher for the 5%
GIRD condition. We would expect to see larger increases
in external rotation with a greater amount of stretching;
however, further stretching would have risked capsular
rupture. Fourth, testing was performed in only 1 position
that corresponded to 90 of abduction in the scapular plane.
Several studies have shown that throwers actually have
a more pronounced posterior arm position when in the
late cocking position. If we had incorporated horizontal
abduction, our results may have been affected. Finally,
although we tried to recreate an adequate GIRD model,
cadaveric studies may not demonstrate all of the changes

that are present, including muscular and osseous adaptations, and these results need to be interpreted with caution.
This study adds to our biomechanical understanding of
the glenohumeral changes that occur with increasing
amounts of glenohumeral internal rotation deficit. Biomechanical changes in passive glenohumeral joint motion
were seen with as little as 5% GIRD in this cadaveric
model, and as the amount of GIRD increases, more substantial effects are noted.
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