synonyms: GIRD, posterior capsular contracture, glenoid internal rotation deficit
Posterior Contracture ICD-10
Posterior Contracture ICD-9
- 718.41 Contracture of Joint: shoulder region
Posterior Contracture Etiology / Epidemiology / Natural History
- Posterior shoulder pain associated with loss of internal rotation and horizontal adduction.
- Etiology: (1) idiopathic, (2) posttraumatic, typically low energy injury, (3) postoperative, after posterior capsular shift, (4) overhead throwing athlete, especially baseball pitchers.
- Natural history: Acquired posteroinferior capsular contracture, generally in the throwing athlete, initiates a pathologic cascade, which can lead to high shear stresses on the posterosuperior labrum and biceps tendon insertion occuring during the late-cocking phase of throwing which can lead to SLAP lesions / dead arm syndrome.
- GIRD: glenoid internal rotation deficit.
Posterior Contracture Anatomy
- Posterior capsular contracture alters GH kinematics increasing anterosuperior translation of the humeral head during shoulder flexion. (Harryman DT II, JBJS 1990;72A:1334).
- In throwing athletes the contracture involves the posteroinferior capsule. Posteroinferior contracture likely occurs due to the stress loads associated with the follow-through motion in throwing. (Burkhart SS, Arthroscopy 2003;19:404).
- Inferior Glenohumeral Ligament: Prevents anterior and posterior translations of the humeral head at greater degrees of abduction. Secondary restaint to inferior translation in the abducted shoulder. (O'Brien SJ, AJSM 1990;18:449)
- Posterior capsule limits posterior translation when the armis forward flexed, adducted, and internally rotated.
Posterior Contracture Clinical Evaluation
- Pain and difficulty with sleeping as well as in reaching both across the body and up the back (eg, to fasten a bra).
- Internal rotation is restricted. Glenohumeral internal rotation deficit (GIRD) is the loss in degree of glenohumeral internal rotation of the throwing shoulder compared with the nonthrowing shoulder. Internal rotation in 90° of abduction is assessed with the patient supine, and compared to normal side. Normal = 12°. Shoulder at risk >20° GIRD.
- ROM is limited in internal rotation in abduction, crossbody adduction, internal rotation up the back, and flexion.
- Measure maximal cross-body adduction (minimal distance from the antecubital fossa to the contralateral acromion when the arm is adducted horizontally across the body)
- If motion is restricted in all planes consider Adhesive Capsulitis.
- Often have positive impingement tests.
Posterior Contracture Xray / Diagnositc Tests
Posterior Contracture Classification / Treatment
- Posterior capsular stretches performed five times per day2 (see figure ). Each stretch is performed until tightness is felt, but not pain. Each stretch is performed for 1 minute. Improvement generaly occurs within the first month, but 3 months may be required for resolution. @90% of patients will improve.
- Arthroscopic capsular release is indicated for chronic painful loss of internal rotation which has failed to respond to posterior capsular stretching.
Posterior Contracture Associated Injuries / Differential Diagnosis
Posterior Contracture Complications
Posterior Contracture Follow-up Care
Posterior Contracture Review References