Measuring Humeral Retroversion

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Humeral retroversion is a well know entity in overhead athletes.  Several authors have done a great job exposing this phenomenon to us all.  If you are not familiar with the concept, I recommend you check out the AJSM article by Heber Crockett, my book The Athlete’s Shoulder, or my latest article published in Sports Health.

 

Can we clinically measure humeral retroversion?

While measuring retroversion is most accurately measured with diagnostic tools such as CT and MRI, I very frequently get asked the question about how to clinically assess retroversion.  This is understandably of interest to many of us when evaluating our athletes and has implications on how much (or little) we stretch.

Measuring this clinically is actually pretty simple.  Well, nothing is that simple guess.  It is simple if they do not have any restrictions in range of motion.  Let me explain:

  • First measure both shoulder external rotation and internal rotation at 90 degrees of abduction.  Do this on both sides.
  • Now add up ER + IR on each side.  This is your “total motion.”
  • In the normal person, including overhead athletes, the total motion should be very similar.  Let’s say that the total motion for this example is 180 degrees.
    • Dominant arm: ER = 130 deg + IR 50 deg = 180 deg total motion
    • Nondominant arm: ER = 115 deg + IR 65 deg = 180 deg total motion

In this scenario the amount of humeral retroversion is 15 degrees.  How did I come up with that?  Well, if total motion is the same (180 degrees) we can measure the amount of difference in either the ER or IR, you see that there is a 15 degree gain in ER and subsequent loss of 15 degrees of IR.  So the humerus must be retroverted 15 degrees. 

What if the person is tight, or total motion is not symmetrical, but rather the dominant arm has less than the 180 degrees that the nondominant arm exhibits?  Then measuring gets a little trickier.

A simple measurement technique is to measure the amount of rotation the arm sits in when relaxed.  This may be a decent indicator of retroversion, though I would bet there is a high standard deviation.  Regardless this is close.  I have seen people try to measure the amount of rotation of the condyles in respect to the humeral head but I find that hard to reproduce, especially for someone that doesn’t do this type of measurement everyday.

 

Try This Simple Technique

imageLay the person supine and place the arm in simple horizontal adduction, similar to how you would perform a stretch in this position.  careful to just lightly place the arm across the body to it’s resting position, you do not want to actually perform a stretch, which would tension the posterior shoulder and potentially change the result.  Then measure the amount of resting external rotation.  As you can see in the photos, the imagedominant arm is resting in much more external rotation.  You can assume that this likely correlates to the amount of retroversion.  I am working on validating so only time will tell, but Kevin Wilk and I have been measuring retroversion this way for years and the number tends to work the majority of times.  It isn’t perfect but I think it works well enough to provide you with valuable information to begin working with your athlete.

 

What do you think?  What have you used?

10 replies
  1. Rod Whiteley
    Rod Whiteley says:

    Good luck changing opinions on this one, there’s a lot of inertia and dogma to overcome.
    We originally tried to publish validity of how to measure torsion (using ultrasound – still better accuracy than CT btw) in 2004, and here’s the rejection from AJSM:

    Reviewer Comments for the Author…
    Primarily anatomical study which could be submitted to a journal
    of clincial anatomy. How this information would assist in treating
    an athlete with TADSIR — throwing aggrevated decreased shoulder
    internal rotation is unclear.

    how would this change treatment or prognosis?

    would you tell athlete and his coach that he had a bony abnormality
    and no future??

    would you propose a derotational osteotomy???

    other than profiling the athlete to a negative advantage i’m lost on
    the clinical significance of this finding.

  2. Jarod Hall
    Jarod Hall says:

    Mike,
    At the clinic I recently interned at we used diagnostic ultrasound to measure the degree of humeral retro torsion. We did this by lying the athlete supine in 90 degrees of abduction and adjusting from there to position the bicipital groove level using the US for visual feedback. Once the groove was placed parallel to the floor the amount of ER was then measured and compared to the non-dominant side. I feel that this is a critical topic that many clinicians aren’t fully aware of. Leading them to frequently sleeper stretch/posterior GH mob patients do death. In essence creating hyper mobility into IR because they believe the lag in “GIRD” is soft tissue related instead of realizing it is not GIRD but instead bony adaptation.

  3. arobb
    arobb says:

    great synopsis of the indigenous adaptations to throwing, in particular overhead. Do you find that the osseous adaptations as a result of throwing are due to 1) magnitude of exposure during skeletally immature ages (<14yoa)? 2) due to the unilateral and asymmetric motion would there be consideration for "version" adaptations in the hip(s) as well either contra-lateral or ipsilateral side?

  4. Alex nielen
    Alex nielen says:

    Very interesting, could the increased external rotation be due to a tighter rhomboid resulting in an adducted scapula.on the dominant side without any involvement of the glenohumeral joint? Is it important to ascertain whether the external rotation derives from the humerus or scapula position?

  5. Mike Reinold
    Mike Reinold says:

    Like everyone's comments. This works well for all types of patients. I think John's comments say it all, if there is a 15deg difference, all this tells you is that if your ER is increased by 15 and IR decreased by 15, you do nothing!

  6. john.walkermpt
    john.walkermpt says:

    Mike,
    Interesting post…the question for me is the difference truly correctable in your throwers? Is it a bony adaptation or a muscular imbalance that you can correct with soft tissue work, stretching, etc?

    JW

  7. Carl
    Carl says:

    More importantly,
    how will this affect your rehabilitation Mike?
    Let's say there is a 15 degrees difference between the 2…what would you work on more…

    Interesting post.
    Carl.

  8. Anonymous
    Anonymous says:

    Mike,
    In what clinical situations have you not been successful with this type of measurement?

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