Sports Medicine Research: In the Lab & In the Field: Sleeper Stretch: Proven Remedy for GIRD in Overhead Athletes (Sports Med Res)


Monday, June 26, 2017

Sleeper Stretch: Proven Remedy for GIRD in Overhead Athletes

Effectiveness of a Posterior Shoulder Stretching Program on University-Level Overhead Athletes: Randomized Controlled Trial

Chepeha, J; Magee, D; Bouliane, M; Sheps, D; Beaupre, L. Clinical Journal of Sports Medicine. 2017 April, e-pub ahead of print.

Take Home Message: Performing the sleeper stretch increases internal rotation in overhead athletes with an internal rotation deficit. Effectively managing posterior shoulder tightness could be important in reducing the incidence of shoulder pathology in overhead athletes.

In overhead athletes, the intense demands placed on the glenohumeral joint lead to anatomical adaptations that result in altered range of motions; such as, reduced internal rotation and increased external rotation.  Posterior shoulder tightness due to changes in the posterior capsule and posterior rotator cuff contribute to these rotational alterations.  Stretching programs that address posterior shoulder tightness, such as the “cross-body stretch” and “sleeper stretch”, are effective in baseball players.  However, few studies have investigated the benefits of the stretch in other overhead athlete populations.  Additionally, the optimal dosage parameters, expected rates of change, and the effect on pain and function of the sleeper stretch are poorly defined.  Therefore, the authors of this study had two goals: 1) to determine if an 8-week posterior shoulder stretching program increased range of motion (ROM) in a variety of overhead university-level athletes with deficits in internal rotation and 2) to investigate the rate of change in internal rotation and horizontal adduction ROM over time and to determine whether pain and/or function changes with stretching.  A total of 37 university-level athletes from a variety of sports (i.e., volleyball, swimming, and tennis) and with internal rotation ROM deficits (≥ 15º) were randomized into intervention or control groups.  The intervention group performed the “sleeper stretch” once daily for 5 repetitions, holding each stretch for 2 minutes. The control group performed usual activities.  Study staff used a goniometer to measure internal rotation ROM and horizontal adduction ROM at baseline and 4 and 8 weeks.  Participants self-reported shoulder pain and functional ability at similar time points using visual analog scores. The researchers found that internal rotation ROM was increased in a clinically meaningful way (>10º) at 4 and 8 weeks in the intervention group.  The athlete’s self-reported shoulder function was also improved in the intervention group at these time points  

Results from this study show that overhead athletes with an internal rotation ROM deficit (≥ 15º) benefit from performing posterior shoulder stretching daily.  These changes were observed during the athlete’s competitive season as early as 4 weeks into the stretching intervention and continued at 8 weeks. It is not clear whether these increases in internal rotation ROM could be maintained and at what time point the effect of stretching will level-off. The authors acknowledge that many reports advise doing the sleeper stretch 3 to 5 times daily for 5 to 7 days per week, holding each stretch for 30 to 60 seconds for 4 to 6 weeks.  The authors modified this dosage slightly to incorporate longer duration stretching in an attempt to affect the viscoelastic (time-dependent) properties of the posterior soft tissues.  It would be interesting to determine if modifying dosage parameters for the stretch will lead to greater changes.  Ultimately, clinicians could use the sleeper stretch as an effective method to combat glenohumeral internal rotation deficit (GIRD).  The critical question that remains is whether posterior shoulder stretching is effective in reducing the incidence of shoulder injuries in overhead athletes.

Questions for Discussion: Do you prescribe the sleeper stretch for your overhead athletes with internal rotation deficits?  What dosage parameters have you used? Do you think this may be an effective way to prevent shoulder pathology in overhead athletes?

Written by: Katie Reuther
Reviewed by: Stephen Thomas

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Dan said...

Thanks for the summary. I’m glad that the sleeper stretch was studied in this article.

As a clinician, I am slightly skeptical about this stretch. While it does target the posterior capsule directly, it also puts the shoulder into an impinged position. When you think about the Hawkins-Kennedy test for shoulder impingement, the sleeper stretch is essentially this test but the athlete is side-lying and they are applying the force themselves. I think it is largely important to use this stretch sparingly because putting the shoulder into an impinged position 5 times a day for 2 minutes for 8 weeks may potentially do some harm in a larger sample size. If an athlete has shoulder impingement as well as posterior capsule tightness, this stretch probably shouldn’t be an option.

That being said, I definitely still use the sleeper stretch, but I make sure to educate my athletes on the positining it puts them in (without scaring them and thinking that it is a “bad” stretch) and that if they start to feel any pain other than a stretch to stop. Without this stretch it is particularly hard to target the posterior capsule, so I am wondering if there may be a way to implement a stretch that can target the posterior capsule without impinging the glenohumeral joint.

Katie Reuther said...

Thanks for the comment. I agree that the stretch is similar to the Hawkins impingement test and that this stretch might not be indicated for someone with active impingement symptoms. Interestingly, this study also looked at self-reported pain and function and found no differences in pain but did find improved function in the sleeper stretch group.

Mike Reinold said...

This was an absolutely horrible study with poor methodology, but more importantly, the title of this blog post sensationalizes it even more. The authors incorrectly measured GIRD and defined it as pathological, when it was likely just the normal bony adaptation seen in overhead athletes. Having a 20 degree difference in IR ROM is fairly normal. Since the authors did not measure ER or total ER+IR motion, we'll never know, and making this study completely flawed. Assuming that the subjects had 20 less degrees or IR at the start of the study would likely mean they had 20 degrees greater ER, but now at the end of the study, they have torqued the joint into more IR and effectively increased total rotational motion by 20 degrees, and decreased static stability.

This should not be done and this actual injures overhead athletes.

As a frequent reader (and promotor) of this website. I respectfully request that this post be removed. It certainly should not be sensationalizing and promoting the sleeper stretch.

Katie Reuther said...

Thanks for your feedback. I think your interpretation and clinical expertise really adds to the discussion around this post, which aimed to summarize the already peer-reviewed publication.

Allison Wagner said...

Thank you for this article. I am a fan of the sleeper stretch and how it allows the athlete or patient to take the stretch at their own pace. I am glad that the study used self reported measures from the athletes. I believe that one of the biggest concerns during treatment should be the athlete as a whole not just the elbow, ankle or shoulder we are working on. When using this stretch clinically, I found that many athletes enjoyed the sleeper stretch, making them feel less stiff and restricted. I would like to think that this stretch combined with other treatments and methods will prevent shoulder pathology, and I don’t see a down side to utilizing this stretch in treatments and interventions.

Katie Reuther said...

Thanks for the comment. I think it is pretty clear that additional evidence-based research is needed in this area. Hopefully, future studies can address whether or not the sleeper stretch is useful or harmful for certain populations and ultimately, whether or not posterior shoulder stretching will prevent injury.

Kim Twait said...

As a clinician I have always been skeptical of the benefits of the sleeper stretch due to the fact that the athlete is the one performing the stretch. Sometimes the athlete may not be performing the stretch correctly or applying enough pressure. So I was excited to see that it does help with gaining back internal rotation deficits in patients with GIRD. I will keep this in mind when stretching my overhead athletes and make sure that when they are performing the sleeper stretch they do it correctly to get the full benefit of the stretch.

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