Proximal Humerus Fracture Exercises

Rehab After Proximal Humerus Fracture Isn't Linear

The typical non-operative protocol for a minimally displaced surgical neck fracture breaks down into phases, but the boundaries between them are blurry in practice. Phase one runs from injury through approximately week six and is strictly about pain control and protected passive motion. You keep the arm in a sling most of the time, but you do not leave it completely motionless. Passive pendulums and assisted range of motion with the other arm are the standard starting point, usually beginning within the first one to two weeks once acute pain settles enough to tolerate them. I have seen too many patients skip straight to active motion because they feel fine. The fracture is not healed just because the swelling went down. Pushing into active shoulder flexion at week three will typically cause displacement or at minimum significant callus irritation, and then you are back to square one with another six weeks of reduced mobility.

Proximal Humerus Fracture Exercises by Phase

Phase two begins around week six when radiographic union becomes visible on X-ray. This is where most of the actual work happens. The goal is restoring active range of motion before you worry about strengthening. Table top exercises with fingers interlaced, pulley-assisted flexion and abduction, and finger wall climbing are the bread and butter here. Scapular retraction and depression exercises also belong in this phase because the rotator cuff mechanics are disrupted after any proximal humerus injury, and if you ignore the scapula you will compensate badly later. By phase three around week eight to twelve you introduce light resistance. Theraband rows, internal and external rotation with a light band anchored at waist height, and dynamic stabilization drills on a wall or ball. The rotator cuff is the structure most people neglect during recovery, and it is also the structure that determines whether your final range of motion is functional or frustrating. A 2018 study in the Journal of Shoulder and Elbow Surgery found that isometric rotator cuff strengthening initiated at six weeks post-injury improved functional outcomes compared to standard protocols alone. I encountered a specific edge case last year involving a 58-year-old patient with a two-part surgical neck fracture who developed significant anterior shoulder tightness by week five. The standard pendulum program was not addressing the anterior capsule adequately. We switched to a cross-body assisted stretch using a towel held behind the back, performed in a supported seated position with no weight through the injured arm. This modified approach restored about 15 degrees of internal rotation that would have otherwise been lost to capsular tightening. It is a small adjustment but one that makes a measurable difference.

The biggest mistake people make is treating all proximal humerus fractures as the same thing. A greater tuberosity fracture with minimal displacement follows a different timeline than a surgical neck fracture, and a three- or four-part fracture managed non-operatively is in a completely different universe. The exercise progression I am describing here applies to the straightforward cases. If your fracture involved the articular surface or had significant varus angulation, your surgeon or physical therapist will have a different protocol, and you should follow theirs without deviation. Strengthening phase, roughly weeks 12 to 16 and beyond, introduces progressive resistance. Start with bodyweight exercises like wall push-ups and progress to weight-bearing on an exercise ball, then light dumbbells. External rotation in the side-lying position with a 2-3 pound weight is particularly effective for the infraspinatus and teres minor, which often inhibit recovery when weak. You are not trying to rebuild pre-injury strength at this stage. You are rebuilding movement quality first. Strength follows eventually if you do not rush it. One counter-intuitive point worth noting: pain during the early rehab phases is expected but should always be sharp versus dull. A dull ache during stretching means the tissue is being mobilized. Sharp pinching pain, especially anteriorly or deep in the joint, means you are hitting something you should not be hitting yet. I had a patient who reported good progress through week eight and then experienced sharp anterior pain during overhead pulley exercises. We stopped the pulley work immediately and substituted wall walks instead. The pulley was creating impingement at 90 degrees of flexion because his supraspinatus was still not firing properly. Wall walks kept the motion more controlled and avoided the impingement angle entirely. We returned to pulleys at week 11 and they were fine by then.

Range of motion targets are achievable but not guaranteed. Most patients recover about 120 to 140 degrees of forward flexion and 40 to 50 degrees of external rotation with the arm at the side within six months. That is sufficient for most daily activities. Anything beyond that usually requires persistence with the rotator cuff and scapular work through the later phases. Night pain can persist for several months after the fracture has clinically healed, and this is normal. It does not mean the bone is not healing or that you are doing something wrong. The main limitation of any structured exercise protocol is compliance. Patients either do too little because they are afraid or too much because they are impatient. Both directions produce poor outcomes. The middle path is slow, boring, and exactly what works. There is no shortcut through the biological healing process, and no amount of aggressive stretching will make the humeral head fuse faster to the shaft. You are working within the constraints of bone biology, not against them.