What physical therapy exercises are appropriate for a 4‑week‑old comminuted, impacted, displaced left proximal humerus fracture with minimal healing?

Physical Therapy for 4-Week-Old Comminuted, Impacted, Displaced Proximal Humerus Fracture with Minimal Healing

At 4 weeks post-fracture with minimal healing, you should initiate passive range of motion (ROM) exercises immediately, starting with pendulum exercises and therapist-assisted passive ROM, while continuing sling immobilization between exercise sessions for another 2 weeks, then progressing to active-assisted ROM at 6 weeks.

Current Phase: Transition from Immobilization to Early Mobilization

At 4 weeks post-injury with minimal healing evidence, this fracture is in a critical window. The literature demonstrates substantial variability in rehabilitation protocols 1, but the most recent systematic review shows that passive ROM most commonly starts at 2 days to 3 weeks post-injury, with active-assisted ROM typically beginning at 3 weeks 1.

Immediate Interventions (Weeks 4-6)

Passive Range of Motion:

• Begin pendulum exercises immediately - these are safe and reported in 21 cohorts as starting at post-intervention day 1 1
• Therapist-guided passive ROM in all planes (flexion, extension, abduction, internal/external rotation)
• Perform 2-3 sessions per week with a trained physical therapist 2
• Each session should include gentle stretching to the point of tension, not pain
• Continue sling use between therapy sessions for 2 more weeks (total 6 weeks immobilization) 1, 3

Critical Caveat: For comminuted fractures with minimal healing at 4 weeks, you must balance early mobilization against fracture stability. A 2017 randomized controlled trial 2 comparing intensive versus conventional mobilization in impacted osteoporotic fractures found that conventional mobilization (10 sessions of passive motion twice weekly) was equally effective and had better patient compliance (97.5% vs 90%) than aggressive protocols.

Weeks 6-8: Active-Assisted ROM Phase

Progress to active-assisted exercises at 6 weeks:

• Patient uses the unaffected arm or therapist assistance to move the injured shoulder
• Perform 3 sessions per week 2
• Include all planes of motion: flexion, abduction, internal/external rotation
• Discontinue sling use at 6 weeks 1
• Add gentle stretching exercises holding 10-30 seconds per stretch, 2-4 repetitions 4

Evidence shows that minimally displaced fractures treated with this staged protocol (3 weeks immobilization, 3-6 weeks passive/active-assisted, then active exercises at 6+ weeks) achieve average Constant scores of 95/100 at final follow-up 3.

Weeks 8-12: Active ROM and Early Strengthening

At 8 weeks post-fracture:

• Begin active ROM exercises without assistance
• Start with low-resistance exercises using 10-15 repetitions 4
• Focus on rotator cuff strengthening and scapular stabilization 5
• Perform exercises 2-3 days per week on non-consecutive days 4

Strengthening protocol:

• Use light resistance (40-50% of 1-repetition maximum) 4
• Target all major shoulder muscle groups: rotator cuff, deltoid, scapular stabilizers
• Avoid overhead activities and heavy lifting until 12 weeks minimum 1

Weeks 12+: Progressive Strengthening

After 12 weeks with radiographic evidence of healing:

• Progress to moderate resistance (60-70% of 1-repetition maximum) 4
• Increase to 8-12 repetitions per set 4
• Add functional exercises mimicking daily activities
• Continue 2-3 sessions per week 4

Specific Exercise Prescription

Weeks 4-6 (Passive Phase):

• Pendulum exercises: 5-10 minutes, 2-3 times daily
• Supine passive flexion with opposite arm assistance: 10 repetitions, 2 sets
• Passive external rotation with stick: 10 repetitions, 2 sets
• Therapist-guided passive ROM: all planes, 2-3 sessions/week

Weeks 6-8 (Active-Assisted Phase):

• Pulley-assisted flexion: 10-15 repetitions, 2 sets
• Stick-assisted external rotation: 10-15 repetitions, 2 sets
• Wall walks for flexion: progress distance gradually
• Supine active-assisted exercises: all planes

Weeks 8-12 (Active ROM Phase):

• Active flexion/abduction: 10-15 repetitions, 2 sets
• Isometric rotator cuff exercises: hold 5-10 seconds, 10 repetitions
• Scapular retraction exercises: 10-15 repetitions, 2 sets
• Light resistance band exercises: external/internal rotation

Critical Warnings

Stop exercises immediately if:

• Sharp pain develops during movement (dull ache is acceptable)
• Swelling or warmth increases in the shoulder
• Any grinding or clicking sensations occur
• Pain persists more than 2 hours after exercise 6

Common pitfalls to avoid:

• Starting active ROM too early (before 6 weeks) risks fracture displacement
• Excessive passive stretching causing pain can delay healing
• Skipping the passive ROM phase leads to stiffness and poor outcomes 7
• Patient non-compliance with gradual progression - studies show 8 months average for full recovery 3

Pain Management During Rehabilitation

• Expect some discomfort during exercises - this is normal
• Use ice for 15-20 minutes after therapy sessions 5
• Pain should not exceed 4/10 during exercises
• If pain persists beyond 2 hours post-exercise, reduce intensity 8

Expected Timeline

Realistic expectations: Full recovery from a comminuted, displaced proximal humerus fracture takes 8-12 months on average 3. At 4 weeks with minimal healing, you are in the early phase. Most patients achieve 95% of final shoulder function by 6-12 months with proper rehabilitation 3, 9.

The key is controlled stress application to the fracture site through graduated ROM exercises, which optimizes bone repair without increasing complication rates 7. This requires close coordination between the orthopedic surgeon and physical therapist to ensure fracture stability is maintained while preventing the harmful effects of prolonged immobilization.