Early Range of Motion for Mildly Displaced Proximal Humerus Fractures
Range of motion exercises should begin within the first postoperative days (or within the first week for non-operative management), with strengthening delayed until 6 weeks when fracture healing is evident.
Initial Mobilization Phase (Days 1-7)
For mildly displaced and angulated proximal humerus fractures, the evidence strongly supports early mobilization regardless of whether the fracture is managed operatively or non-operatively. Begin pendulum exercises and passive range of motion within the first few days to one week after injury 1. This early approach has been validated by multiple recent randomized trials showing improved short-term functional outcomes without increasing complication rates 2, 3.
Specific Early Exercises Include:
- Pendulum exercises: Start immediately or within days
- Passive ROM: Shoulder, elbow, wrist, and hand motion within first postoperative days
- Sling use: For comfort only, can be discarded as pain allows (typically around 3 weeks) 4
The 2025 meta-analysis demonstrates that early mobilization (within one week) provides moderate-certainty evidence for improved function at 3 months compared to delayed mobilization, with no increase in secondary fracture displacement or complications 2.
Critical Restriction Period (Weeks 1-6)
Above chest level activities must be restricted until fracture healing is evident 1. This is a crucial caveat that applies to both operative and non-operative management. Overly aggressive physical therapy during this period increases the risk of fixation failure in surgical cases and displacement in non-operative cases 1.
Progressive Mobilization Timeline:
- Weeks 1-3: Passive ROM and pendulum exercises only
- Week 3: Begin active-assisted ROM exercises 4
- Week 4-6: Progress to unlimited ROM below shoulder level 4
- Week 6: Remove all restrictions, begin strengthening exercises 4
Strengthening Phase (6+ Weeks)
Strengthening exercises should not begin until 6 weeks post-injury when fracture healing is evident 4. This timing is consistent across multiple rehabilitation protocols and represents the point at which bone stability allows resistance training without risk of displacement or fixation failure.
The guideline evidence emphasizes that while early ROM is beneficial, overly aggressive physical therapy before healing increases fixation failure risk 1. This creates a critical balance: early gentle motion prevents stiffness, but premature strengthening jeopardizes fracture stability.
Key Clinical Pitfalls to Avoid
Do not delay all motion for 3-4 weeks: Traditional immobilization protocols are outdated. Recent evidence shows delayed mobilization provides no benefit and may worsen short-term outcomes 2, 3, 5
Do not allow overhead activities before 6 weeks: Even with early ROM, above-chest-level movements must wait until healing is confirmed 1
Do not start strengthening before 6 weeks: The most common error is progressing too quickly to resistance exercises, which risks displacement 4
Evidence Quality Note
The recommendation for early mobilization is supported by high to moderate certainty evidence from recent systematic reviews and meta-analyses of randomized trials 2, 3. The 2025 meta-analysis specifically provides the strongest evidence, showing early mobilization is safe and effective 2. The guideline recommendations from EULAR/EFORT (2017) provide the framework for timing restrictions on overhead activities and strengthening 1.