What are the physical therapy recommendations for a patient with a surgical neck humerus fracture six weeks post‑injury with radiographic healing?

Physical Therapy Recommendations at 6 Weeks Post-Injury for Healing Surgical Neck Humerus Fracture

At 6 weeks post-injury with radiographic evidence of healing, initiate active range-of-motion exercises immediately without restrictions, focusing on shoulder, elbow, wrist, and hand motion, while avoiding above-chest-level activities until complete fracture consolidation is confirmed.

Evidence-Based Rehabilitation Protocol

Immediate Mobilization (Starting at 6 Weeks)

The strongest evidence supports early active mobilization once healing is noted. Begin range-of-motion exercises for the shoulder, elbow, wrist, and hand immediately 1. The traditional approach of prolonged immobilization (3+ weeks) is outdated and leads to worse outcomes.

• Active ROM exercises: Start with pendulum exercises, progressing to active-assisted and then active ROM in all planes
• Elbow, wrist, and hand motion: Essential from day one to prevent edema and stiffness 1
• Sling use: For comfort only and may be discarded as pain allows 1

Critical Restriction

Restrict above-chest-level activities until complete fracture healing is evident 1. This applies to both operative and non-operative management. Overly aggressive physical therapy may increase fixation failure risk in the postoperative period 1.

Supervised vs. Self-Directed Exercise

The evidence strongly favors a pragmatic approach. Instruction in self-training with periodic follow-up assessments is equally effective as supervised physiotherapy 2, 3. A 2026 randomized trial found supervised rehabilitation was comparable to a single advice session, with no clinically meaningful difference in Oxford Shoulder Score at 6 or 12 months 3.

Practical approach: Provide detailed home exercise instructions with scheduled reassessments rather than routine referral to supervised therapy for all patients. Reserve supervised therapy for patients with:

• Poor compliance or understanding
• Complications (stiffness, pain syndromes)
• Functional plateaus despite appropriate home exercise

Exercise Progression Timeline

Weeks 6-8 (Current phase):

• Active ROM in all planes below shoulder level
• Gentle stretching as tolerated
• Isometric strengthening exercises
• Focus on scapular stabilization

Weeks 8-12:

• Progress to above-shoulder-level activities once radiographic consolidation confirmed
• Begin rotator cuff strengthening (low resistance)
• Periscapular muscle strengthening
• Core musculature exercises 4

Beyond 12 weeks:

• Progressive resistance training
• Return to functional activities
• Address any residual deficits

Strength and Balance Training

Incorporate fall prevention strategies immediately 1. This includes:

• Core and lower extremity strengthening
• Balance and coordination exercises
• Single-leg balance training
• Timed up-and-go exercises

This is critical because proximal humerus fractures indicate fall risk and osteoporosis, predisposing to future fractures 1.

Key Clinical Pitfalls to Avoid

1. Prolonged immobilization: The evidence is clear that immobilization beyond 1-2 weeks leads to worse pain and function 5, 6. At 6 weeks, any remaining immobilization should be discontinued.

2. Overly aggressive therapy: While early motion is beneficial, forcing ROM or heavy resistance before adequate healing increases complication risk 1.

3. Ignoring the kinetic chain: Focus only on the shoulder misses the opportunity to address fall risk and overall functional decline 1.

4. Routine supervised therapy referral: This wastes resources without improving outcomes for most patients 3.

Expected Recovery Timeline

Greatest functional improvement occurs between 3-8 weeks post-injury 2. Patients typically report normal daily function by 8 weeks, though objective measures may take longer to normalize 2. By 16 weeks, most patients achieve near-maximal recovery with appropriate early mobilization 5.

Monitoring and Reassessment

Schedule follow-up at:

• 8 weeks: Assess ROM, pain, and functional progress
• 12 weeks: Confirm radiographic healing before advancing to unrestricted activities
• 16-24 weeks: Final assessment of functional outcome

Use objective measures: ROM (especially forward flexion and external rotation), strength testing (when appropriate), and patient-reported outcomes (DASH or Oxford Shoulder Score).

Adjunctive Interventions

Avoid electrotherapy and hydrotherapy - these do not enhance recovery 6. Joint mobilization has limited evidence of efficacy 6. Focus resources on active exercise and patient education.