What is the average time to start strengthening after a proximal humerus fracture?

Timing of Strengthening After Proximal Humerus Fracture

Strengthening exercises should begin at 6 weeks post-injury for most proximal humerus fractures, regardless of operative or nonoperative management. 1

Evidence-Based Timeline

The most comprehensive recent systematic review examining 3,507 patients with proximal humerus fractures found that strengthening most commonly started at 6 weeks across all management types (nonoperative, plate fixation, and intramedullary nailing). 1 This represents the current standard of care based on aggregated data from 40 studies published through 2024.

Progressive Rehabilitation Phases

Early Phase (0-3 weeks):

• Sling immobilization is typically maintained for 3 weeks. 1
• Pendulum exercises begin at post-intervention day 1 in most protocols. 1
• Passive range of motion exercises start at 2 days post-intervention. 1

Intermediate Phase (3-6 weeks):

• Active-assisted range of motion begins at 3 weeks. 1
• Active range of motion exercises start at 3 weeks. 1
• Unlimited range of motion is permitted at 4-6 weeks. 1
• Non-weight-bearing restrictions are maintained for 6 weeks when applicable. 1

Strengthening Phase (6+ weeks):

• Formal strengthening exercises targeting the rotator cuff (supraspinatus, infraspinatus, teres minor, subscapularis) and periscapular muscles begin at 6 weeks. 2, 1
• All restrictions are typically removed at 6 weeks. 1

Functional Recovery Timeline

The greatest improvement in function occurs between 3 and 8 weeks post-injury. 3 Patients typically report their daily life functions as normal by 8 weeks, though objective assessments may normalize later. 3

Normal upper limb function is regained at an average of 21-27 weeks (approximately 5-7 months) after fracture. 4 This timeline applies to both operatively and nonoperatively managed fractures, with no significant differences in functional outcomes between treatment methods. 4

Important Clinical Considerations

Psychological factors significantly influence recovery:

• Kinesiophobia (fear of movement) measured within the first week post-injury is the strongest early predictor of limitations at 6-9 months (accounting for 14% of variance). 5
• Self-efficacy measured at 2-4 weeks is the strongest predictor overall (accounting for 26.6% of variance in outcomes). 5
• These modifiable psychological factors should be addressed early through enhanced communication and cognitive behavioral approaches. 5

Protocol variability exists but outcomes are similar:

• Despite substantial variability in published rehabilitation protocols, functional outcomes remain comparable across different approaches. 1, 3
• Both supervised physiotherapy and instruction in self-training with follow-up control produce equivalent results. 3

Special Population: Skeletally Immature Patients

For adolescents with proximal humeral epiphysiolysis (Little League shoulder), a completely different timeline applies: eliminate throwing for a minimum of 6 weeks after diagnosis, followed by an additional 6 weeks during the strengthening phase, for a total of at least 3 months of rest from throwing. 6, 2

Common Pitfalls to Avoid

• Do not delay strengthening beyond 6 weeks without specific contraindications. Prolonged immobilization leads to rapid bone loss (1% per week) and muscle strength loss (15% of lower extremity strength after just 10 days of bed rest). 6
• Address kinesiophobia early. Fears of movement or reinjury within the first week significantly impair long-term recovery. 5
• Monitor for complications. Patients who develop complications demonstrate significantly worse range of motion and lower functional scores. 7