What can an adult patient with no significant medical history take for muscle atrophy due to a fracture of the greater tuberosity?

Management of Muscle Atrophy Following Greater Tuberosity Fracture

For an adult patient with muscle atrophy following a greater tuberosity fracture, initiate early physical training and muscle strengthening exercises beginning within the first week after injury, combined with adequate calcium (1000-1200 mg/day) and vitamin D (800 IU/day) supplementation. 1

Rehabilitation Protocol

Early Phase (Week 1-3)

• Begin rehabilitation within the first week after injury to prevent prolonged muscle atrophy and optimize functional recovery. 2, 3
• Implement physical analgesic therapy means to control pain and facilitate early mobilization. 2
• Initiate pendular and passive range-of-motion exercises during the immobilization period. 2, 3
• Avoid prolonged immobilization beyond 3 weeks, as extended bed rest accelerates bone loss and muscle weakness. 4

Active Rehabilitation Phase (Week 3-6)

• Progress to active-assisted exercises starting at 3 weeks post-injury, focusing on shoulder, elbow, wrist, and hand motion. 5, 2, 3
• Implement positioning, splinting, and muscle stretching to preserve joint mobility and skeletal muscle length. 1
• For patients unable to perform voluntary muscle contractions, consider neuromuscular electrical stimulation (NMES) applied daily for at least 6 weeks to prevent disuse muscle atrophy. 1

Strengthening Phase (Week 6 onwards)

• Commence active strengthening exercises at 6 weeks, using low-resistance multiple repetitions (3 sets of 8-10 repetitions at 50-70% of 1 repetition maximum). 1
• Continue progressive muscle strengthening exercises long-term, as the rehabilitation program becomes similar to that for rotator cuff disease after fracture healing. 5, 2
• Implement proprioceptive stabilization exercises to improve shoulder function. 2

Pharmacological Support

Nutritional Supplementation

• Prescribe calcium 1000-1200 mg/day plus vitamin D 800 IU/day, which reduces non-vertebral fractures by 15-20% and falls by 20%. 1, 4, 6
• Avoid high pulse dosages of vitamin D as they increase fall risk. 1, 4
• Calcium supplementation alone has no demonstrated fracture reduction effect and should not be used without vitamin D. 1, 4

Muscle Relaxants (If Needed)

• Cyclobenzaprine may be used as an adjunct to rest and physical therapy for relief of muscle spasm associated with acute, painful musculoskeletal conditions, but only for short periods (up to 2-3 weeks). 7
• This medication is indicated only for acute muscle spasm relief and should not be used for prolonged periods. 7

Long-Term Management

Balance and Fall Prevention

• Establish long-term balance training and multidimensional fall prevention programs, which reduce fall frequency by approximately 20%. 1, 4
• Continue muscle strengthening exercises indefinitely, as patients with avulsion fractures should actively maintain muscle strength even after more than a decade. 8

Monitoring for Complications

• Assess for rotator cuff tears and muscle atrophy, as 16% of patients develop full rotator cuff tears and significant atrophy (>50%) of the supraspinatus and infraspinatus correlates with the worst functional outcomes. 9
• Monitor for residual displacement of the greater tuberosity, as displacement ≥7mm combined with muscle atrophy is associated with poor outcomes. 9
• Evaluate for subacromial impingement, which occurs in 57% of patients and correlates with decreased function. 9

Critical Pitfalls to Avoid

• Do not delay rehabilitation beyond the first week, as earlier rehabilitation allows rapid range of motion and functional recovery while limiting care duration. 2
• Do not allow prolonged immobilization beyond 3 weeks, as this accelerates bone loss, muscle weakness, and increases risk of deep vein thrombosis and pressure ulcers. 4, 6
• Do not use calcium supplementation alone without vitamin D and appropriate rehabilitation, as this provides no fracture reduction benefit. 1, 4
• Be aware that full recovery may take an average of 8 months, and patients should be counseled accordingly to maintain realistic expectations. 3

Expected Outcomes

• With appropriate rehabilitation, the Constant shoulder score typically improves from 40 points at baseline to 95 points at final follow-up (average 31 months). 3
• Pain and decreased range of motion typically resolve within 8.1 months from the time of injury. 3
• Patients with severe baseline pain or advanced age may experience poorer functional results. 2