Nonoperative management of proximal humerus fractures typically begins with maximal support using a sling. The progression to motion and strengthening exercises is guided by patient comfort, fracture healing, and radiographic confirmation.
Summary of Phases
Phase I (Weeks 0–3): Immobilization, pendulums, isometrics, sling use
Phase II (Weeks 3–6): Active-assisted motion, therapy tools, light strengthening
Phase III (Week 6 and beyond): Full AROM, progressive strengthening, functional return
Phase I – Immobilization Phase (Weeks 0–3)
Goals:
Protect fracture site
Minimize pain and inflammation
Initiate early motion without compromising stability
Precautions:
Full-time sling use, including during sleep, for 2–3 weeks
Avoid active shoulder use; hand and wrist use encouraged
Sleep in a reclined or upright position if uncomfortable
Therapeutic Activities:
Pendulum exercises as tolerated
Active hand and forearm use
Isometric scapular and shoulder girdle exercises as tolerated
Monitoring:
Obtain X-rays to rule out displacement
Phase II – Assisted Motion Phase (Weeks 3–6)
Goals:
Begin active-assisted motion
Maintain mobility and alignment
Prevent stiffness
Therapeutic Activities:
Active-assisted shoulder motion (flexion and abduction)
Begin use of shoulder therapy tools if needed:
Exercise bar: Use opposite arm to guide passive motion
Pulley system: Allows passive forward flexion
Continue isometric exercises and progress as tolerated
Phase III – Progressive Strengthening Phase (Week 6 and Beyond)
Goals:
Restore full active range of motion (AROM)
Improve strength and endurance
Return to functional activities
Therapeutic Activities:
Initiate isotonic strengthening as tolerated
Focus on forward flexion before abduction against gravity
Use elastic resistance bands, progressing to machines and free weights
Monitor rotator cuff strength
Caution:
Weakness or poor progression may indicate rotator cuff tear requiring further evaluation
Key Considerations
Pitfalls – Shoulder Stiffness:
Discontinue immobilization early if appropriate
Encourage pendulum exercises and assisted motion
Initiate formal PT if progress stalls
Special Circumstances:
Glenohumeral Dislocation: Sling and swath use may improve comfort and reduce redislocation risk
Weight Bearing: Avoid until fracture healing is secure
Implant Removal: Only indicated with symptoms like loosening or impingement
