Proximal humerus fractures are breaks in the upper part of the arm bone (humerus) near the shoulder joint. This region includes the humeral head, anatomical neck, surgical neck, and the greater and lesser tuberosities where the rotator cuff muscles attach. These fractures can significantly affect shoulder movement, strength, and function.
Proximal humerus fractures commonly occur after a fall onto an outstretched arm or directly onto the shoulder. In older adults, they are frequently associated with low-energy falls and reduced bone density, while in younger individuals they usually result from higher-energy trauma such as sporting collisions or motor vehicle accidents.
Symptoms range from mild pain and stiffness in stable fractures to severe pain, swelling, and loss of shoulder movement in displaced injuries. Many proximal humerus fractures can be managed without surgery, while others require operative fixation or shoulder replacement depending on fracture pattern, displacement, and patient factors.
Physiotherapy for proximal humerus fractures is essential for restoring shoulder mobility, rebuilding strength, and achieving functional recovery. Early, appropriately timed rehabilitation helps minimise stiffness, which is one of the most common long-term complications.
Key Facts
- Proximal humerus fractures account for approximately 5–6% of all fractures and are among the most common fractures in older adults.
- Most proximal humerus fractures are minimally displaced and can be managed non-operatively with good outcomes. 🔗
- Shoulder stiffness is a common complication following proximal humerus fracture, particularly when immobilisation is prolonged.
- Physiotherapy-guided rehabilitation improves functional outcomes following proximal humerus fracture.
- 86% of proximal humerus fractures occur in those over 50. However, they can also present in younger individuals following high energy trauma 🔗
Risk Factors
- Increasing age and reduced bone density.
- Falls, particularly onto an outstretched arm.
- Balance impairments or previous falls.
- High-energy trauma such as sports or motor vehicle accidents.
- Previous shoulder injury or surgery.
Symptoms
- Pain in the shoulder or upper arm after a fall or trauma.
- Swelling and bruising around the shoulder and upper arm.
- Difficulty or inability to lift the arm.
- Pain with shoulder movement or when lying on the affected side.
- Visible deformity in more severe or displaced fractures.
- Reduced shoulder range of motion as pain and stiffness develop.
Aggravating Factors
- Attempting to lift or reach with the affected arm.
- Rolling onto the injured shoulder in bed.
- Pushing, pulling, or carrying objects.
- Sudden or uncontrolled shoulder movements.
- Accidental knocks or bumps to the shoulder.
Causes
Proximal humerus fractures typically occur when a force is transmitted through the arm to the shoulder, such as during a fall onto an outstretched hand or directly onto the shoulder. The bone fails when the applied force exceeds its strength.
In older adults, reduced bone density means lower-energy falls can result in fracture. In younger individuals, these fractures usually occur following higher-energy trauma and may be associated with additional injuries.
The pattern of fracture depends on the direction of force, arm position at the time of injury, and muscle pull from the rotator cuff. Displacement can occur due to muscle forces pulling fracture fragments apart.
From a physiotherapy perspective, understanding fracture stability, displacement, and healing timelines is essential to guide safe progression of shoulder movement and strengthening.
How Is It Diagnosed?
Proximal humerus fractures are diagnosed through a combination of clinical assessment and imaging. A fracture is suspected when there is significant shoulder pain, swelling, and loss of movement following trauma.
On examination, there may be tenderness around the shoulder, bruising extending down the arm, and pain with any attempt to move the shoulder. Physiotherapists play an important role in recognising possible fractures and referring promptly for imaging.
Once the fracture has been diagnosed, physiotherapists use the imaging report, fracture type, and medical guidance to plan appropriate rehabilitation timing and progression.
Investigations & Imaging
- X-ray
- Primary imaging to confirm the presence, location, and displacement of a proximal humerus fracture.
- CT scan
- Used when fracture complexity needs further clarification or for surgical planning.
- MRI
- Occasionally used to assess associated soft tissue injuries such as rotator cuff tears.
Grading / Classification
- Non-displaced fracture
- Fracture fragments remain aligned and are often managed non-operatively.
- Displaced fracture
- Fragments are separated or angulated and may require surgical intervention depending on severity.
- Neer classification
- Commonly used system classifying fractures based on the number of displaced parts, guiding treatment decisions.
Physiotherapy Management
Physiotherapy for proximal humerus fractures focuses on restoring shoulder movement, strength, and function while respecting fracture healing timelines. Rehabilitation is tailored to fracture type, treatment method, and individual goals.
Early physiotherapy emphasises pain control and safe movement to reduce stiffness, followed by progressive strengthening and functional retraining.
Exercise
Proximal humerus fracture physiotherapy exercises usually begin with gentle, supported range-of-motion exercises once cleared by the treating doctor or surgeon.
As healing progresses, exercises advance to active shoulder movement, rotator cuff strengthening, scapular control, and functional tasks such as reaching and lifting.
Activity Modification
Activity modification is essential early, including use of a sling and avoidance of lifting or overhead tasks. Gradual reintroduction of activities is guided by pain, movement, and strength recovery.
Manual Therapy
Manual therapy may be used later in rehabilitation to address shoulder stiffness and improve movement quality once fracture healing allows.
Heat & Ice
Ice can help manage pain and swelling in the early stages. Heat may assist with stiffness later when appropriate.
Education
Education is vital to help patients understand healing timelines, the importance of gradual progression, and strategies to avoid reinjury.
Other
Other considerations include fall prevention strategies, workplace modifications, and coordination with medical teams.
Other Treatments
Other treatments may include sling immobilisation, pain relief prescribed by a doctor, and follow-up imaging to monitor fracture healing.
Surgery
Surgery may be required for significantly displaced, unstable, or complex proximal humerus fractures. Surgical options include fixation with plates and screws or shoulder replacement in severe cases.
Physiotherapy is essential after surgery to restore movement, strength, and functional independence.
Prognosis & Return to Activity
The prognosis for proximal humerus fractures is generally good, particularly for minimally displaced fractures managed conservatively.
Recovery timelines vary, with bone healing typically occurring over 6–8 weeks, while full shoulder function may take several months. Consistent physiotherapy is key to minimising long-term stiffness and weakness.
Complications
- Shoulder stiffness and reduced range of motion.
- Persistent shoulder weakness.
- Rotator cuff dysfunction.
- Post-traumatic shoulder arthritis in severe cases.
Preventing Recurrence
- Address balance and fall risk, particularly in older adults.
- Maintain shoulder strength and mobility once recovered.
- Optimise bone health through exercise and medical care.
When to See a Physio
- You have shoulder pain and limited movement after a fall.
- You have been diagnosed with a proximal humerus fracture and need rehabilitation guidance.
- Your shoulder stiffness or weakness is not improving as expected.