Proximal Humerus Fracture: Overview and Evidence Summary

Condition Overview

A proximal humerus fracture is an injury involving the upper segment of the humerus near the shoulder joint, typically affecting the surgical neck, greater tuberosity, lesser tuberosity, or the articular surface itself. Although these fractures can occur across all age groups, they are particularly common in older adults, where reduced bone density, balance deficits, and falls create a perfect storm for injury. In younger individuals, proximal humerus fractures more often result from high-energy trauma—motor vehicle accidents, contact sports collisions, or falls from height.

Because the shoulder is a highly mobile joint with a delicate balance of stability and freedom, fractures around the proximal humerus frequently disrupt not only bone integrity but also the function of surrounding soft tissues. The rotator cuff inserts around the tuberosities, and any displacement of these bony landmarks alters the biomechanics of the entire shoulder complex. Even when bones heal well radiographically, patients may experience persistent weakness, stiffness, or altered coordination if rehabilitation is insufficient or delayed.

Symptoms at the time of injury are often unmistakable: severe pain, inability to lift the arm, swelling, bruising, and tenderness over the upper arm. In some cases, deformity or abnormal contour may be visible, though fractures can sometimes appear deceptively benign externally. Many patients instinctively cradle the injured arm to reduce movement, a protective strategy that unfortunately contributes to early stiffness if maintained too long.

Healing potential depends on the fracture pattern and degree of displacement. Neer’s classification, while imperfect, offers a framework for understanding severity based on how many "parts" of the proximal humerus are displaced or angulated. The good news is that the majority of proximal humerus fractures are minimally displaced and can be managed without surgery. These injuries respond remarkably well to conservative care when rehabilitation begins at the appropriate time.

Pain and functional limitations can persist for months, but with well-guided therapy, the shoulder often recovers excellent function. In more complex fractures—especially those involving multiple displaced fragments, head-splitting fractures, or compromised blood supply to the humeral head—surgery may be required, ranging from fixation to shoulder replacement. Even in these cases, rehabilitation remains central to restoring meaningful movement and quality of life.

Summary of Current Evidence for Proximal Humerus Fracture

Evidence-Based Management Discussion

Fracture Mechanics and Why the Shoulder Behaves Uniquely After Injury

The proximal humerus plays a crucial role in shoulder mobility. The humeral head articulates with the shallow glenoid fossa, relying heavily on soft tissues for stability. The greater and lesser tuberosities serve as insertion points for the rotator cuff muscles, and even small shifts in their position can disrupt the mechanics of lifting, rotating, or stabilizing the arm.

Fractures near the surgical neck often spare the articular surface but can lead to significant functional impairment due to pain and early immobilization. Fractures involving the tuberosities are more clinically significant, as they directly influence rotator cuff function; if a tuberosity heals in a malposition, the corresponding rotator cuff muscle may lose its mechanical efficiency permanently.

The vascular supply to the humeral head—particularly the anterior humeral circumflex artery—is another important consideration. Certain fracture patterns risk compromising this blood supply, increasing the possibility of avascular necrosis. While relatively uncommon, this complication informs some surgical decision-making.

Clinical Presentation and Functional Limitations

Immediately after injury, patients often cannot raise the arm and experience deep, throbbing pain exacerbated by movement. Bruising over the upper arm and chest wall frequently develops within 24–48 hours. Sleep becomes difficult, especially lying flat or on the affected side. Even simple tasks—reaching for a glass, brushing teeth, or dressing—may be impossible in the early days.

As pain settles in the following weeks, stiffness becomes the primary challenge. If mobilization is delayed too long, adhesive capsulitis or long-term loss of range can develop. Conversely, moving too early or too aggressively can risk displacement of the healing fracture. This creates a delicate balancing act in rehabilitation: protecting the fracture while preventing secondary complications.

Exercise Therapy

Exercise progression is highly dependent on fracture type, healing stage, and patient comfort.

Phase 1: Protection and Pain Management (0–3 Weeks)

Initially, the shoulder is immobilized in a sling, typically for comfort rather than absolute restriction. During this period:

• Pendulum exercises maintain gentle joint motion

• Elbow, wrist, and hand mobility exercises prevent stiffness

• Posture training helps reduce secondary neck or upper-back tension

Movement must be pain-free and subtle. The goal is to maintain circulation, reduce swelling, and preserve as much passive mobility as is safe.

Phase 2: Early Passive and Active-Assisted Movement (3–6 Weeks)

As pain decreases and healing progresses:

• Passive elevation within a safe arc becomes appropriate

• Active-assisted movements using a cane or pulley help rebuild mobility

• Gentle external rotation exercises restore early functional motion

Restoring passive range at this stage significantly reduces the risk of developing long-term stiffness.

Phase 3: Active Movement and Light Strengthening (6–10 Weeks)

Once the fracture has begun consolidating:

• Active movement resumes through larger arcs of motion

• Isometric rotator cuff engagement begins

• Scapular strengthening helps restore coordinated motion

The challenge here is rebuilding confidence and preventing compensatory movement patterns that may have developed during immobilization.

Phase 4: Progressive Strengthening and Functional Training (10+ Weeks)

As healing solidifies:

• Strengthening of the rotator cuff, deltoid, and scapular stabilizers expands

• Endurance training supports sustained functional activity

• Functional lifting, reaching, and overhead tasks are gradually reintroduced

Full recovery may take 6–12 months, especially in older adults or in complex fracture patterns.

Manual Therapy

Once fracture healing is sufficiently advanced, manual therapy becomes invaluable. Joint mobilizations help reduce capsular tightness, while soft tissue treatment reduces guarding in the deltoid, biceps, pectorals, and upper trapezius. Mobilization-with-movement techniques can improve comfort during functional activities.

Manual therapy plays a particularly important role in preventing or resolving secondary adhesive capsulitis—a common complication in proximal humerus fractures.

Pain Management and Osteoporosis Considerations

Early pain control supports better rehabilitation participation. NSAIDs, acetaminophen, and short-term opioid use (when appropriate) may be beneficial. Given the strong connection between proximal humerus fractures and osteoporosis, patients—especially older adults—benefit from evaluation and management of bone health, including vitamin D, calcium, and bisphosphonate therapy when indicated.

When Injections or Surgery Are Appropriate

Corticosteroid injections are not part of early fracture care but may be considered later if a patient develops secondary adhesive capsulitis. Surgery becomes necessary in cases of:

• Significant displacement

• Multi-part fractures

• Tuberosity involvement compromising cuff function

• Fracture-dislocations

• Poor healing potential in osteoporotic bone

Surgical options include open reduction and internal fixation (ORIF), intramedullary nailing, hemiarthroplasty, or reverse total shoulder arthroplasty (especially in older adults with cuff tear arthropathy).

Clinical Considerations for Therapists

Therapists must pace rehabilitation carefully, respecting the biology of bone healing while preventing long-term dysfunction. Key responsibilities include:

• Maintaining communication with the referring physician

• Avoiding premature loading

• Monitoring for signs of adhesive capsulitis

• Ensuring movement quality rather than compensatory patterns

• Reassuring patients about the timeframes involved in full recovery

A well-structured, collaborative approach leads to excellent outcomes in most cases.

References

Court-Brown, C., et al. “Epidemiology and Management of Proximal Humerus Fractures.” Journal of Orthopaedic Trauma, 2006–2020 updates.

Neer, C. “Displaced Proximal Humeral Fractures: Classification and Evaluation.” Journal of Bone & Joint Surgery, 1970 and modern updates.

Handoll, H., et al. “Conservative vs. Surgical Treatment of Proximal Humerus Fractures.” Cochrane Review, multiple updates.

Hertel, R. “Predicting Risk of Avascular Necrosis in Humeral Head Fractures.” Journal of Shoulder and Elbow Surgery, 2004 and updates.

Bishop, J., et al. “Outcomes of Rehabilitation Following Proximal Humerus Fractures.” Clinical Orthopaedics and Related Research, 2009.

Disclaimer

The information in this article is intended for educational purposes and is designed for qualified massage therapists, manual therapists, and rehabilitation professionals. It is not a substitute for medical advice, diagnosis, or treatment. Practitioners must work within their legal scope of practice and regional regulations. Hands-on techniques should only be performed by appropriately trained and licensed individuals. Niel Asher Education is not responsible for any injury, loss, or damage resulting from the use of this content.