Shoulder greater trochater fracture physiotherapy

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The library has good content on fracture classification and management but limited physiotherapy-specific protocols. I'll now compile a comprehensive, evidence-based physiotherapy answer from the textbook content plus established clinical knowledge.

Clarification First

Quick anatomical note: The greater trochanter is on the femur (hip). The equivalent structure on the shoulder/humerus is the greater tubercle. I'll cover physiotherapy for both, as this is a common mix-up:

If you meant the shoulder → Greater Tubercle of Humerus Fracture
If you meant the hip → Greater Trochanter Fracture

Greater Tubercle of Humerus Fracture — Physiotherapy

Anatomy & Clinical Significance

The greater tubercle is the bony prominence on the proximal humerus where the supraspinatus, infraspinatus, and teres minor (rotator cuff) attach. Fractures here are often associated with rotator cuff tears, and significant displacement (>5 mm) implies rotator cuff disruption requiring surgical repair.

"Significant displacement of a greater tuberosity fracture implies a concomitant rotator cuff tear, with surgical repair often necessary for the active patient." — Tintinalli's Emergency Medicine

Physiotherapy Rehabilitation Phases

Phase 1 — Acute/Protective Phase (Weeks 0–3)

Goals: Pain and swelling control, protect healing bone, prevent joint stiffness

Immobilization in a sling/sling-and-swathe for 2–4 weeks (non-displaced or minimally displaced fractures)
Cryotherapy — ice application 15–20 min, 3–4× daily to reduce pain and swelling
Pendulum (Codman) exercises — gentle gravity-assisted shoulder circumduction starting when pain allows (Day 1–7 post-injury for non-displaced)
Elbow, wrist, and hand active range of motion — full fist, wrist flexion/extension, elbow flexion/extension to prevent disuse stiffness
Cervical spine mobility — gentle neck ROM to prevent referred stiffness
Posture education — avoid shoulder girdle elevation and protraction

Phase 2 — Early Mobilization Phase (Weeks 3–6)

Goals: Restore passive and active-assisted ROM, reduce pain

Passive ROM — supported shoulder flexion, abduction (avoiding impingement arc 70–120°), external and internal rotation in scapular plane
Active-assisted ROM — pulleys, wand/stick exercises for elevation and rotation
Scapular stabilization — scapular retraction and depression (no rotator cuff load yet)
Sling weaning — gradual discontinuation of sling by week 4–6 (non-displaced)
Hydrotherapy — if available, buoyancy-assisted shoulder movement is well-tolerated
Joint mobilization — Grade I–II glenohumeral and acromioclavicular mobilization for pain modulation

Target ROM milestones by Week 6:

Movement	Target
Flexion	90–120°
External rotation	30–45°
Abduction	90°

Phase 3 — Progressive Strengthening (Weeks 6–12)

Goals: Restore active ROM, begin rotator cuff and periscapular strengthening

Cleared only after radiological evidence of fracture healing and surgeon approval

Rotator cuff strengthening — isometric → isotonic with Thera-Band:
- External rotation (side-lying or standing)
- Internal rotation
- Supraspinatus — "empty can" or "full can" in scapular plane
Deltoid strengthening — side-lying abduction, forward flexion
Scapular stabilizers — rows, shrugs, wall push-ups
Periscapular muscles — serratus anterior, trapezius (middle and lower)
Proprioception — closed kinetic chain exercises on unstable surfaces

Phase 4 — Functional/Return-to-Activity Phase (Weeks 12–24)

Goals: Full ROM, full strength, return to work/sport

Progressive resistance training — dumbbell presses, rows, overhead activities
Functional task training — reaching overhead, behind-back, and carrying
Sport/occupation-specific exercises — throwing progressions, racquet sports, manual labour tasks
Glenohumeral joint stabilization — PNF patterns, dynamic stabilization drills
Full ROM target — by 3–4 months

Surgical Cases (ORIF / Suture Anchor Repair)

Post-operative rehabilitation is more conservative:

Weeks 0–4: Strict sling immobilization; pendulums only
Weeks 4–8: Passive and active-assisted ROM
Weeks 8–12: Begin rotator cuff strengthening
Weeks 12+: Progressive resistance and return to sport

Complications to Monitor During Physio

Complication	Signs	Action
Adhesive capsulitis (frozen shoulder)	Painful end-range restriction in all planes	Aggressive but pain-free stretching, joint mobilization
Rotator cuff tear	Weakness in external rotation/abduction, positive lag signs	Refer back to surgeon
Malunion	Bony block to movement, pain at arc	Imaging; modify program
Axillary nerve injury	Deltoid weakness, lateral shoulder numbness	Nerve conduction study; modify exercises
Subacromial impingement	Pain 70–120° arc	Scapular control, posture correction, avoid arc

Key Outcome Measures

Constant-Murley Score — functional shoulder assessment
DASH / QuickDASH — upper limb disability
ASES (American Shoulder and Elbow Surgeons) Score
NRS/VAS — pain

If You Meant Greater Trochanter Fracture (Hip)

Greater trochanter fractures of the hip (where gluteus medius/minimus and short external rotators attach) follow a different protocol:

Phase 1 (0–4 weeks): Partial weight-bearing with crutches/walker; hip abductor protection; avoid active abduction
Phase 2 (4–8 weeks): Progressive weight-bearing; gentle hip abductor strengthening (isometric → isotonic); gait retraining
Phase 3 (8–12 weeks): Full weight-bearing; Trendelenburg strengthening; balance and proprioception; hip strengthening in all planes
Phase 4 (12+ weeks): Return to full function; advanced strengthening; sport-specific training

Let me know if you want me to focus specifically on the shoulder (greater tubercle) or hip (greater trochanter), or if you'd like more detail on any particular phase.

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