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Frame a deatil physiotherapht protocol for this patinet with exercise and their doses
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clavicle fracture ORIF physiotherapy rehabilitation protocol
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clavicle ORIF physiotherapy protocol phases exercises doses evidence based 2024
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https://www.massgeneral.org/assets/MGH/pdf/orthopaedics/spor…
I now have everything needed to frame a comprehensive, evidence-based physiotherapy protocol. Here it is:
Physiotherapy Protocol: Left Clavicle Midshaft Fracture - Post ORIF
Imaging Findings
X-ray (AP Right chest/shoulder): Left clavicle midshaft fracture treated with Open Reduction and Internal Fixation (ORIF) - superior locking reconstruction plate with 6-7 cortical screws, good bony alignment, no hardware failure visible.
General Precautions (All Phases)
- No lifting > 1 lb until Phase III
- No behind-the-back reaching until 8 weeks
- No contact sports until surgeon clearance (~4-6 months)
- Monitor for signs of hardware irritation, wound complications, or neurovascular changes (tingling, paraesthesia in arm)
- All exercises guided by pain - do NOT push through sharp/severe pain (NRS > 5/10)
- Always communicate with the operating surgeon before advancing phases if in doubt
PHASE I - Protection and Acute Care (Weeks 0-2)
Goals
- Control pain and oedema
- Protect surgical repair
- Maintain distal joint mobility
- Prevent muscle atrophy and shoulder stiffness onset
Sling
- Arm sling at all times (including sleep) - remove only for hygiene and exercises
Modalities
| Modality | Dose |
|---|---|
| Cryotherapy (ice pack over towel over surgical site) | 15-20 min, 4x daily PRN |
| Transcutaneous Electrical Nerve Stimulation (TENS) | 80-100 Hz, 20 min, 2x daily for pain control |
| Gentle wound area management | Per surgeon/nurse guidance |
Exercises
| Exercise | Technique | Sets x Reps | Frequency |
|---|---|---|---|
| Pendulum (Codman) exercises | Lean forward, arm hangs freely, make small circles 10 cm diameter in clockwise and anticlockwise direction | 3 sets x 10 reps each direction | 2-3x daily |
| Elbow active ROM - flexion/extension | Seated, bend and straighten elbow through full range | 3 x 15 reps | 2-3x daily |
| Wrist active ROM - flexion/extension/circumduction | Seated, move wrist in all planes | 3 x 15 reps | 2-3x daily |
| Finger/grip exercises - ball squeeze or finger tendon glides | Squeeze a soft sponge/stress ball | 3 x 20 reps | 3x daily |
| Cervical ROM - gentle neck rotation, lateral flexion | Seated, pain-free range only | 5 reps each direction | 2x daily |
| Diaphragmatic breathing | Lying, expand lower chest; prevents post-op splinting | 5 deep breaths | Every hour while awake |
ROM Targets (Week 2)
- Shoulder PROM: Forward flexion 0-90°, Abduction 0-90°, IR/ER 0-30° only
- No active shoulder movement yet
PHASE II - Early Motion (Weeks 2-6)
Goals
- Progressively restore passive and assisted active shoulder ROM
- Begin scapular and periscapular muscle activation
- Maintain elbow/wrist/hand mobility
Sling
- Continue sling in public/crowded situations; may remove during supervised exercises
- May remove at night from week 4 if comfortable
Exercises - Range of Motion
| Exercise | Technique | Sets x Reps | Frequency |
|---|---|---|---|
| Passive ROM - Supine shoulder flexion with dowel | Lie supine, hold a cane/dowel with both hands, unaffected arm lifts affected arm overhead into forward flexion | 3 x 10 reps, hold 2 sec at end range | 2x daily |
| Wall slides (forward flexion) | Stand facing wall, fingers walk up the wall in forward direction | 3 x 10 reps | 2x daily |
| Pulley exercises (shoulder flexion/abduction) | Using overhead pulley, unaffected arm assists affected arm into elevation | 3 x 10 reps | 2x daily |
| Supine shoulder elevation - scapular plane (Scaption) | Lie supine, elevate arm 30° anterior to the frontal plane (scapular plane) to ~90° - gravity-assisted | 3 x 10 reps | 2x daily |
| Pendulums continued | Progress to slightly larger circles | 3 x 15 reps each direction | 2x daily |
| Seated shoulder ER - side-lying | Lie on unaffected side, elbow at 90°, rotate forearm away from body (ER) | 3 x 12 reps | Daily |
Exercises - Strengthening (Start Week 3-4)
| Exercise | Technique | Sets x Reps | Frequency |
|---|---|---|---|
| Scapular retraction | Seated or standing, squeeze shoulder blades together, hold 5 sec | 3 x 10 reps, 5 sec hold | 2x daily |
| Scapular depression | Seated, push shoulders down away from ears, hold 5 sec | 3 x 10 reps | 2x daily |
| Prone scapular retraction | Lie prone, arms at sides, lift arms slightly while squeezing scapulae | 3 x 10 reps | Daily |
| Serratus anterior activation - supine punch | Lie supine, arm at 90° flexion, push fist towards ceiling (protraction) | 3 x 12 reps | Daily |
| Isometric shoulder flexion | Stand facing wall, press affected arm forward into wall (no movement) | 3 x 10 reps, 5 sec hold | Daily |
| Isometric ER/IR | Stand beside wall, forearm pressed into wall in neutral - no movement | 3 x 10 reps, 5 sec hold | Daily |
| Biceps/triceps strengthening | Light dumbbell (0.5-1 kg) or Theraband, elbow flexion/extension | 3 x 15 reps | Daily |
Aerobic Conditioning
- Stationary bike (legs only, arm in sling) - 15-20 min, 3x per week
ROM Targets (Week 6)
- PROM: Full in all planes
- AROM: Forward flexion 90-100°, Abduction 90°, ER 30-40°
PHASE III - Strengthening Phase (Weeks 6-12)
Goals
- Achieve full active shoulder ROM
- Progressive rotator cuff and periscapular strengthening
- Restore neuromuscular control
- Return to bilateral upper limb ADLs
Sling
- Discontinued completely by 6 weeks (or surgeon instruction)
Exercises - ROM and Flexibility
| Exercise | Technique | Sets x Reps / Hold | Frequency |
|---|---|---|---|
| Doorway pectoral stretch | Stand in doorway, forearm on frame, lean forward | 3 x 30 sec hold | 2x daily |
| Latissimus dorsi stretch | Overhead reach with arm, lean to opposite side | 3 x 30 sec hold | 2x daily |
| Posterior capsule stretch (Sleeper stretch) | Side-lying, affected arm at 90°, gently push forearm towards table | 3 x 30 sec | Daily |
| Corner stretch / Pec stretch | Face corner of room, both forearms on walls, lean in | 3 x 30 sec | Daily |
Exercises - Rotator Cuff Strengthening
| Exercise | Technique | Resistance | Sets x Reps | Frequency |
|---|---|---|---|---|
| Theraband ER (at neutral) | Elbow at side, 90° flexion, rotate forearm outward against band | Light band (yellow/red) | 3 x 12-15 reps | Daily |
| Theraband IR (at neutral) | Elbow at side, 90° flexion, rotate forearm inward against band | Light-moderate band | 3 x 12-15 reps | Daily |
| Side-lying ER with dumbbell | Lie on unaffected side, elbow 90°, small dumbbell, rotate forearm up | 0.5-1 kg | 3 x 12 reps | Daily |
| Scaption raises (shoulder elevation in scapular plane) | Stand, thumbs up, raise arm to 90° in scapular plane | 0.5-1 kg dumbbell | 3 x 12 reps | Daily |
| Prone horizontal abduction (T's) | Lie prone, arms hanging, lift to horizontal | Bodyweight then 0.5 kg | 3 x 12 reps | 3x/week |
| Prone Y's | Lie prone, arms in Y position, lift into scapular elevation | Bodyweight | 3 x 10 reps | 3x/week |
Exercises - Scapular Stabilizers
| Exercise | Technique | Resistance | Sets x Reps | Frequency |
|---|---|---|---|---|
| Low row (Theraband) | Seated, pull band to waist with elbows close | Moderate band | 3 x 12-15 reps | Daily |
| Mid row (seated row) | Pull band to chest level, retract scapulae | Moderate band | 3 x 12-15 reps | Daily |
| Wall push-ups | Stand facing wall, push-up against wall - scapular protraction | Bodyweight | 3 x 15 reps | Daily |
| Serratus roll-ups | Supine, arm extended to ceiling, protract scapula further ("reach for ceiling") | Bodyweight then 0.5 kg | 3 x 12 reps | Daily |
| Resisted straight arm extension (Theraband) | Stand, arm forward at 90°, pull band down to thigh | Light-moderate band | 3 x 12 reps | Daily |
ROM Targets (Week 12)
- Full AROM in all planes matching uninvolved side
- Criteria to progress to Phase IV: Full AROM, >/=90% ROM compared to opposite side, pain </= 3/10 with resistance, 4/5 MMT strength all rotator cuff
PHASE IV - Functional Strengthening (Weeks 12-16)
Goals
- Isotonic progressive strengthening
- Closed chain upper limb exercises
- Full return to ADLs and light work activities
Exercises
| Exercise | Technique | Resistance | Sets x Reps | Frequency |
|---|---|---|---|---|
| Progressive dumbbell shoulder press | Seated, controlled overhead press | 1-3 kg as tolerated | 3 x 10-12 reps | 3x/week |
| Dumbbell lateral raises | Standing, arm to 90° - controlled | 1-2 kg | 3 x 12 reps | 3x/week |
| Front raises (anterior deltoid) | Standing, arm forward elevation to 90° | 1-2 kg | 3 x 12 reps | 3x/week |
| Biceps curls | Seated/standing, full range | 2-4 kg | 3 x 12-15 reps | 3x/week |
| Triceps overhead extension | Seated, arm overhead, elbow extension | 1-2 kg | 3 x 12 reps | 3x/week |
| Face pulls (Theraband) | Pull band to face level, elbows wide, targets posterior cuff | Moderate band | 3 x 12-15 reps | 3x/week |
| Resisted PNF diagonals D1/D2 | Diagonal patterns with Theraband | Light-moderate band | 3 x 10 reps each pattern | 3x/week |
| Plantigrade shoulder taps | Weight-bearing through hands on table, alternate tapping | Bodyweight | 3 x 10 taps each hand | 3x/week |
| Counter push-ups (incline push-ups) | Hands on bench/counter, body inclined | Bodyweight | 3 x 10-15 reps | 3x/week |
| Rhythmic stabilizations | Therapist applies alternating gentle perturbations to arm in various positions | Manual | 3 x 30 sec | 3x/week |
Aerobic
- Walking, cycling, elliptical (bilateral arm use), swimming (surgeon clearance)
- 20-30 min, 3-5x per week, moderate intensity
PHASE V - Return to Sport / Full Function (Weeks 16-24)
Goals
- Achieve >90% symmetry in strength vs. opposite side
- 0% disability on QuickDASH
- Sport-specific or occupation-specific training
Criteria for Full Clearance
- Full pain-free shoulder AROM
- Dynamometry: >/=90% strength symmetry compared to uninvolved shoulder
- QuickDASH score: 0% disability
- No pain with high-resistance exercises
Exercises
| Exercise | Technique | Notes |
|---|---|---|
| Standard push-ups | Full plank position | Progress from counter → incline → floor |
| Overhead press (barbell or dumbbell) | Seated or standing, controlled | Build load gradually from Phase IV weight |
| Plyometric exercises | Ball chest passes, wall ball throws, partner catch | Start light, progress speed and load |
| Resisted ER/IR in abduction | Arm abducted 90°, Theraband or cable | Sport-specific cuff preparation |
| Wall walks | Hands on wall, walk up/down with fingers | Scapular control + cuff endurance |
| Return to throwing program | Interval throwing program (if applicable) | Weeks 20-24 under therapist supervision |
| Return to sport drills | Sport-specific activities | Full collision sport cleared at 4-6 months post-op |
Summary Timeline
| Phase | Weeks | Focus |
|---|---|---|
| I - Protection | 0-2 | Pain control, distal mobility, sling use |
| II - Early Motion | 2-6 | Passive/assisted ROM, scapular activation |
| III - Strengthening | 6-12 | Full AROM, rotator cuff and scapular strengthening |
| IV - Functional | 12-16 | Isotonic loading, closed chain, full ADLs |
| V - Return to Sport | 16-24 | Plyometrics, sport drills, full clearance |
Key Outcome Measures to Track
- ROM (goniometry, compared to uninvolved side): at each phase transition
- QuickDASH score: at 6 weeks, 12 weeks, 6 months
- NRS pain score: at each session
- MMT (Manual Muscle Testing) or handheld dynamometry: at Phase III and onwards
Clinical Note: This protocol is based on the Mass General Hospital Clavicle ORIF Rehabilitation Protocol and peer-reviewed guidelines. Phase progression should be criterion-based, not purely time-based. Always liaise with the operating surgeon - especially before advancing to Phase IV and V - and adjust the protocol based on the patient's fracture healing on follow-up X-rays, pain levels, and functional capacity.
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