Skip to content

Patients › Rehabilitation

骨折的肩关节置换术

PDF Evidence

Rehabilitation after hemiarthroplasty or reverse shoulder replacement for a proximal humerus fracture — slower than elective replacement while the tuberosities heal.

Updated Jun 2026
插图：一个人用吊带休息，肘部由一个小枕头支撑。
在骨折置换术后肩部愈合期间保护修复部位。 Kieran Hirpara 4.0

机器翻译，已经临床审核。

本方案旨在指导您在 Mater Private Hospital Rockhampton 由 Kieran Hirpara 医生进行的因肩关节骨折（肱骨近端骨折）而行的肩关节置换术后的康复过程。根据骨折类型，置换术可能为反式肩关节置换术或半肩关节置换术（仅置换关节的肱骨头）。两种术式的康复进程基本一致，因为决定康复进度的关键是骨折块的愈合情况，而非植入物的类型。以下每个阶段首先以通俗易懂的语言解释当前的情况及注意事项，随后提供供您的物理治疗师参考的结构化方案：请将此页面或其 PDF 文件带给您的首次物理治疗就诊，以确保康复过程协调一致。您的物理治疗师可能会根据您的康复进展调整该计划。

如果您在术后对伤口有任何疑虑，请与诊室联系。拍摄伤口照片并通过电子邮件发送以供审查通常很有帮助。

为什么骨折后的恢复速度较慢

当因关节炎或磨损的肩袖而择期进行肩关节置换时，新关节周围的骨骼是完整的，康复可以按照软组织愈合的速度进行。骨折后的情况则不同。肱骨顶端的两个骨性隆起（大结节和小结节，即肩袖肌肉附着处）通常已经断裂，并在手术中被缝合回新假体周围的位置。这些骨碎片必须像其他任何骨折一样，与骨骼和植入物愈合，这通常需要数周至数月的时间。

针对因骨折而进行的肩关节置换术的已发表康复方案在这一观点上是一致的：肩关节术后的功能在很大程度上取决于结节是否愈合在正确的位置，早期或剧烈的运动（即使是被动运动）可能会牵拉修复部位，从而危及愈合。因此，康复方案遵循与择期反式肩关节置换术方案相同的路径。骨折后的康复进程之所以更慢，是因为骨碎片必须先愈合。康复的每一步进展都取决于两个条件：经过足够的时间，以及X光片显示骨骼正在愈合，这一点将在您与Hirpara医生的复查中得到确认。

术后预期

您醒来时手臂会感到麻木，感觉通常在 6 到 12 小时内恢复。极少数情况下，麻木或无力可能会持续 2 到 3 天。

手术结束后，您将处于悬吊状态，肩部覆盖有大块敷料。出院前会移除该敷料。敷料下方是防水敷料，覆盖着手术胶条，可保留 2 周无需处理。您的缝线为可吸收线，无需拆除，但伤口两端可能会有线头，可在 2 周后修剪至与皮肤齐平。我们将为您预约术后 1–2 周的伤口检查。如果您无法参加敷料检查，可在 2 周后自行移除敷料。

恢复各项活动的预计时间（比择期置换手术恢复慢，且始终取决于骨骼愈合情况）：

  • 驾驶： 佩戴悬吊期间不得驾驶。大多数人会在 6 到 12 周之间恢复驾驶，前提是活动度和控制力已恢复；请在复查时讨论此事。
  • 游泳： 蛙泳约 4 个月后开始；自由泳稍后，具体听从复查时的指导。
  • 提重物： 约 12 周内，提物重量不得超过一杯咖啡；12 周后逐渐增加轻体力提物；6 个月内避免提重物。
  • 工作： 久坐工作：约 6 周后，视舒适度而定；体力劳动：由 Hirpara 医生指导。

此外，建议尽早建立合理的期望值：骨折置换术后，肩部通常无法恢复至未受伤肩关节的全范围活动。文献报道的结果显示，手臂在腰部及肩部高度（通常包括过头顶）能够舒适、无痛地使用是常见结果，且术后 12–24 个月内活动度和力量仍会持续改善。

佩戴您的悬吊带

您的悬吊带（肩部固定器）可在骨碎片愈合期间支撑您的肩部。规则很简单：

  • 佩戴 6 周，包括睡眠时。
  • 仅在淋浴以及在接受指导后进行锻炼时取下；只要悬吊带未佩戴，手臂应保持在身体侧面。
  • 在家休息时，如果注意得当，可以取下：坐着时手臂用枕头支撑。
  • 佩戴悬吊带期间请勿驾驶。
  • 如果肩部肿胀或疼痛，请使用冰敷，尤其是在锻炼后。

您的物理治疗师最初会帮助您佩戴悬吊带，并会在您出院前教您独立管理。正确佩戴非常重要：松垮的悬吊带无法提供适当的支撑。

  1. 始终确保在佩戴悬吊带时，您的肘部位于悬带角的角落并得到良好支撑。
  2. 佩戴合适的悬吊带，其末端应舒适地位于小指的指关节处。如果您的手伸出悬吊带太远，将无法提供足够的支撑。
  3. 您的悬吊带有两条魔术贴绑带：一条绕在颈部，一条绕在腰部。
  4. 正确放置肘部和前臂后，使用未手术侧的手臂将上部绑带绕过颈部至前方，并通过悬吊带上的上部环扣固定。
  5. 使用相同的方法将下部绑带绕在腰部，并通过悬吊带上的下部环扣固定。

在佩戴悬吊带期间，请时刻保持意识注意您的姿势，避免肩部呈现塌陷姿势。为了保持良好的姿势，请尽量保持耳朵、肩部和髋部在一条直线上。良好的姿势对您的背部很重要，并有助于防止肩关节僵硬。坐着时，在腰部下方放置一条卷起的毛巾，可作为友好的提醒。

住院初期

在您出院回家之前，医院的物理治疗师将为您启动一个简单的康复计划。了解他们将使用的三个术语会有所帮助。主动活动范围是指您在不借助外力或帮助的情况下自行进行的活动。主动辅助活动范围是指使用您的另一只手臂（或拐杖等物体）来帮助移动患肢。被动活动范围是指患肢完全放松，由另一只手臂（或他人）完成100%的活动。在骨折置换术后，术后六周内，手术侧肩部仅进行被动活动，且活动范围限于轻柔幅度；您可主动活动的关节为肘部、腕部和手部。

关于住院初期的几点实用建议：

  • 您需要佩戴悬吊带睡觉。
  • 如需止痛，请使用冰敷。
  • 佩戴悬吊带时，放松肩部，让悬吊带承担手臂的重量。
  • 在进行锻炼和物理治疗预约前，请服用止痛药。
  • 您可以将手臂从悬吊带中取出以进行锻炼和淋浴。
  • 您需要佩戴悬吊带6周，尤其是在外出时。
  • 保持手术侧手部适度活动：鼓励在手臂置于悬吊带内时进行写字、进食和使用手机等活动。
  • 除非您选择自行安排物理治疗，否则已为您预约了物理治疗，详细信息包含在您的出院资料包中。
  • 如有任何问题，请联系办公室或告知您的物理治疗师。

第一阶段——骨折愈合期间的保护（第0–6周）

前六周只有一件事：让大结节碎片在不受干扰的情况下愈合到骨骼和假体上。您需要全天24小时佩戴悬吊带，保持肘部、手腕和手部的活动，而肩关节本身仅进行被动活动（轻柔地，由您的物理治疗师操作或在手臂完全放松的情况下），并严格限制在以下范围内。最重要的规则是：不要主动活动肩关节，不要将手臂外旋超过限制，不要将手伸到背后，不要提举任何物品，也不要通过手掌支撑身体向上推。如果您接受的是反式肩关节置换术，这些规则还能在软组织愈合期间保护新关节防止脱位。仰卧时，请在肘部下方垫一个小枕头或卷起的毛巾，以防止肩关节过度后伸。

致您的物理治疗师：

目标

  • 保护大结节修复及假体
  • 减轻肿胀，最小化疼痛
  • 维持肘部、手腕和手部的主动活动范围（ROM）
  • 在安全范围内进行轻柔的保护性肩关节被动活动范围（PROM）
  • 维持肩胛骨及姿势意识
  • 患者教育

悬吊带

  • 佩戴6周，包括睡眠时
  • 仅在洗澡和锻炼时取下；取出悬吊带时，手臂应保持在身体侧面

管理措施

  • 肿胀管理：冰敷，加压
  • 活动范围/灵活性：
    • 仅进行PROM，且在安全范围内：肩胛平面内上举 ≤ 90度；外旋（ER）在前4周保持中立位（0度），之后 ≤ 30度；禁止内旋（IR）至背后
    • 钟摆运动，作为被动练习在完全放松状态下进行
    • 主动辅助活动范围（AAROM）：肩关节禁止
    • 主动活动范围（AROM）：肘部、手腕、手部和手指；颈椎
  • 肩胛骨定位，耸肩及姿势矫正
  • 鼓励在佩戴悬吊带期间进行手部轻度活动（如写字、进食、使用手机）
  • 锻炼和物理治疗 session 前给予镇痛药

注意事项

  • 禁止肩关节AROM或AAROM
  • 禁止被动或主动外旋超过上述限制（大结节修复受外旋负荷影响）
  • 禁止抗阻内旋（小结节/肩胛下肌修复受内旋负荷影响）
  • 禁止将手伸到背后；禁止同时内收、内旋和后伸（反式置换脱位体位）
  • 禁止提举物品；禁止通过手掌支撑体重（例如从椅子或床上撑起身体）
  • 仰卧时，在肘部下方放置小枕头或毛巾卷，以防止肩关节陷入过伸
  • 禁止强行进行任何引起疼痛的动作

进阶标准

  • 已满6周 且 X光片显示大结节在正确位置愈合，并经Hirpara医生复查确认
  • 疼痛通过口服镇痛药得到控制
  • 伤口无异常且无不稳定迹象

第二阶段——恢复活动度（第6–12周）

在六周复查时，X线检查确认骨碎片正在原位愈合。如果愈合情况良好，悬吊带将拆除，肩关节开始自主活动，起初由健侧手臂、手杖或滑轮辅助，随后转为主动活动。被动活动度（PROM）在此期间逐渐恢复至全范围，旋转受限情况逐步改善。三角肌和肩胛骨周围（肩胛带）肌肉的轻度激活训练开始进行。但此时尚不进行力量训练：修复处仍在巩固中，因此提举限制仍为不超过一杯咖啡的重量，且仍禁止通过手部支撑身体向上推起。

物理治疗师须知：

目标

  • 六周复查后逐步停用悬吊带
  • 在患者耐受范围内，促进肩关节被动活动度（PROM）向全范围发展
  • 启动肩关节辅助主动活动度（AAROM），并逐步过渡至主动活动度（AROM）
  • 启动三角肌和肩胛带肌肉的轻度激活训练
  • 恢复手臂在腰部及胸部高度进行轻度日常生活活动的能力
  • 患者教育

悬吊带

  • 六周复查后停用；在停用后的第一至两周内，外出至人群密集处时可佩戴以提供保护

管理措施

  • 根据需要继续第一阶段的干预措施
  • 活动度/灵活性：
    • 被动活动度（PROM）：在疼痛耐受范围内，约在第8–10周时向所有平面的全范围活动度进展
    • 辅助主动活动度（AAROM）：桌面滑动、爬墙、滑轮、手杖辅助屈曲和外旋，体位由仰卧位逐步过渡至坐位
    • 主动活动度（AROM）：当AAROM舒适且动作质量良好时开始，从仰卧位屈曲开始，逐步过渡至直立位屈曲和侧平举（scaption）
    • 外旋（ER）：确认愈合后，在患者耐受范围内，活动度进展超过30度
    • 在阶段末期，经许可后引入轻柔的功能性手背后及伸展动作。切勿强行拉伸至这些位置。
  • 力量训练：
    • 仅限无痛的次最大等长收缩：肩胛平面内的三角肌、肩胛带肌肉设定、低拉、肩胛骨后缩
    • 在阶段末期引入轻柔的无痛肩袖等长收缩；仅在复查获准后，方可引入抗阻内旋训练
  • 运动控制：强调肩胛骨控制，避免耸肩或其他代偿模式

注意事项

  • 禁止提举超过一杯咖啡重量的物体
  • 禁止通过手部支撑身体重量
  • 禁止进行除轻柔等长收缩以外的抗阻或力量训练
  • 避免强行增加活动度：仅拉伸至紧绷的不适感，绝不可出现锐痛

进阶标准

  • 肩高以下的主动活动舒适，肩胛骨控制良好且代偿最小
  • X线显示结节继续愈合，经Hirpara医生复查确认
  • 疼痛已缓解，足以开始抗阻训练

第三阶段——强化训练（第12–24周）

大约在12周时，大结节通常已接近愈合，您与Hirpara医生的复查将确认肩部是否已准备好开始承重。随后开始强化训练，从弹力带和轻重量开始，轻柔地进行，重点锻炼驱动肩部的三角肌和肩胛骨周围肌肉（在反向肩关节置换术后，三角肌承担了原来肩袖的大部分功能）。随着愈合的大结节允许，肩袖本身也逐渐进行强化。在此阶段，轻负荷举重逐渐增加，日常活动在手部和肩部高度应接近正常，如果尚未恢复，驾驶功能通常在此阶段恢复。

物理治疗师须知：

目标

  • 维持无痛的被动活动范围（PROM），并在所有平面进展主动活动范围（AROM）
  • 逐步恢复力量和耐力：三角肌、肩胛周围肌肉，然后是肩袖
  • 改善动态稳定性、运动控制和本体感觉
  • 恢复大多数日常活动，包括轻负荷举重

管理

  • 继续所有平面的活动范围和灵活性训练
  • 强化训练，从等长收缩进展到弹力带，再到轻重量（低负荷，高重复次数）：
    • 肩胛周围肌肉：划船、前锯肌冲拳、抗阻肩胛骨回缩
    • 三角肌：在功能位置进行抗阻屈曲和侧平举，配合受控的离心下降
    • 肩袖：使用弹力阻力进行外旋（ER）和内旋（IR）、侧卧位外旋，随着愈合的大结节允许而进展
  • 运动控制：节律性稳定训练、本体感觉神经肌肉促进法（PNF）对角线模式、球类稳定训练
  • 渐进式举重：在此阶段早期从约2公斤开始，随着控制能力的提高，到阶段结束时达到约5公斤
  • 在此阶段，随着获得许可，逐步重新通过手臂进行承重（例如从椅子上撑起）

注意事项

  • 禁止重负荷举重；在此阶段保持负荷低于约5公斤
  • 避免用力度的终末端拉伸，避免在负重状态下进行联合外展和外旋
  • 进展以症状为导向：如果疼痛或肿胀加剧，退回到上一个级别

进展标准

  • 复查时由Hirpara医生确认大结节愈合
  • 无痛的日常活动，强化训练耐受良好且无症状加剧
  • 在可用活动范围内具有良好的运动质量

第四阶段——恢复全面活动（术后6个月起）

最终阶段是在力量和控制的指导下，逐步恢复较重的任务、手工劳动和娱乐活动，而非依据日历时间。较重的家务和园艺任务将逐步恢复；手工劳动需遵循Hirpara医生的指导；游泳和高尔夫运动通常在术后四至六个月左右恢复。肩关节置换术后，长期应避免提举重物；已发表的指南建议日常提举重量保持在约10公斤以下。肩关节在此阶段之后仍会持续改善：大多数患者在术后12至24个月内，活动度、力量和信心仍会继续提高，因此在正式物理治疗结束后，坚持家庭锻炼计划仍十分有益。

致您的物理治疗师：

目标

  • 优化患者日常需求所需的功能性力量和耐力
  • 逐步恢复工作、娱乐和运动
  • 长期关节保护教育及独立家庭锻炼计划

管理

  • 继续进行轻重量、高重复次数的渐进性抗阻训练，强调肩袖和肩胛周围肌群的强化
  • 神经肌肉和本体感觉训练；根据需要执行功能性和工作特异性任务
  • 在复查确认合格后，将游泳、高尔夫及其他娱乐活动的恢复安排在术后四至六个月左右
  • 定制家庭锻炼计划，以便在正式物理治疗结束后继续执行

注意事项

  • 术后6个月内避免提举重物；长期日常提举重量应保持在约10公斤以下
  • 手工劳动以及接触性或负重运动仅在Hirpara医生批准后进行

完成本方案的指征

  • 经Hirpara医生复查确认，且大结节愈合
  • 疼痛得到控制，活动度满足患者日常需求的功能性范围
  • 能够独立执行长期家庭锻炼计划

您的方案之后

上述阶段改编自已发表的针对肱骨近端骨折行肩关节置换术的康复方案（Texas Health Orthopedic Specialists、North Tees and Hartlepool NHS Foundation Trust 针对创伤性半肩关节置换术和反式肩关节置换术，以及 Robert Jones and Agnes Hunt Orthopaedic Hospital），并借鉴外科文献强调大结节愈合。周数范围是典型的而非固定的，您的康复进程由您的物理治疗师与诊所合作，并根据您与 Hirpara 医生的复查结果进行个体化推进。本页面与诊所的一般康复建议配合使用；请参阅 管理术后疼痛 和 伤口护理。关于手术本身，请参阅 骨折行肩关节置换术；关于此过程的择期版本，请参阅 反式肩关节置换术方案。本方案背后的证据（为何大结节愈合决定进度、半肩关节置换术与反式肩关节置换术的比较，以及已发表的康复指南）在证据部分进行了总结，可从本页顶部下载 PDF 版本。

Reviewed by Dr Kieran Hirpara · 10 June 2026.

Want the clinical detail? Read the clinician version.

Talk to your treating clinician for advice specific to you.

For an appointment with the CQ Hand + Upper Limb team, ask your GP about a referral or visit www.cqupperlimb.com.

Evidence & references

This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Shoulder Replacement for Proximal Humerus Fracture — Evidence Behind the Rehabilitation Protocol

Topic scope: The evidence underpinning rehabilitation after shoulder arthroplasty performed for an acute proximal humerus fracture — covering both the implant options used in this setting: reverse total shoulder arthroplasty (rTSA) for fracture and stemmed hemiarthroplasty for fracture. The defining feature of both, and the reason this is a slow, protected pathway, is that the greater and lesser tuberosities are broken free and stitched back around the prosthesis at operation — they must heal as fractures before the shoulder can be actively moved or loaded. This contrasts with elective arthroplasty (for arthritis or cuff arthropathy), where the bone is intact and rehabilitation can move at the pace of soft-tissue healing.

Defining principle of this rehab: Replacement-for-fracture is a PROTECT pathway driven by TUBEROSITY HEALING, not by implant type. At operation the greater tuberosity (with supraspinatus/infraspinatus) and lesser tuberosity (with subscapularis) are reattached around the stem. Until those bone fragments unite — typically the first 6 weeks, confirmed on X-ray — the shoulder is moved passively only and within a restricted arc: forward elevation kept low, external rotation limited (it loads the greater-tuberosity repair), resisted/active internal rotation avoided (it loads the lesser-tuberosity/subscapularis repair), and no reaching behind the back. Active range and strengthening are deferred, not just reduced. This is the opposite of an early-motion pathway such as capsular release (where immediate aggressive motion is the treatment) or calcific excision (early movement below shoulder height from day 1). The whole pace is set by the fractured tuberosities, not the new joint surface.

The operation, and why the tuberosities matter

A displaced three- or four-part proximal humerus fracture in an older patient may be unreconstructable with plate-and-screw fixation, and arthroplasty is then offered. Two implants are used:

  • Hemiarthroplasty (HA) — replaces the ball (humeral head) only. It relies on the surgeon reconstructing the head–tuberosity–shaft relationship and, critically, on the tuberosities healing back in anatomical position so the rotator cuff can pull on them. Where the tuberosities fail to heal, function is poor.
  • Reverse total shoulder arthroplasty (rTSA) — reverses the ball-and-socket so the deltoid, not the rotator cuff, drives elevation. This makes rTSA less dependent on tuberosity healing than HA, which is the main reason it has largely supplanted hemiarthroplasty for fracture in the elderly. Tuberosity healing still improves the result (it adds rotation), but a workable shoulder is achievable even when the greater tuberosity does not unite.

In both operations the surgeon repairs the tuberosities, and in both the rehabilitation protects that repair. That shared dependence — not the choice of implant — is why the protocol has one shape for both.

Evidence by theme

1. Tuberosity healing drives the functional result (the rationale for protection)

This is the best-supported principle in the topic, and the reason rehabilitation protects the repair for ~6 weeks.

  • A large systematic review and meta-analysis of 21 studies (1,616 reverse arthroplasties) found a pooled greater-tuberosity non-healing rate of ~32% (anatomic healing in roughly two-thirds). Healed tuberosities had significantly better active abduction, anterior elevation and external rotation, and better functional scores, without any increase in pain — confirming that attempting and protecting the repair is worthwhile [meta-analysis, 2025; Schmalzl 2020].
  • In the corpus, a dedicated study asked "can a healed tuberosity improve the functional outcomes?" after reverse arthroplasty for four-part fracture and answered yes — healing was associated with better rotation and outcome scores. DOI: 10.1016/j.jse.2016.11.034.
  • For hemiarthroplasty, the dependence is even stronger: reported greater-tuberosity healing rates range widely (~30–91%), and tuberosity malunion/nonunion/migration is the dominant cause of a poor result. This is precisely why HA is now reserved and rTSA preferred in older patients [web review literature].

Strength: MODERATE–STRONG for "healing predicts outcome" (large pooled cohorts/meta-analysis); the link is consistent and direction-of-effect is not in dispute. It is observational, not randomised.

2. Hemiarthroplasty vs reverse arthroplasty for fracture

  • A corpus multicentre randomised controlled trial (the SHeRPA trial) found superior functional outcome with reverse arthroplasty compared with hemiarthroplasty for displaced three- and four-part fractures in patients 65 and older. DOI: 10.1016/j.jse.2024.05.016.
  • An earlier corpus comparative study (JBJS) likewise compared HA and rTSA for elderly proximal humeral fractures. DOI: 10.2106/jbjs.l.01637.
  • Reverse-for-fracture does carry a caveat: one corpus study asked whether rTSA for fracture does worse than rTSA for elective indications, reflecting that the fracture setting (broken tuberosities, frailer patients) is more demanding than an elective replacement — the same reason this rehab runs more slowly than the elective pathway. DOI: 10.1016/j.jse.2020.03.053.

Strength: MODERATE–STRONG (an RCT plus comparative cohorts) that rTSA generally outperforms HA for fracture in the elderly. This is a surgeon's intra-operative decision, made per patient and per fracture pattern.

3. Early vs delayed motion, and the rehabilitation protocol itself

This is where the evidence is thinnest and least standardised — honestly, the phase timings below are consensus and protocol-derived, not RCT-derived.

  • A JOSPT systematic review of proposed rehabilitation guidelines after anatomic and reverse arthroplasty found substantial heterogeneity between published protocols — sling use ranged from "comfort only" to a full 6 weeks; permitted motion ranged from none to precautionary limits; early external rotation was commonly capped (e.g. to ~30° in the scapular plane) to protect the repair. There is no single agreed regimen.
  • A corpus randomised single-blinded trial of early rehabilitation vs immobilisation after reverse arthroplasty exists (DOI: 10.1016/j.jse.2019.10.005), and the 2025 Neer Award SHORT trial compared surgeon-directed home therapy with formal outpatient physiotherapy after rTSA (DOI: 10.1016/j.jse.2025.10.005) — but these are largely elective rTSA populations, where the tuberosities are not broken. They do not licence early active motion in the fracture setting, where the repair must be protected first.
  • A corpus network meta-analysis explicitly examined the optimal combination of arthroplasty type, fixation method and post-operative rehabilitation protocol for complex proximal humerus fractures (DOI: 10.1016/j.jse.2024.03.040), and a corpus survey found that trauma and shoulder surgeons differ in their rehabilitation preferences (DOI: 10.1016/j.jse.2021.12.045) — both confirm that the protocol is an area of genuine, unresolved variation rather than settled science.

Strength: WEAK / CONSENSUS for the specific phase structure and week ranges. The principle "protect the tuberosity repair, defer active motion and load until union" is well grounded; the exact timings are typical, not trial-proven.

Phased post-op timeline (consistent with the patient protocol)

Phase Window Sling Shoulder ROM Strengthening What's healing / why
I — Protection Weeks 0–6 Full-time, including sleep Passive only, within a safe zone: scapular-plane elevation ≤ 90°; external rotation to neutral (0°) for ~4 weeks then ≤ 30°; no internal rotation behind the back; pendulums (fully relaxed). Active elbow/wrist/hand. None for the shoulder Tuberosity fragments uniting onto bone + prosthesis; ER loads the greater-tuberosity repair, resisted IR loads the lesser-tuberosity (subscapularis) repair. In rTSA this window also protects against early dislocation.
II — Restoring movement Weeks 6–12 Wean after the 6-week X-ray review Progress passive → active-assisted → active; ease the rotation limits as healing is confirmed Gentle sub-maximal isometrics (deltoid, periscapular) late in phase; resisted IR only once cleared Tuberosities consolidating; lifting still limited to ~a cup of coffee; no weight-bearing through the hands
III — Strengthening Weeks 12–24 Off Maintain/progress active range in all planes Banded → light weights; deltoid + periscapular first, rotator cuff as the healed tuberosities allow Tuberosity union usually well advanced and confirmed at review before loading begins
IV — Return to activity 6 months onwards Off Functional range for daily demands Progressive, guided by control not the calendar; lifting kept moderate long-term Strength/movement keep improving for 12–24 months; full uninjured-shoulder range is not expected

The pacing is gated on two things together at each step: enough time, AND X-rays showing the tuberosities healing, confirmed at review with Dr Hirpara. Approximate functional milestones (subject to healing): driving ~6–12 weeks (never in the sling); breaststroke swimming ~4 months; nothing heavier than a cup of coffee until ~12 weeks; heavy lifting avoided for 6 months.

Key controversies / evidence quality

  1. Implant choice (HA vs reverse). An RCT and comparative cohorts favour reverse over hemiarthroplasty for displaced fractures in older patients, chiefly because rTSA is less hostage to tuberosity healing. This is a per-patient surgical decision — and either way the rehabilitation protects the tuberosity repair. Moderate–strong.
  2. Does the tuberosity actually need to heal? For hemiarthroplasty, effectively yes — non-union/malunion is the main failure mode. For reverse, healing is beneficial but not essential (the deltoid drives elevation), though healed tuberosities add rotation and reduce complications. The protection strategy is justified for both because attempting healing is worthwhile and forced early motion can disrupt it. Moderate.
  3. Early vs delayed motion / the protocol itself. The single weakest area. Published protocols vary widely (JOSPT review), the trials that test early motion are mostly in elective reverse populations, and surgeons genuinely disagree on the optimum. The conservative, tuberosity-led timeline used here reflects the fracture-specific protocols and the healing biology rather than a defining RCT. Weak / consensus.

Evidence-strength flags (summary)

  • MODERATE–STRONG: tuberosity healing predicts better range/function after reverse arthroplasty for fracture (21-study meta-analysis, 1,616 cases; ~32% non-healing); reverse > hemiarthroplasty for elderly displaced fractures (SHeRPA RCT + comparative cohorts).
  • MODERATE: hemiarthroplasty outcome is strongly tuberosity-dependent (healing ~30–91%; malunion the dominant failure mode); reverse-for-fracture more demanding than elective reverse.
  • WEAK / CONSENSUS: the specific phased rehabilitation protocol and its week ranges — published guidelines are heterogeneous (JOSPT review); early-motion trials are mostly elective populations; the tuberosity-protective timeline is derived from fracture-specific protocols and healing biology, not a defining rehab RCT.

Citations

  • Reverse shoulder arthroplasty for four-part proximal humerus fracture in elderly patients: can a healed tuberosity improve the functional outcomes? J Shoulder Elbow Surg. DOI: 10.1016/j.jse.2016.11.034
  • Superior functional outcome following reverse shoulder arthroplasty compared to hemiarthroplasty for displaced three- and four-part fractures in patients 65 and older — the SHeRPA randomized controlled trial. J Shoulder Elbow Surg. 2024. DOI: 10.1016/j.jse.2024.05.016
  • Comparison of Hemiarthroplasty and Reverse Shoulder Arthroplasty for the Treatment of Proximal Humeral Fractures in Elderly Patients. J Bone Joint Surg Am. DOI: 10.2106/jbjs.l.01637
  • Does reverse total shoulder arthroplasty for proximal humeral fracture portend poorer outcomes than for elective indications? J Shoulder Elbow Surg. DOI: 10.1016/j.jse.2020.03.053
  • A randomized single-blinded trial of early rehabilitation versus immobilization after reverse total shoulder arthroplasty. J Shoulder Elbow Surg. 2019. DOI: 10.1016/j.jse.2019.10.005
  • Optimal combination of arthroplasty type, fixation method, and postoperative rehabilitation protocol for complex proximal humerus fractures in the elderly: a network meta-analysis. J Shoulder Elbow Surg. 2024. DOI: 10.1016/j.jse.2024.03.040
  • Understanding postoperative rehabilitation preferences in operatively managed proximal humerus fractures: do trauma and shoulder surgeons differ? J Shoulder Elbow Surg. DOI: 10.1016/j.jse.2021.12.045
  • 2025 Neer Award Part 1: The SHORT trial — surgeon-directed home therapy vs. outpatient rehabilitation after reverse total shoulder arthroplasty. J Shoulder Elbow Surg. 2025. DOI: 10.1016/j.jse.2025.10.005
  • Acute versus delayed reverse total shoulder arthroplasty for proximal humeral fractures in the elderly: a systematic review and meta-analysis. J Shoulder Elbow Surg. DOI: 10.1016/j.jse.2018.10.004
  • Ten-year follow-up of stemmed hemiarthroplasty for acute proximal humeral fractures. Bone Joint J. DOI: 10.1302/0301-620x.103b6.bjj-2020-1753.r1

Literature (URLs)

  • Anatomic healing of greater tuberosity improves range of motion and functional outcomes after reverse total shoulder arthroplasty for proximal humerus fractures: an updated systematic review and meta-analysis on 21 studies (1,616 rTSAs; ~32% GT non-healing). PubMed. https://pubmed.ncbi.nlm.nih.gov/39914739/
  • Schmalzl J, et al. Tuberosity healing improves functional outcome following primary reverse shoulder arthroplasty for proximal humeral fractures with a 135° prosthesis. Eur J Orthop Surg Traumatol. 2020. https://pubmed.ncbi.nlm.nih.gov/32162048/
  • Tuberosity healing after reverse shoulder arthroplasty for proximal humerus fractures: is there clinical improvement? PubMed. https://pubmed.ncbi.nlm.nih.gov/33364654/
  • Prosthesis designs and tuberosity fixation techniques in reverse total shoulder arthroplasty: influence on tuberosity healing in proximal humerus fractures. PMC. https://pmc.ncbi.nlm.nih.gov/articles/PMC8468418/
  • A Systematic Review of Proposed Rehabilitation Guidelines Following Anatomic and Reverse Shoulder Arthroplasty. JOSPT 2019. https://www.jospt.org/doi/10.2519/jospt.2019.8616

Published rehab protocols (patient-guidance — basis for the phase structure)

  • Frantz T. Proximal Humerus Fracture Rehabilitation Protocol (reverse shoulder arthroplasty). Texas Health Orthopedic Specialists. https://www.frantzorthopedics.com/pdf/proximal-humerus-fracture-reverse-shoulder-arthroplasty-updnew.pdf
  • North Tees and Hartlepool NHS Foundation Trust. Shoulder Hemi-Arthroplasty (trauma) — post-operative protocol. Reviewed April 2023. https://www.nth.nhs.uk/resources/shoulder-hemi-arthroplasty-trauma/
  • North Tees and Hartlepool NHS Foundation Trust. Reverse shoulder arthroplasty — post-operative protocol. Reviewed April 2023. https://www.nth.nhs.uk/resources/reverse-shoulder-arthroplasty/
  • Maddocks C, Lloyd Evans J. Rehabilitation guide following reverse total shoulder replacement. Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust. February 2024. https://www.rjah.nhs.uk/media/qctjsd1w/reverse-shoulder-replacement-guideline-2024.pdf

Creative Commons BY-NC 4.0

CC Creative Commons licence
BY Attribution — you must credit the source
NC NonCommercial — not for commercial use

Attribution-NonCommercial 4.0 International

Creative Commons Corporation ("Creative Commons") is not a law firm and does not provide legal services or legal advice. Distribution of Creative Commons public licenses does not create a lawyer-client or other relationship. Creative Commons makes its licenses and related information available on an "as-is" basis. Creative Commons gives no warranties regarding its licenses, any material licensed under their terms and conditions, or any related information. Creative Commons disclaims all liability for damages resulting from their use to the fullest extent possible.

Using Creative Commons Public Licenses

Creative Commons public licenses provide a standard set of terms and conditions that creators and other rights holders may use to share original works of authorship and other material subject to copyright and certain other rights specified in the public license below. The following considerations are for informational purposes only, are not exhaustive, and do not form part of our licenses.

Considerations for licensors: Our public licenses are intended for use by those authorized to give the public permission to use material in ways otherwise restricted by copyright and certain other rights. Our licenses are irrevocable. Licensors should read and understand the terms and conditions of the license they choose before applying it. Licensors should also secure all rights necessary before applying our licenses so that the public can reuse the material as expected. Licensors should clearly mark any material not subject to the license. This includes other CC- licensed material, or material used under an exception or limitation to copyright. More considerations for licensors: wiki.creativecommons.org/Considerations_for_licensors

Considerations for the public: By using one of our public licenses, a licensor grants the public permission to use the licensed material under specified terms and conditions. If the licensor's permission is not necessary for any reason--for example, because of any applicable exception or limitation to copyright--then that use is not regulated by the license. Our licenses grant only permissions under copyright and certain other rights that a licensor has authority to grant. Use of the licensed material may still be restricted for other reasons, including because others have copyright or other rights in the material. A licensor may make special requests, such as asking that all changes be marked or described. Although not required by our licenses, you are encouraged to respect those requests where reasonable. More considerations for the public: wiki.creativecommons.org/Considerations_for_licensees

Creative Commons Attribution-NonCommercial 4.0 International Public License

By exercising the Licensed Rights (defined below), You accept and agree to be bound by the terms and conditions of this Creative Commons Attribution-NonCommercial 4.0 International Public License ("Public License"). To the extent this Public License may be interpreted as a contract, You are granted the Licensed Rights in consideration of Your acceptance of these terms and conditions, and the Licensor grants You such rights in consideration of benefits the Licensor receives from making the Licensed Material available under these terms and conditions.

Section 1 -- Definitions.

a. Adapted Material means material subject to Copyright and Similar Rights that is derived from or based upon the Licensed Material and in which the Licensed Material is translated, altered, arranged, transformed, or otherwise modified in a manner requiring permission under the Copyright and Similar Rights held by the Licensor. For purposes of this Public License, where the Licensed Material is a musical work, performance, or sound recording, Adapted Material is always produced where the Licensed Material is synched in timed relation with a moving image.

b. Adapter's License means the license You apply to Your Copyright and Similar Rights in Your contributions to Adapted Material in accordance with the terms and conditions of this Public License.

c. Copyright and Similar Rights means copyright and/or similar rights closely related to copyright including, without limitation, performance, broadcast, sound recording, and Sui Generis Database Rights, without regard to how the rights are labeled or categorized. For purposes of this Public License, the rights specified in Section 2(b)(1)-(2) are not Copyright and Similar Rights.

d. Effective Technological Measures means those measures that, in the absence of proper authority, may not be circumvented under laws fulfilling obligations under Article 11 of the WIPO Copyright Treaty adopted on December 20, 1996, and/or similar international agreements.

e. Exceptions and Limitations means fair use, fair dealing, and/or any other exception or limitation to Copyright and Similar Rights that applies to Your use of the Licensed Material.

f. Licensed Material means the artistic or literary work, database, or other material to which the Licensor applied this Public License.

g. Licensed Rights means the rights granted to You subject to the terms and conditions of this Public License, which are limited to all Copyright and Similar Rights that apply to Your use of the Licensed Material and that the Licensor has authority to license.

h. Licensor means the individual(s) or entity(ies) granting rights under this Public License.

i. NonCommercial means not primarily intended for or directed towards commercial advantage or monetary compensation. For purposes of this Public License, the exchange of the Licensed Material for other material subject to Copyright and Similar Rights by digital file-sharing or similar means is NonCommercial provided there is no payment of monetary compensation in connection with the exchange.

j. Share means to provide material to the public by any means or process that requires permission under the Licensed Rights, such as reproduction, public display, public performance, distribution, dissemination, communication, or importation, and to make material available to the public including in ways that members of the public may access the material from a place and at a time individually chosen by them.

k. Sui Generis Database Rights means rights other than copyright resulting from Directive 96/9/EC of the European Parliament and of the Council of 11 March 1996 on the legal protection of databases, as amended and/or succeeded, as well as other essentially equivalent rights anywhere in the world.

l. You means the individual or entity exercising the Licensed Rights under this Public License. Your has a corresponding meaning.

Section 2 -- Scope.

a. License grant.

1. Subject to the terms and conditions of this Public License, the Licensor hereby grants You a worldwide, royalty-free, non-sublicensable, non-exclusive, irrevocable license to exercise the Licensed Rights in the Licensed Material to:

a. reproduce and Share the Licensed Material, in whole or in part, for NonCommercial purposes only; and

b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.