Efficacy of scapular-focused rehabilitation protocol on shoulder function following Proximal Humeral Internal Locking...

Proximal humeral fractures (PHFs) are a significant healthcare burden, representing the third most common osteoporotic fracture in older adults. Although open reduction and internal fixation (ORIF) with the Proximal Humeral Internal Locking System (PHILOS) provides a reliable rate of osseous union, postoperative complications such as shoulder stiffness and residual pain remain prevalent. Current rehabilitation protocols are predominantly glenohumeral-centric and often overlook fracture-associated scapular dyskinesis. This randomized controlled trial (RCT) aims to evaluate whether incorporating a systematic scapular control and stabilization program into standard postoperative rehabilitation yields superior outcomes after PHILOS fixation.

A single-centre, prospective RCT was conducted from June 1, 2023, to December 31, 2024. Sixty eligible patients (aged 18 to 80 years) with severely displaced two- or three-part PHFs were randomized (1:1) to a scapular-focused rehabilitation (SFR) group (n = 30) or a standard rehabilitation (SR) group (n = 30). Both groups attended supervised physiotherapy twice weekly for 12 weeks, with the SFR group receiving additional systematic scapular stabilization exercises. The primary outcome was the Constant-Murley score (CMS) at 12 months. Secondary outcomes included the Disabilities of the Shoulder, Arm, and Hand (DASH) score, the American Shoulder and Elbow Surgeons (ASES) score, the Shoulder Pain and Disability Index (SPADI), and visual analog scale (VAS) pain scores assessed at one, three, six and 12 months, along with EuroQol (EQ) scores, patient-reported satisfaction and radiographic evaluations (neck-shaft angle [NSA] and humeral head height [HHH]).

Baseline characteristics were well balanced between the two cohorts. The SFR group had significantly higher adjusted mean CMS at 1 month (46.1 ± 7.5 vs. 41.5 ± 8.4; P = 0.039) and three months (63.4 ± 9.6 vs. 57.2 ± 9.1; P = 0.018) postoperatively than the SR group. Similarly, the SFR cohort had significantly superior DASH, ASES, SPADI pain, and VAS pain scores at one and three months (all P < 0.05). Furthermore, health-related quality of life, comprehensively evaluated via EQ-5D and EQ-VAS indices (P < 0.05), as well as patient-reported satisfaction metrics (P < 0.001), were markedly higher in the experimental cohort during the initial three months of intensive rehabilitation. However, these functional differences attenuated over time, with no statistically significant differences in CMS (P = 0.325) or secondary clinical outcomes at the 12-month final follow-up. Radiographic analysis revealed no significant intergroup differences in NSA or HHH at any time point (P = 0.600 and P = 0.462 at 3 months, respectively), indicating that the targeted intervention did not compromise construct stability.

Incorporating systematic scapular-focused exercises into standard postoperative rehabilitation after PHILOS fixation for PHFs serves as a beneficial adjunct that significantly accelerates early functional recovery, reduces early postoperative pain, and improves patients' overall health utility and satisfaction in the early stages. These early gains are achieved without compromising fracture reduction or implant stability. Although long-term functional outcomes converge by 12 months, this accelerated recovery trajectory provides substantial clinical value by effectively reducing the burden of early postoperative disability in a vulnerable demographic.