Introduction

There is a particular kind of frustration that accompanies the later stages of shoulder rehabilitation. The acute pain has subsided. The bone has healed. Medical clearance has been given. And yet the arm still does not move the way it once did — not with the same confidence, the same range, or the same strength. This gap between structural healing and functional recovery is one of the most misunderstood aspects of musculoskeletal rehabilitation, and it is precisely what weeks six through nine of a humeral head fracture recovery program are designed to close.

This article explores the principles, exercises, and clinical reasoning behind late-stage shoulder rehabilitation — specifically the phase when bone healing is confirmed and the focus shifts entirely to soft tissue restoration and neuromuscular re-education.

Why Soft Tissue Work Begins After Bone Healing

Following a humeral head fracture, the initial rehabilitation phases are necessarily conservative. The priority is protecting the fracture site while preventing the joint from freezing entirely. Range of motion is introduced gradually, usually through passive and active-assisted movements that do not load the healing bone.

Once imaging confirms that the fracture has healed — typically between six and ten weeks depending on the individual, the fracture type, and overall bone health — the rehabilitation emphasis shifts. The soft tissue structures surrounding the shoulder joint, including the rotator cuff muscles, the joint capsule, the surrounding ligaments, and the biceps tendon, have been immobilized or underused for weeks. They are deconditioned, often stiff, and poorly coordinated.

Resistive exercise — where the muscles are asked to work against load — becomes appropriate at this stage. However, the approach must remain methodical. Jumping into heavy resistance too quickly can overload structures that are not yet prepared, while progressing too slowly delays functional recovery unnecessarily. The exercises in this phase occupy the precise middle ground: meaningful challenge with controlled risk.

Broomstick Mobility: A Foundation of Late-Stage Recovery

A simple dowel rod or broomstick remains one of the most effective tools in this phase of rehabilitation. Its value lies in versatility: it can be used for passive stretching, active-assisted range of motion, and light resistive strengthening — all within a single session.

Forward Flexion with Serratus Anterior Activation

Lifting the stick overhead in front of the body targets forward flexion of the shoulder while simultaneously engaging the serratus anterior — a fan-shaped muscle that wraps around the ribcage and plays an essential role in rotating the scapula upward during arm elevation. The serratus anterior is commonly inhibited following shoulder injury, and its weakness is a frequent contributor to impingement and poor overhead mechanics.

During this movement, the intercostal spaces (the areas between the ribs) also receive a gentle stretch. Maintaining slight abdominal engagement throughout helps stabilize the thoracic spine and prevents the lumbar region from hyperextending to compensate for limited shoulder mobility. A slow, sustained hold at the end range — combined with a deliberate breath in — deepens the stretch and allows the nervous system to relax its protective tension around the joint.

Extension with Pectoral Stretch

Bringing the stick behind the body into extension while leaning forward with the chest lifted produces a stretch along the anterior shoulder and pectoral region. The pectoralis major and minor are prone to shortening after periods of immobilization, pulling the shoulder forward and internally and disrupting normal joint mechanics. Sustained stretching of this area is essential for restoring the balanced muscle tension required for pain-free shoulder movement.

The cue to "keep the chest up" during this movement is clinically significant. An anteriorly tilted thoracic spine — what is commonly described as a rounded upper back — limits the subacromial space and increases the risk of impingement during arm elevation. By encouraging thoracic extension during the pectoral stretch, the exercise simultaneously addresses posture and shoulder mechanics.

Horizontal Abduction

With the stick held at shoulder height and the arms extended, moving the stick outward into horizontal abduction opens the anterior chest and activates the posterior rotator cuff and rhomboids. This movement pattern is the direct opposite of the slouched, internally rotated posture that many people adopt following shoulder injury — and for that reason, it serves as both a corrective exercise and a functional strength movement.

Strengthening Progressions in Phase 7

Shoulder Flexion with Postural Control

Using the stick for assisted shoulder flexion — lifting it upward in front of the body — transitions in this phase from a purely passive stretch to an active strengthening movement. The critical technical point is suppressing the compensatory strategies that patients frequently develop: shrugging the shoulders upward, thrusting the hips forward, or using trunk momentum to achieve elevation.

Keeping the shoulders depressed (pulled down and away from the ears) during active flexion trains the lower trapezius to counterbalance the upward pull of the upper trapezius, which tends to dominate following injury. This balance between the upper and lower portions of the trapezius is fundamental to smooth, pain-free overhead mechanics.

Bent-Over Rowing

Adopting a hip-hinge position — feet slightly wider than hip-width apart, knees softly bent, pelvis tilted forward, spine in neutral — allows rowing movements to be performed with the stick. The arms are brought toward the body by squeezing the scapulae together, and the shoulders are actively held down toward the hips throughout the movement.

The consistent emphasis on scapular depression during rowing exercises reflects an important biomechanical principle: the lower trapezius and serratus anterior must be active if the glenohumeral joint is to move safely. When the upper trapezius dominates — which tends to happen when the shoulders are allowed to elevate — the scapula tilts forward and the subacromial space narrows, creating the conditions for impingement.

Bicep Curls with Deltoid Engagement

Bringing the stick in toward the body and curling it upward incorporates the anterior deltoid along with the biceps brachii. This compound movement pattern begins to reintroduce coordinated upper extremity function — the kind of multi-joint, multi-muscle activation that characterizes real-world arm use.

The goal at this stage is not maximal hypertrophy but rather neuromuscular control: training the muscles to activate in the correct sequence, at the correct intensity, and through a progressively larger range of motion.

Posterior Stick Work: Scapular Retraction Under Tension

Holding the stick behind the body with palms facing forward and then pulling it away from the hips — imagining the hands sliding toward each other along the stick — creates significant activation of the scapular retractors: the rhomboids and middle trapezius. This grip and pull technique generates isometric tension through the upper back that directly counters the protracted (forward-displaced) scapular position commonly seen in post-injury patients.

A burning sensation in the mid-upper back is a normal and expected response to this exercise in patients whose scapular stabilizers have been underused for weeks or months.

Prayer Lift in the Founder Position

The prayer lift — performed with both hands pressed together — is progressed in this phase by incorporating it into the "founder" position: a hip-hinge stance with the feet slightly pigeon-toed (internally rotated). This foot position increases gluteal engagement and reduces excessive piriformis activity, providing a more stable base of support through the lower body during the upper extremity movement.

With the hands in prayer, the arms are lifted upward and slightly forward, engaging the shoulder elevators and serratus anterior in a controlled, bilateral pattern. Using the stronger arm to assist the recovering arm continues to be appropriate if the recovering shoulder cannot yet complete the full range independently. The bilateral assistance gradually reduces as single-arm strength returns.

Arm Circles and Hip-to-Shoulder Patterns

Arm Circles

Large, slow, controlled arm circles — performed with the arm hanging freely or with the stick — maintain the full circumferential mobility of the glenohumeral joint. The emphasis in Phase 7 shifts from passive gravity-assisted motion to active conscious control of the movement, reinforcing proprioceptive awareness and smooth joint mechanics.

Keeping the shoulder depressed throughout the circles prevents the compensatory shrugging that tends to limit the inferior range of the movement.

Hip-to-Hip and Hip-to-Shoulder Progressions

Functional cross-body movements are progressively extended in this phase. Hip-to-hip patterns — moving the hand from one hip to the other — establish the foundation. Hip-to-butt and hip-to-shoulder progressions increase both the range and the complexity of the cross-body path, mimicking actions like reaching across the body to fasten a seatbelt, lift a bag from a car seat, or embrace someone.

These diagonal movement patterns activate the shoulder in coordinated, functional arcs that isolated exercises cannot replicate. They are a bridge between clinical rehabilitation and the movements of daily life.

Cervical Mobility: The Overlooked Component

The relationship between the cervical spine and the shoulder girdle is bidirectional and clinically important. The muscles of the upper neck and shoulder region — including the upper trapezius, levator scapulae, and scalenes — share attachments and fascial connections that mean restriction in one area directly affects the other.

In Phase 7, targeted neck mobility work is incorporated to prevent cervical guarding from limiting shoulder progress. Lateral flexion (ear to shoulder), rotation (chin to shoulder), and chin tucks all address different aspects of cervical mobility and neuromuscular control.

The chin tuck in particular is noteworthy: by gently drawing the chin straight back — creating a "double chin" — it lengthens the suboccipital muscles and decompresses the upper cervical joints, counteracting the forward head posture that invariably develops during periods of pain and protective guarding.

Movement, as a general principle, is one of the most effective lubricants for joint health. Articular cartilage — which covers the ends of bones in joints — lacks a direct blood supply and depends on the mechanical compression and decompression of movement to receive nutrients and remove metabolic waste. Every range of motion performed, in every joint, every day, contributes to long-term joint health.

Self-Massage and Soft Tissue Care

By Phase 7, self-massage of the anterior deltoid and biceps tendon region becomes an important adjunct to active exercise. The biceps tendon — which attaches the long head of the biceps brachii to the superior rim of the glenoid — is particularly vulnerable to developing tendinopathic changes following shoulder injury. When the tendon becomes thickened and disorganized (a process called tendinosis), it can contribute to internal rotation of the humerus, disrupting shoulder mechanics and limiting the effectiveness of strengthening exercises.

Gentle strumming (transverse friction applied perpendicular to the tendon fibers) of the anterior shoulder and lateral deltoid region helps maintain tissue pliability, promote local circulation, and reduce myofascial adhesions that accumulate during immobilization. This can be performed with the fingertips using moderate pressure, working systematically across the anterior and lateral shoulder musculature.

The Mindset of Long-Term Recovery

One principle consistently emphasized in Phase 7 rehabilitation is that there are no shortcuts. Structural healing of the bone is just the beginning of the recovery process. The months that follow require patience, consistency, and a willingness to work through discomfort without abandoning the process.

Visualization — mentally rehearsing the movements and activities that are the eventual goal of rehabilitation, whether that means throwing a ball, lifting a child, or returning to a physical profession — has a documented role in motor recovery. Mental practice activates overlapping neural pathways with physical practice, reinforcing the motor programs required for skilled movement even when the shoulder cannot yet perform those movements at full capacity.

Maintaining connection with qualified healthcare providers throughout this phase remains essential. Manual therapy, assessment of joint mechanics across the entire shoulder complex (including the sternoclavicular joint, acromioclavicular joint, glenohumeral joint, and scapulothoracic articulation), and individualized progression of the exercise program all contribute to outcomes that self-directed rehabilitation alone cannot fully achieve.

Phase 7 is not the end of the journey. But it is the phase where patients begin to recognize that the shoulder they are rebuilding may, with dedication, become stronger and more resilient than it was before the injury occurred.