Clavicle Fracture PART 2. Getting Back on the Bike

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If you haven’t done so already, please read post #1 which covered conservative and surgical management options of a clavicle fracture with a cycling bias. Post #2 now follows explaining the things you need to know to get back to sport and life.

The first step after such an injury is learning about pain control because broken bones really hurt! Obtaining good pain relief allows rehab to start sooner and improves not only your short term outcome but also long term results.

Pain Relief Post-Injury / Surgery

Post-injury or post-operative pain relief requirements will differ from one individual to another, even for the same surgery or injury.  Dr Mark McGrath, G.P. (and also cyclist who has suffered a clavicle fracture!), suggests that as a general principle, it's good to use a combination of medications which can work together to minimise the side-effects from stronger medications such as narcotics. Your doctor can help tailor a pain relief plan and it should be regularly reviewed during the course of your recovery.  At its most basic level, pain relief may involve regular simple analgesia such as paracetamol and anti-inflammatories, with stronger prescription analgesics used as required.  This basic plan needs modification based on the individual, accounting for factors such as injury severity, and whether other fractures or injuries were also sustained.   

The “take-home message” is that it is always preferable and easier to control pain from the early stages with regular medication.  Pain is harder to treat if you let it get out of control.  If you use analgesic medication effectively (ie regularly in the correct dose) you will tend to use a lower total amount of medication than if you let the pain build up.  Medications are “weaned off” as your clavicle heals and becomes less painful.

 

The Psychology of Recovery

Pain management in the early weeks is very important, but remember that pain is modulated by your psychological state.  The same injury can be experienced as more severely painful when you are anxious or sleep deprived, for example.  Getting back on the bike, and especially at the time you resume racing in a high speed bunch, can pose some significant psychological challenges especially if your injury happened in similar circumstances.

Psychologist Dr Matthew Evans notes that emotional reactions to injury can vary a lot between individuals.  Frustration, sadness and anxiety are common and normal reactions. For many people, support from others, seeing themselves progress over time and getting back on the bike is sufficient for these emotions to improve.  It might be worth seeking professional help if:

  • Your emotional state is interfering with your ability to follow through on recommendations from your treating team or your return to cycling. In other words if you are struggling to complete your rehab exercises or conversely find yourself unable to resist pushing yourself too hard;
  • Your emotional state remains “stuck”, for example you feel down all day, every day, for 2+ weeks;
  • Your level of distress is very high and overwhelming despite your best efforts to manage it;
  • Your relationships with loved ones decline significantly. It is natural when we are hurt to seek out support from others. After an injury, differences in ways of coping with an injury can easily exacerbate interpersonal conflicts. Conflicts can escalate and cause even more distress than the original physical injury.

Of special note with injuries that occurred at high speeds such as many bike crashes, if there was a perceived risk of death or significant harm or in some other way the accident was particularly traumatic, it is common to have intrusive memories of the events (“reliving experiences”, nightmares, emotional numbness, and avoidance of reminders).  For a cyclist these memories / fears often arise when you return to riding in a bunch or descending.  If these intrusive memories are allowed to “come and go” they will typically die down over time.  It is important not to feel pressured to talk about the accident if you do not want to in the early stages as this can cause traumatisation, and of course seek help if symptoms persist.

 

Physiotherapy: What You Need to do if You Manage the Fracture Conservatively

Physical rehabilitation with your Physiotherapist should start immediately, with the first 6 weeks (whilst in your sling) being aimed at preventing long term problems like a frozen  shoulder and preventing some muscles such as the rotator cuff from completely shutting down.  Getting back on the stationary trainer is slower with conservative care as this is hard to do with your arm in a sling and the bones not united together.  Between weeks 6-9, movement can usually be commenced above shoulder level, along with using a trainer and light strength work.  Contact sports and heavier weights are not usually recommended until after 12 weeks and even then only after your specialist has cleared you to do so.

Soft tissue injury to the surrounding structures may become evident over the first week or so after your accident. The knock-on effect to your whole body needs to be considered as you may develop poor postural habits whilst initially in a sling or changing sleeping positions to avoid pressure to your recovering arm.  Needing some neck or back treatment during this time is common.

  

Physio Rehab: What You Need to do Following Clavicle Surgery

Pain typically settles quicker after surgery as the bone is stable.  This allows rehab to start earlier when compared to conservative care.  Hydrotherapy, low load strength work and aerobic exercise including stationary bike, elliptical trainer, treadmill, or water running are all possible inside the first 6 weeks.  A sling may not be required for as long as with conservative care.

Whichever treatment you choose, progression of your rehab in weeks 6-12, and weeks 12-18, is in my view critical for an excellent rather than a mediocre outcome, and to prevent longer term problems.  These longer term problems may include shoulder or neck pain that may appear some years down the track resulting from persistent imbalances not addressed soon after the injury has healed.  From the third month onwards regaining muscle bulk and strength in a balanced manner is crucial, as persistent muscle imbalances are thought to be the precursors to chronic problems.

 

  
Surgical scar 6 months post clavicle surgery.  The faint "caterpiller" under the skin is the plate.  Check the Xray above. (The vertical scar is an old scar from a shoulder reconstruction which on Xray above is the 3 dots).

Getting Back on the Stationary Trainer After Clavicle Surgery

Please check with your Surgeon first before “jumping on”, as sweating under your wound dressing can cause an infection and delay your recovery.  Typically you can consider getting on the trainer 10-14 days after surgery.  As a Physiotherapist I would recommend being pain-free enough that any prescription pain killers are no longer needed – you don’t want to be exercising whilst on narcotics!  Any pain in the clavicle region would indicate that you are starting back on the trainer too soon and risk doing more harm than good.   How would that “harm” show up?  You’ll be sore afterwards and set your progress back several days.  Your first trainer session should be a short easy 15mins and there should be no lasting pain afterwards.  It is advisable to ice the clavicle bone afterwards (wrap the ice pack in a damp cloth) for 10mins. The clavicle is superficial so icing for longer increases the risk of an ice burn.

Follow-Up Checks

To make sure your fracture is healing well, Dr Pritpal Bansi, specialist upper limb Surgeon, recommends a follow-up X-ray at 6 weeks, and if the bones are healing then movement above shoulder height is usually commenced.  A CT scan to check bony union may be performed after 9-10 weeks following surgery to confirm bony healing, after which time your Surgeon may recommend a further progression of your rehab.  Regular check-ups with your Physiotherapist help to prevent errors in rehab such as “over-doing it” or “under-doing it”, both of which will delay your recovery.  Seek professional advice about when it is safe to resume cycling on the road / track / trails.  If you have any doubts always consult your Surgeon.

Remember These Tips to Help You Through Your Rehab:

  1. Bones take a certain amount of time to heal – you don’t control this time, and you can’t make it go faster but you can certainly make errors in your rehab by doing too much too soon and make it take a whole lot longer.  
  2. Do your exercises. Physiotherapists don’t give them to you for the sake of it. Rehab might not be as much fun as riding but rehab is what gets you back on the bike sooner and more successfully.  Doing nothing is just as bad as over-doing it.
  3. Pain is a good guide – your rehab or time on the trainer should not aggravate your pain. This can be tricky to judge as sometimes the activity does not cause pain at the time, but results in a sore clavicle later in the day.  If this happens take a day off and try doing less the following day.  Just because there is no immediate pain with a certain activity after surgery doesn’t mean that it is ok – seek advice from your Surgeon or Physiotherapist first.
  4. Focus on what you can do. Long term rehab is as much a mental game as it is physical. Getting back on the trainer or into the pool and being more active in other areas of your life such as spending more time with family and friends or catching up on some paperwork might take the place of your regular ride.  Don’t spend time dwelling on what you can’t do as this leads to frustration and depression.
  5. Don’t try to lose weight whilst your bones are healing. You need to eat plenty as bones take an enormous amount of energy to heal (remember high calcium and protein foods).  This is especially true if you broke more than one bone.  It is normal to find yourself fatiguing much faster as much of your energy is being taken up healing bone.  So listen to your body and rest or sleep more if required, and consider easing your way back into work part-time initially and see how you cope.
  6. Get your rehab right the first time. It’s much quicker and easier this way.  A skilled Physiotherapist can guide you here.

 

So if you break your clavicle, consult an upper limb Surgeon and seek their advice about best management in your individual situation.  The earlier you consult your Physiotherapist the better.  Make sure your early pain relief is regular and appropriate for you, and that you understand how and when to wean off the analgesics.  Regular X-rays need to be organised to ensure everything heals properly with good alignment.  If you are feeling down in the dumps about it and this isn’t improving over a couple of weeks, then speak to a Psychologist.  And do your rehab – it works if done appropriately and consistently.  There are no shortcuts!

 

 

References:

Burnham JM et al (2016): Midshaft Clavicle Fractures: A Critical Review. Orthopedics 39:e814-21.

Wijdicks  F et al (2012): Systematic review of the complications of plate fixation of clavicle fractures. Arch Orthop Trauma Surg 132:617–625

Canadian Orthopedic Trauma Society (2007): Nonoperative Treatment Compared with Plate Fixation of Displaced Midshaft Clavicular Fractures. A Multicenter, Randomized Clinical trial. JBJS 89A: 1-10.