You flew over the handle bars and came crashing down onto your shoulder. Now you have a constant niggle in your shoulder and you’re left with many questions. Can I cycle again? Should I go see a doctor? Why is the pain not going away? Did I fracture my collarbone?

Let’s start with what you know. You have a dull burning pain in your shoulder, your arm feels weak and you struggle to lift it. These signs can be linked to various injuries like nerve irritation, a rotator cuff strain or a fractured collarbone. But what is your specific injury?

The collarbone is the only link between the arm and the torso. Therefore if the collarbone is fractured the link is broken. Since you have a burning sensation and power loss in your arm, it is highly likely that you have a collarbone fracture. Don’t worry, this is quite a common injury. It is easy to manage, if you follow the correct recovery process. It’s what you do next that determines how well & fast you recover.

The collarbone (also known as the clavicle) is located between the breastbone and the shoulder joint. It is a slender S-shaped bone and is approximately 15 centimeters long. It serves as a link between the shoulder blade and the breastbone. There are 2 collarbones one on the left and one on the right of the chest bone (sternum). Interesting fact is that the collarbone is the only long bone in the human body that lies horizontally.

The location of the collarbone is clearly visible, from the front. It received its name from the Latin clavicula (“little key”), because the bone rotates along its axis like a key. The clavicle has various structures that attach to it for example other bones to form joints, ligament and muscle attachments.

Joints

Joints are formed when two adjacent bones move or glide on one another, giving rise to movement. The clavicle forms a joint with the sternum known as the sternoclavicular joint.

Your clavicle forms a joint with the scapula known as the acromion-clavicular joint. This joint is very prone to dislocation in contact sports. A prominent bump can be seen and felt just above the shoulder joint with an acromion-clavicular dislocation and often requires surgery.

The acromion-clavicular joint is also known to lead to pinching (impingement) and even fraying of certain muscles due to the small tunnel that it forms with your shoulder joint. This pinching of muscles is known as shoulder impingement or rotator cuff syndrome.

Ligaments

Ligaments are string like structures that connects bone to bone. The clavicle has a few ligaments that keeps it in place to form a joint with the chest bone, known as the sternoclavicular joint and the shoulder blade known as the acromion-clavicular joint. Lastly the clavicle also has ligament attachments with the shoulder blade known as the coraco-clavicular ligaments.

Sternoclavicular joint ligaments stabilize the joint by two sets of ligaments and the ligaments are divided into:

• Intrinsic ligaments: anterior and posterior sternoclavicular ligaments.
• Extrinsic ligaments: interclavicular and costoclavicular ligaments.

Coraco-clavicular ligaments :
These two ligaments (trapezoid and conoid ligaments) attach the clavicle to the coracoid process of the scapula. The trapezoid and conoid ligaments play an important role in keeping the scapula attached to the clavicle and thus keeps your shoulder ‘square’. They carry a massive load and are extremely strong. A fall on the point of the shoulder can rupture these ligaments with dislocation of your Acromion-clavicular joint.

Muscles

A total of five muscles attach to the clavicle. The trapezius, deltoid, sternocleidomastoid, pectoralis major and the subclavius muscle. The sternocleidomastoid and the trapezius muscles are known to give significant headaches when in spasm. Whereas the pectoralis muscle gives a dull ache into the arm. These headaches and radiating pain into the arm are common with collarbone fractures which leads to spasm of the surrounding muscles.

The collarbone serves several functions:

• It serves as a rigid support from which the shoulder blade (scapula) and the arm are suspended. This ensures that the arm is kept away from the body so that the arm has maximum range of movement, to reach for your coffee cup on the top shelve.
• Acting as a flexible, crane-like reinforcement, it allows the shoulder blade to move freely on the chest wall.
• The collarbone also plays an important role in protecting delicate structures like veins, arteries and nerves that run underneath the collarbone. Without the protection of the collarbone when falling, it would easily result in serious injury to the nerve or blood supply.
• The clavicle also transmits physical impact or forces from the arm to the rest of the body.
• Lastly the collarbone provides attachment for numerous muscles and ligaments of the neck and shoulder area. Therefore neck and shoulder pain is common after a clavicle fracture.

Your collarbone is the only bony link between the arm and the trunk. Due to its superficial location under the skin and the numerous forces applied by ligaments and muscles, the collarbone is easily fractured. Because the middle third of the collarbone is the thinnest segment and does not have any ligament attachments, it is the most easily fractured location.

A force that is stronger than your collarbone itself is needed to break it. Younger individuals often get injured by moderate to high-energy mechanisms, such as car accidents or sports injuries. Whereas older individuals are more likely to get injured with a low-energy fall, because of less dense bone.

The most common mechanism of injury is a direct fall onto your shoulder. It would make sense that if you have fractured your collarbone, you would have difficulty and experience pain when attempting to move your arm.

Collarbone fractures are typically classified into 3 types based on the area of the bone:

• Group 1: Middle third or midshaft of the collarbone. This is also the most common fracture site of the collarbone.
• Group 2: Distal third or the third that is closest to the shoulder joint.
• Group 3: Proximal third or the third closest to the breast bone

Your body will respond with an inflammatory reaction when you fracture or even just bruise your clavicle. This inflammatory response is the body’s natural way of healing an injury. Common symptoms of inflammation after a clavicle fracture would be swelling, redness, increased pain and increase in temperature over your broken collarbone.

When you fracture your clavicle you will most probably also have some bruising to the surrounding muscles. Muscles that are commonly bruised and that goes into spasm are the upper Trapezius, Sternocleidomastoid and Scaleni muscles. When these muscles are inflamed and in spasm you will have difficulty in moving your neck and you might also be burdened by headaches, nausea and ringing in your ears.

Collarbone fractures are very common injuries in adults (2-5%) and the most common fracture in children (10-15%). Clavicle fractures represent 44-66% of all shoulder fractures. A fall directly onto the shoulder most frequently causes a collarbone fracture, typically seen in contact sports like rugby.

Common causes of collarbone fractures usually occur after an accident or incident for example:

• Falling directly onto your shoulder.

• Landing on an outstretched arm when falling.

• Getting hit directly on your shoulder.

• Motor vehicle or motorbike accidents.

Collarbone fractures are usually not a seen as a very serious injury. In rare cases collarbone fracture can result in life-threatening complications. These life-threatening complications can occur when the fractured bone fragments lead to a pierced lung or severed nerves or arteries. This will require immediate medical care.

While most collarbone fractures are treated without surgery, but severely displaced fractures may require surgical fixation. You can look at the severity of a collarbone fracture from a medical point of view:

Non-displaced fracture:

• The bone has cracked but not separated.
• This type of fracture does not require surgery.
• If treated conservatively the shoulder is strictly immobilized in a sling for 6 weeks.
• Recovery time: 4-6 weeks depending on the severity of the fracture. A full recovery and return to sport will take longer and should not be confused with the healing period. To return to the sport can depend on the specific sport, but will only be 3-4 months after injury.

Minimally displaced fracture:

• The two pieces of bone has shifted slightly away from each other.
• This type of fracture is treated with or without surgery depending on the degree of bone displacement, your age, your functional demands and the orthopedic surgeon’s preferred protocol.
• If treated conservatively the shoulder is strictly immobilized in a sling for 6 weeks.
• Recovery time: 4-6 weeks depending on the severity of the fracture. A full recovery and returning to sport will take longer approximately 3-4 months after injury.
• If treated surgically an ORIF (open reduction internal fixation) will be done under general anesthesia.
• Recovery time: 4-6 weeks depending on the severity of the fracture. A full recovery and returning to sport will take longer, approximately 3-4 months after injury.

Displaced fracture:

• This is the most severe type of fracture because the broken bone has become completely detached and that makes it a lot harder to get it back into a useful position.
• This type of fracture is treated surgically, an ORIF (open reduction internal fixation) will be done under general anesthesia.
• Recovery time: 4-6 weeks depending on the type of the fracture. A full recovery and return to sport will take longer, approximately 3-4 months after injury.

Our physiotherapists are experts in anatomy and have years of experience to know when a bone is fractured and requires medical intervention. If you have a fractured clavicle, we will refer you to the correct medical professionals to do a X-ray to confirm a clavicle fracture.

We understand the healing process and will be able to provide you with guidance and advice. A personalized treatment program will be formulated for your specific injury and will assist you back to full function.

If you perhaps don’t have a clavicle fracture we will be able to confidently identify the root cause of your shoulder pain by testing other structures like joints, muscles, ligaments and nerves in the area and provide you with an accurate diagnosis. That’s why our physiotherapists are the best equipped at diagnosing shoulder pain.

X-rays shows the integrity and alignment of your clavicle. This will enable us to see if something is wrong with the structure of your clavicle and whether it is indeed fractured.

Your physiotherapist can refer you to get x-rays taken.

Diagnostic ultrasound will not be an effective tool to confirm a clavicle fracture. It’s very seldom any of the vital soft tissue structures are injured when the collarbone is fractured.

However, if your physiotherapist suspects that you have a soft tissue injury like a muscle tear (muscle strain), ligament tear, dislocation, inflammation or simply increased contraction of a muscle (muscle spasms) an ultrasound will be able to diagnose these injuries. Our physio will refer you.

A MRI will show all of the structures in and around your collarbone. This includes bones and soft tissue like muscles, ligaments and nerves. It will show your collarbone fracture and any accompanying soft tissue injuries, like bleeding, swelling or muscle tears.

However, MRI studies are not done routinely with collarbone fractures seeing that it is not classified as a serious injury.

This is an expensive test and you need to be referred by a specialist to get one. If your physiotherapist suspects that you have a complex broken collarbone, you will be referred to a specialist.

Initially, after you had a collarbone fracture, the pain that you feel in and around your collarbone will be normal. The pain serves as a warning if you’re doing an activity that is too strenuous. It reminds you that your broken collarbone still needs to heal and thus you can see the pain as a protective mechanism.

If everything goes well, your pain should decrease with time as you recover. However, if you neglect to work through your rehabilitation process and don’t get the right treatment from the start, you’ll continue to feel pain. With time, it will bother you more and more, it will prevent you from using your arm properly and your shoulder and neck will get painful, weak and stiff. You become stuck in a cycle of pain, not knowing if it is better to move or not.

Make sure you are getting the right treatment for your collarbone fracture from the start. This includes getting the right medical treatment and working through a proper rehabilitation program. The medical treatment might include surgery to fixate the broken bone and ensure good healing of the bone. If this goes well, then you know you have a strong collarbone and a strong foundation to start from.
After surgery you will need rehabilitation. This is the only way to ensure that you regain optimal function of your arm and shoulder. This rehabilitation will ensure that you can return to driving, cycling, dressing and lifting heavy objects overhead.

Maybe you feel like you didn’t recover well from a broken collarbone that happened years ago…

Seeing that you’re still struggling to lift that heavy barbell overhead or to do that last set of push ups at the gym. However, you don’t have to lose hope. You can still get the help you need. In this case, your fractured collarbone has already healed, but the pain that you are feeling is caused by other problems. Weakness of neck and shoulder muscles, non-union of the collarbone fracture, mal-union of the collarbone fracture, poor shoulder joint stability or even early arthritis are some of the things that can cause your pain even years later.

If not diagnosed accurately and mismanaged, a collarbone fracture can lead to secondary complications. Chronic pain leads to a protective posture of keeping your neck still, your shoulder pulled up and your elbow bent (like you are wearing a sling). This can lead to scar tissue formation, joint stiffness, muscle weakness, neck or shoulder pain and even headaches.

The same goes for wearing a sling too long and incorrectly. Incorrect fitment and lack of support in a sling can lead to muscle weakness and faulty biomechanics once the sling is removed. A sling has its place and time. Think of a sling the same way you think of a crutch, you only need it for a short time to lighten the load on the leg.

Trying out, but not completing different forms of treatment. Often, while recovering from a broken collarbone, patients try to get pain relief by taking their own medication or getting a voltaren injection. However, these treatments will only give you temporary pain relief, because you are not addressing the root of the problem. The pain that you are feeling on your collarbone is due to poor shoulder stability, weak shoulder muscles and a poor movement pattern. The only way to address this is by working through all the steps of a rehabilitation program to get your shoulder conditioned to handle more load. It takes time and effort, but it will be worth your while.

Resting too much or too little. Resting too much leaves you weaker than before. Moving too much causes extra pain and inflammation. Finding the balance between resting and doing safe movements is key!

We can provide the best possible treatment after you’ve had a collarbone fracture. Patients are often anxious to get back to their normal daily routine and that is why we are here to provide guidance and answers to address your fear.

We’ll implement a very effective and structured plan of action that treats all the aspects of your collar bone fracture. This way your shoulder pain, weakness and fracture will recover and you’ll be able to move and exercise with confidence again. However, it’s important that you commit to the treatment plan, as this improves your chances of successful long-term recovery.

Physiotherapists use these techniques during your treatment:

• Physiotherapy treatment focuses on pain management and accelerating the healing process by using Ultrasound and Laser machines.
• Strapping and Taping to support and protect you from further injury.
• Acupuncture or Dry Needling of the surrounding compensating muscles, to relieve pain and muscle spasm.
• Massage and Soft tissue mobilization.
• Joint mobilization techniques of all the surrounding joints.
• Myofascial release of the upper arm muscles to guide the scar tissue formation.
• Eccentric loading exercises to condition the muscle fibers.
• Compression bandaging like compression gloves can promote blood flow through the site of injury and prevent the blood from pooling.
• A sling to immobilize the collarbone for the first few weeks.
• We will gradually progress your rehabilitation exercises to regain full function of the whole arm and shoulder.

Depending on the severity of your collarbone fracture and which other soft tissue structures got injured, it takes 4 to 6 weeks for the initial healing of your broken collarbone. A collarbone fracture is luckily not a very serious type of injury. It takes about 3 to 4 months to get back to exercises and sports.

You will definitely have a range of other soft tissue trauma around the broken collar bone. At first our main concern is bone healing, but during the weeks and months it will take to recover, there are other things that needs our attention as well. It is important to start with physiotherapy and recovery program as soon as possible. This way, you can prevent problems of compensation, muscle weakness and poor shoulder stability. Patience is key when you recover from a broken collarbone, because it takes time. Even if you decide to get treatment for the shoulder pain and you’re still feeling pain years after your collarbone fracture, it will be a step-by-step process of clearing up different problems.

Initially, you need physiotherapy treatment twice a week for the first two weeks. After this, your treatment sessions is spread out to once a week or once in two weeks. You only spend an hour at a time with your physiotherapist. How fast you recover will greatly be up to you. If you complete our treatment protocol, you should be able to make a full recovery.

Medication: Initially, you need medication to manage your pain, but it must be reduced gradually to get a true picture of what’s happening with the tissue. Be careful to not use these medications for too long as they delay healing and mask your symptoms.

Cortisone injections: Your doctor might suggest that you get a cortisone injection if your pain persists. This eases the discomfort and pain coming from inflammation in and around your shoulder joint. However, long-term use of cortisone is not good for the integrity of your joints and if the problem is of a biomechanical nature, it won’t be the sole solution to your problem.

Getting a manipulation done: Your shoulder feels stiff after you had a collarbone fracture and it might feel like it needs to be ‘clicked’ back in. However, getting a manipulation or re-alignment done is not a good idea. It could cause a whole rang of problems.

Seeing a biokineticist: When you have worked through your treatment plan with your physiotherapist, you’ll need help with further rehab, a biokineticist is valuable to help you reach your optimal functional level for your body.

Treatment of your collarbone fracture might involve surgery. Depending on which area of the collarbone the fracture took place, how much displacement of the fractured bone took place, if any vital structures are at risk of injury and lastly what the physical demands of the specific individual is. An orthopedic surgeon will use various devices such as nails, plates and screws to stabilize and fixate your collarbone fracture. Occasionally the plate that was inserted to fixate the collarbone fracture is removed if you are still going to participate in contact sports.

Surgery is not be an option is when the fracture is still well aligned, or when it’s too dangerous for the patient to undergo surgery or if the patient’s functional demands are very low for example bed ridden elderly or disabled person that is not actively using the arm. Under these circumstances, your arm will be immobilized in a shoulder sling for 4-6 weeks to ensure optimal bone healing.

After surgery, rehabilitation is the only way to get you back to full function. Initially, your surgeon might not permit certain movements and you won’t be allowed to carry any heavy objects. However, you must start with physiotherapy in the first few days after surgery. Even if you aren’t allowed to do much, your physiotherapist can help you by moving your arm and shoulder for you ,to prevent any joints from becoming stiff. This way, when the orthopedic surgeon gives you the green light to start moving, your physio is up to date and ready to progress your treatment.

We work with a network of expert orthopedic surgeons that has proven their expertise. We’ll refer you to the best specialist that suits your problem. We also help you with post-operative rehabilitation. Remember, surgery is only the halfway mark for a successful surgery, the rest is reintegration, strengthening and adapting your body to the change.

• Shoulder joint pain or arthritis – Pain and stiffness in your shoulder that feels worse in cold weather, in the mornings or when you have overworked the arm.
• Biceps muscle tear, Supraspinatus tendinitis – pain specifically caused by one of these muscles that gets injured to the point of tearing. It feels worse when you try to move or stretch and better when you rest.
• Biceps tendonitis – pain in your shoulder that feels worse after you’ve done exercise or even the next morning.
• Shoulder impingement syndrome – Pain in the shoulder joint that feels especially worse when you lie on your affected side at night or attempt to lift the arm away from the body.
• Sub acromial bursitis – Pain in the shoulder joint. Usually worse when you attempt to lift the arm away from the body.
• Acromioclavicular dislocation– Localized pain in the shoulder joint especially when you move the affected arm across the body and compress the specific joint e.g. reaching for your seatbelt. A visible bump will be seen and felt on the shoulder and will be painful. Usually caused by a fall on an outstretched arm.

• Broken collarbone
• Fractured clavicle
• Dysfunctional shoulder girdle
• Shoulder fracture