Breaking it down: The fractured collarbone
Type “collarbone” into the CyclingTips search bar and 331 results pop up. Now 332. This is unsurprising as collarbone injuries are incredibly common in both professional and amateur fields. The pros often make a collarbone break look like a minor blip in the season, with some returning to the peloton only weeks after injury. For everyone else, a broken collarbone can mean sitting on the sidelines for 12 weeks or longer. Let’s have a look at what happens when you come off your bike, why you won’t be on the trainer the next day and how to maximise your recovery.
Clavicle is the anatomical name for the collarbone. These slender bones attach at the start of the breastbone (sternum), and end at the point of the shoulder, one on either side. On the outside end, the collarbone attaches to the shoulder blade (scapula) via a web of ligaments, and forms part of what is called the shoulder girdle. The collarbone sits directly in front of important arteries and nerves that supply the arms.
The collarbone is a strut that holds the shoulder girdle away from the rib cage. This allows complex movements such as scratching your head, putting on your bra or throwing a ball. As well as bracing the shoulder girdle, it is an anchor point for six muscles including the pectoralis major, trapezuis and deltoids. It also has strong ligament attachments tethering at either end. These attachments all exert forces onto the bone during weight bearing and movement.
Just Like Snowflakes
The mechanism of breaking a collarbone is either by direct force (falling off the bike onto the shoulder) or indirect force (onto an outstretched hand or elbow). These fractures are like snowflakes in that each one is unique. It is possible to break the collarbone anywhere along the length of the bone; however, the most common place is the middle third.
Fractures can be tiny hairline cracks or can split the bone in two. The broken ends may stay together but sometimes they separate or overlap. Some lucky riders may even have multiple fracture sites. These x-rays make the best Facebook updates.
The place and type of fracture affects the treatment given. Usually simple fractures are managed conservatively, that is, without surgery. Surgery is more likely if the break has significantly separated, caused shortening of the collarbone or damage to nerve or blood supply. Certain doctors have different treatment methods based on their experience and up to date evidence, and they also will consider the risks of non-union, surgery and re-injury.
Professional cyclists often opt for surgery because they believe this stabilises the break and allows them to return to regular training and racing more quickly. These athletes train under the very close supervision of medical and coaching staff. Surgery for the sole purpose of returning to riding more quickly should not be a consideration for amateurs.
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Fixing a fracture is about two things:
- Realigning the bones as closely as possible to normal position
- Preventing further movement to allow healing
On a limb, this might be done through a cast, but in the case of the collarbone, options are more limited. Conservative management involves immobilising the shoulder girdle through wearing a sling. Surgical management involves inserting hardware. In either case, back on the bike time will vary depending on the doctor’s guidelines and an individual’s healing rate.
It’s important to keep in mind that there are different stages of bone healing. Repairing the body isn’t like welding it back together; it’s more like very slow drying glue, only slightly more sophisticated.
Within days of a fracture the body has started laying down a mass of repair tissue known as “soft callus”, which helps prevent the ends from moving and starts bony reconfiguration. From this point, stronger bone is gradually laid down, called “hard callus”. This process takes about anywhere from four to six weeks, but the return to full bone strength takes up to 12 weeks. As movement starts again, the bone begins to strengthen through stress lines, and excess bone is removed from where it is not needed.
Rehab is the New Black
The conservative rehab option is usually full time sling or collar wearing for at least four to six weeks. During this time, activity is guided by the doctor’s recommendations or protocol. It is common to be given some posture and gentle shoulder range exercises whilst in the sling. Once the bone is stable enough, more active ranges and strengthening exercises should be commenced with a physiotherapist to get the shoulder movement back to normal.
With a surgical fixation, progress though these stages is generally faster. It is still possible to over-stress a collarbone that’s been plated, so lifting and activity restrictions are still given by surgeons. In most cases, the hardware will be removed down the track via another surgery. The rehab progression is similar to the conservative outline.
Are you Suffering Enough?
Everyone wants to get back on the bike as soon as possible, but it’s important to be guided by your doctor and physio. Sometimes it might feel like medical professionals are being overly cautious; however, there is a reason to take a slowly, slowly approach.
Would you ride your bike with a crack in the frame? No, you wouldn’t. When you return to activity too early, it’s the same thing. Trying to lift the groceries, jumping back on the trainer or not wearing your sling means forces from your joints and muscles go directly through your collarbone. This causes excessive stress, inflammation and even risks movement of the fracture.
Until the hard bone is laid down and remodelling is complete there is a higher risk of re-fracturing. This is true even for collarbones with hardware. In this case, the stress points are around the hardware and this can lead to either bending or snapping of the metal, or fractures further along the bone.
Another consideration is the effect of a period of disuse of the muscles around the shoulder. It’s common to have stiffness, weakness, muscle wastage and altered muscle activation patterns after a few weeks of non-use. This, in turn, will affect bike handling ability.
With any injury there are “physiological outliers”- the ones who don’t follow any advice, jump straight back on the bike and appear to get back to normal activity in no time. Unfortunately these people are the exception, not the rule. For the rest of us, following the advice of your doctor and physio is important to prevent complications and further injury.
Time to Roll
Once you’ve been cleared to get back on the bike, it’s best to start slowly to gauge how your body responds. In general, activity should be pain free and not cause overhanging soreness into the next day.
It is advisable to gently building up fitness and test your tolerance by starting on the stationary trainer for increasing time. Once spinning more than an hour is comfortable, trial an outdoor skill session in an empty car park. Practice cornering, signalling and emergency braking at increasing speeds to ensure your reactions have returned to a good standard and riding is comfortable and safe.
Next step is riding in a small bunch (maximum of four riders) in a quiet environment over a few rides before progressing back into normal training. Any racing should be carefully considered once you have a month or more of pre injury level training back under your belt.
And always make sure you have your doctor’s blessing. You don’t want to be rolling into the emergency department with another fracture next week.
- Have patience – Pushing yourself past the guidelines might end up blowing out healing times or prolonging the rehab process.
- Do your exercises – I get it. Posture and stretchy band exercises are boring. But physio’s don’t just make them up for fun.
- Re-channel your energy – Think about how many hours a week you’d normally train. Now imagine taking all that energy and putting it into doing your exercises well. Your rehab program is your new training program.
- Pain is not gain – Your doctor and physio will let you know at what point it’s okay to “push through” pain, but if you are popping pills to get through a workout then you are likely overdoing it.
- Do it right the first time – This is basically all the tips in one.
Have you broken a collarbone before? How does this compare to your experience? Feel free to leave your comments below.
Disclaimer: The information included in the article is for educational purposes only. It does not constitute professional, personalised medical advice. If you have experienced an injury, please consult the appropriate healthcare provider.
Alana Crimeen is a qualified physiotherapist and Australian Physiotherapy Association member. Her professional background involves working in the public system including as an independent practitioner in an emergency department and in outpatient injury rehabilitation. She was introduced to riding in a velodrome, fell in love with riding on the road and learnt healthy fear for riding on the mountain. She likes to keep up with recent research relating to athletes in order to hassle her training partners about cross-training from a more educated point of view.