You hear it. The awful sound of carbon snapping and bikes and bodies scraping along the road. You are now flying through the air, having detached from your bike completely, launching head first towards the ground. Suddenly you come to a stop, sit up to dust yourself off, and upon standing realize something is terribly wrong. You cannot lift your arm and instead it just hangs lifeless by your side. Worse still, your shoulder is becoming more painful by the second.

A million things go through your head of what may have happened, but you take your hand and run it along your collarbone only to realize there is a large bump in it that was not there before. Unfortunately, you just joined a large contingent of other cyclists who have had to deal with broken collarbones.

Fear not though, bones will mend and your fitness will return! This post will discuss the different varieties of collarbone breaks and what is typically done to repair them to get you back on the bike as quickly as possible as well as give examples of rehabilitation exercises and a return to riding protocol.

Collarbone 101

Your collarbone (clavicle) is a long thin bone that runs from your breast bone (sternum) to your shoulder blade (scapula). Its purpose is to act as a strut between the two attachment points and the shoulder blade fixed to allow the arm to move about unrestricted. For the purpose of this article, we will divide the types of breaks it into three sections: medial (towards the breast bone), shaft, and lateral (towards the shoulder blade). These are the three places the bone can break or fracture, with the severity and location of the break dictating what is done to expedite healing.

Dealing With a Broken Collarbone

Once the collarbone break is confirmed with an x-ray, the doctor will recommend seeking further advice from an orthopedic specialist. Upon meeting with the orthopedist, they will advise you either to go under the knife and have the collarbone reduced surgically with plates and screws. If the pieces of bone have not separated far and are relatively lined up well you are luck and will not require surgery.

Non-surgical

If you are fortunate and the pieces of collarbone are relatively close together and line up well, you will be placed in a sling for 6 to 10 weeks. Every case and orthopedist is different – normally you will be instructed to keep your arm and shoulder as still as possible to encourage the two pieces of bone to mend with the only exercises being pendulums and possibly passive range of motion to discourage the shoulder from freezing.

Surgical

In other cases, surgery is necessary because the two pieces of bones are separated so much and/or are not lined up well.

Here is my collarbone post-crash. As you can see, the two pieces of bone are very far apart and not lined up well at all. Surgery, here I come.

Surgery is done as soon as possible and involves placing a plate along the length of the collarbone to reinforce it, and screws to align the bones up again and keep them in place. This is called a collarbone O.R.I.F. (Open Reduction Internal Fixation).

Here is my collarbone after the surgery. You can see the surgeon used a plate and screws to affix my collar bone back together to allow it to heal properly.

Similarly, once the surgery has been performed you will be placed in a sling for a set amount of time, but can usually progress faster and move your arm more as the metal plate is providing structure and support for your collarbone. Again, each case and surgeon is different.

Rehabilitation Exercise Suggestions

Once you get the clear from the surgeon to remove the sling and begin using the arm again, you can begin to work on regaining your lost range of motion and strength. You will also usually be sent to physical therapy for expert rehabilitation and guidance. The following is what I recommend to my patients, but should only be followed after being cleared by your surgeon and/or physical therapist. You can perform a Google image search and find pictures of all of these.

Range of Motion Exercises

• Pendulums: Perform two minutes each of front to back, side to side, and both clockwise/counter clockwise circles.
• Supine shoulder flexion with cane: Perform 2 x 20 reps staying in a pain-free range of motion.
• Supine shoulder external rotation with cane: Perform 2 x 20 reps staying in a pain free range of motion.

Ideally, perform these exercises two to three times per day until functional range of motion is regained.

Strengthening Exercises

• Sidelying external rotation: This exercise helps strengthen the rotator cuff.
• Prone “I”, “T”, “Y”, and “W”: These exercises help with middle back strength and to regain scapular stability. Start on a flat surface and then progress to a ball.
• Standing shoulder flexion and abduction: These help to strengthen the deltoid and regain functional reaching.
• Rows: Either with bands, cables, or machine. This helps to increase arm and middle back strength. Be sure to focus on engaging the muscles between the shoulder blades and to keep your neck relaxed.
• Lat pulldown: Either with bands, cables, or machine. This helps to strengthen the latissimus dorsi which is involved with many shoulder motions.
• Wall push-ups: These help to maintain pectoral and deltoid strength. Start on the wall and as you feel stronger gradually lower the surface until you reach the floor.
• Shoulder wall flexion: This helps to regain functional overhead motion.

Ideally, these exercises should be performed two to three times per week. Always keep within a pain-free range of motion and be sure to not push into pain. Also, start with just the weight of your arm until you can perform the exercise through the entire range of motion. After this is accomplished, start off with very light weights and gradually progress until functional strength is regained.

Resuming Riding

Resuming riding can occur anywhere from 3 to 12 weeks after a collarbone fracture depending upon:

• The type of rider you are. Professional cyclists have a contract to uphold and need to keep themselves in tip-top shape to be re-signed next year. For this reason, you will hear of some professionals returning to training in less than 3 weeks and competition 4 weeks, whereas recreational riders usually returning around 15 weeks¹.
• How the fracture was repaired. Going the surgical route usually means a return to training sooner than the non-surgical route. However, this is not a guarantee, especially if the surgeon is conservative, or if the fracture sustained is serious.
• Aggressiveness of the treating doctor’s protocol. The more aggressive the protocol, the quicker you will be able to resume training.

Once you are cleared by your doctor to resume riding, you will have lost a significant amount of fitness which can vary depending upon how long of a break you needed off the bike. Fitness lost will come mainly from your cardiovascular system and more so from your body’s ability to utilize oxygen, aka VO2 Max, to the tune of a 16 percent decrease in VO2 Max after a three month hiatus. You will also lose mitochondrial density, overall blood volume, and possess a decreased Functional Threshold Power (FTP).

With that being said, do not assume you can begin repping out 20 minute efforts at your pre-injury FTP, or have the power to create a break and maintain the gap your first race back. Regaining your fitness usually takes as long as losing it, so if you needed to take 8 weeks off the bike, you can safely assume it will take 8 weeks to get back to your previous fitness levels. Fortunately, the more fitness you have pre-injury and the longer you have been an athlete will result in a less fitness loss and a slower decline.

Getting Back in The Saddle

Once you get the nod to return to cycling from your doctor, there are a few key steps you can take to make your transition back to the bike as smooth as possible.

Indoor Riding

Your first ride will probably be on a stationary trainer as you will likely still be in your sling. Have a friend, teammate, significant other, etc. set your trainer and bike up for you in a comfortable space that has lots of windows, a television, fan and as many other creature comforts you need as you will be spending at least the next few weeks on the trainer. You should have zero expectations for the first ride except to get your legs to turn over in circles again. I would also suggest keeping the output in the active recovery zone until you can comfortably spin for an hour. Since you will be in your sling riding, expect the need to either stop and stand up, or sit up to relieve pressure from your bottom and give your other arm a rest from holding you up.

Once you can spin for an hour, you can then begin to increase the intensity of the rides. Here is the blueprint I suggest:

• Warm-up: 15 minutes steadily progressing from Active Recovery zone to Endurance zone
• Main set: 2 x 10 minutes at Endurance zone with 5 minutes easy spin between
• Cool-down: 10 minutes at Active Recovery zone

You should ramp up the time spent at Endurance zone slowly; 2 x 10, 3 x 8, 3 x 10, 3 x 12, etc. spinning easy for half of the active time between sets. Keep the main set at Endurance zone until you can comfortably spend an hour in it.

Outdoor Riding

Once you receive clearance to remove your sling and place weight through your arm again, you can usually resume riding outdoors again. The following is what I did my first few rides back and what I suggest to my athletes:

• Choose short loops. Performing short loops close to home instead of long out and back loops will provide you with the opportunity of stopping at multiple points if your shoulder becomes sore and tired. If you feel good, do more than one loop.
• Select roads that are smooth. Riding over potholes and rough pavement will not feel good for a while. The better the pavement is, the longer your ride can be as your shoulder will stay fresher.
• Keep the elevation gain minimal. Standing up places greater stress through the shoulders and arms which will lead to faster fatigue. Choosing flat routes will allow you to stay seated longer and will keep your shoulder from tiring out.
• Group riding. Riding in a group, and especially racing, is going to take time as you need to regain your confidence in your ability to bump shoulders and push off other riders. I suggest riding only with those who you trust and can predict what they will do. Doing so will allow you to relax more and give you the opportunity to call for a rest break if your shoulder becomes sore.

Breaking your collarbone may feel like the end of your racing and riding career, but I promise you it is not. If you can keep your head up, stay patient, and not become discouraged once you start riding again, it is amazing how quickly your fitness will return. For me, breaking my collarbone wasn’t the end, rather the beginning!

Resources

1. Taylor, F., Watts, A., Walton, M., & Funk, L. (2013, June 14). Return to Biking following Clavicle Fracture Fixation. Retrieved May 04, 2016, from https://www.shoulderdoc.co.uk/news/view/1614
2. O’Mara, K. (2014, March 27). How Long Does It Take To Get Out Of Shape? | Competitor.com. Retrieved May 04, 2016, from http://running.competitor.com/2014/03/training/how-long-does-it-take-to-get-out-of-shape_70267