What are the rehab exercises for a broken collarbone? How long does it take to recover from a collarbone fracture surgery? Get the answers to these questions and more in this detailed guide.

Collarbone Fracture Rehab Exercises

When recovering from a collarbone fracture, it’s important to follow a prescribed set of rehab exercises to regain mobility, strength, and flexibility in the affected area. Here are some common exercises recommended by Kaiser Permanente:

Shoulder Blade Squeezes

While standing with your arms at your sides, squeeze your shoulder blades together. Hold for 6 seconds and repeat 8-12 times. Avoid raising your shoulders as you squeeze.

Wall Angels

Stand with your back against a wall, arms raised overhead. Keeping your arms against the wall, bend your elbows and slowly lower your arms while squeezing your shoulder blades together. Repeat 8-12 times.

Shoulder Flexion (Lying Down)

Lie on your back holding a wand (a piece of PVC pipe or broom handle) with both hands, palms facing down. Keeping your elbows straight, slowly raise your arms overhead until you feel a stretch in your shoulders, upper back, and chest. Hold for 15-30 seconds and repeat 2-4 times.

Chest Stretch (Lying Down)

Lie on your back with your elbows bent and your arms out to the sides, resting on the surface. Raise your hands above your head until you feel a stretch in your chest. Hold for 15-30 seconds and repeat 2-4 times.

Broken Collarbone Surgery Rehab Protocol

If your collarbone fracture requires surgery, you’ll follow a more specific rehabilitation protocol. Here are the key points:

Weeks 1-4

• Do not elevate your surgical arm above 90 degrees in any plane for the first 4 weeks.
• Do not lift any objects over 5 pounds with your surgical arm for the first 6 weeks.
• Avoid repeated reaching for the first 6 weeks.
• Use an arm sling for 4 weeks post-op.
• Maintain good upright shoulder girdle posture.
• Perform exercises like pendulum swings, squeeze ball, and isometric rotator cuff/shoulder movements.

Weeks 4-8

• Start gentle pulley exercises for shoulder range of motion (less than 90 degrees).
• Perform elbow and wrist exercises.
• Begin mid-range rotator cuff external and internal rotation exercises with light resistance.
• Strive for progressive gains in active shoulder flexion and abduction up to 90 degrees.

Weeks 8-12

• Seek full shoulder active range of motion in all planes.
• Increase manual soft tissue and joint mobilizations.
• Avoid heavy resisted exercises or lifting until 3 months post-op.

Weeks 12 and Beyond

• Start a more aggressive strengthening program as tolerated.
• Increase the intensity of strength and functional training for gradual return to activities and sports.
• Complete sports-specific functional testing before returning to sports.

Recovery Time for Broken Collarbone Surgery

The recovery time for a broken collarbone surgery can vary, but typically follows this timeline:

Early Recovery (Weeks 1-4)

During the first 4 weeks after surgery, you’ll be in an arm sling and focused on protecting the surgical site while performing gentle exercises to maintain mobility and prevent stiffness.

Intermediate Recovery (Weeks 4-8)

In the 4-8 week timeframe, you’ll gradually increase your range of motion and start light strengthening exercises, working up to 90 degrees of shoulder flexion and abduction.

Late Recovery (Weeks 8-12)

From 8-12 weeks post-op, you’ll work on regaining full shoulder range of motion and begin more intensive strengthening exercises, while still avoiding heavy lifting or repeated reaching.

Return to Sports (12 Weeks and Beyond)

After 12 weeks, you can start a more aggressive strengthening program and work towards a gradual return to your normal activities and sports, based on completing specific functional testing.

Factors Affecting Recovery

It’s important to note that the recovery timeline is an approximation and can vary based on individual factors, including the severity of the fracture, the specific surgical techniques used, and your body’s natural healing process. Consistent adherence to the recommended rehab exercises and close communication with your healthcare team are key to achieving the best possible outcome.

Staying Positive During Recovery

Recovering from a collarbone fracture can be a lengthy process, but maintaining a positive attitude and staying engaged in your rehabilitation can make a significant difference. Remember to celebrate small milestones, be patient with yourself, and trust that with diligent care, you’ll regain the full function and mobility of your shoulder.

Collarbone Fracture: Rehab Exercises | Kaiser Permanente

Skip Navigation

Introduction

Here are some examples of exercises for you to try. The exercises may be suggested for a condition or for rehabilitation. Start each exercise slowly. Ease off the exercises if you start to have pain.

You will be told when to start these exercises and which ones will work best for you.

How to do the exercises

Shoulder blade squeeze

slide 1 of 4

slide 1 of 4, Shoulder blade squeeze,

1. While standing with your arms at your sides, squeeze your shoulder blades together. Do not raise your shoulders up as you are squeezing.
2. Hold 6 seconds.
3. Repeat 8 to 12 times.

Wall angels

slide 2 of 4

slide 2 of 4, Wall angels,

1. Start this exercise with your back against a wall and your hands raised above your head.
2. Keeping your arms against the wall, bend your elbows and slowly lower your arms while squeezing your shoulder blades together.
3. Repeat 8 to 12 times.

Shoulder flexion (lying down)

slide 3 of 4

slide 3 of 4, Shoulder flexion (lying down),

To make a wand for this exercise, use a piece of PVC pipe or a broom handle with the broom removed. Make the wand about a foot wider than your shoulders.

1. Lie on your back, holding a wand with both hands. Your palms should face down as you hold the wand.
2. Keep your elbows straight, and slowly raise your arms over your head until you feel a stretch in your shoulders, upper back, and chest.
3. Hold for 15 to 30 seconds.
4. Repeat 2 to 4 times.

Chest stretch (lying down)

slide 4 of 4

slide 4 of 4, Chest stretch (lying down),

1. Lie on your back with your elbows bent. Your arms should be out to your sides, and your arms and elbows should be resting on the surface you are lying on, such as the floor.
2. Raise your hands above your head until you feel a stretch in your chest.
3. Hold for 15 to 30 seconds.
4. Repeat 2 to 4 times.

Follow-up care is a key part of your treatment and safety. Be sure to make and go to all appointments, and call your doctor if you are having problems. It’s also a good idea to know your test results and keep a list of the medicines you take.

Broken Collarbone Surgery Rehab Protocol & Recovery Time

• DO NOT elevate surgical arm above 90 degrees in any plane for the first 4 weeks post-op.
• DO NOT lift any objects over 5 pounds with the surgical arm for the first 6 weeks.
• AVOID REPEATED reaching for the first 6 weeks.
• recommend regular icing routine for the first 2 weeks; please consult Post-Op Icing handout for full details
• An arm sling is used for 4 weeks post-op.
• Maintain good upright shoulder girdle posture at all times and especially during sling use.
• Intermittent X-ray to monitor healing as needed
• M.D./nurse follow-up visits at Day 2, Day 14, Month 1, Month 3 and Year 1 post-op.

Week 1

• MD/nurse. visit day 2 post-op to change dressing.
• Exercises (3x per day):

1. Pendulum exercises,
2. squeeze ball,
3. triceps with Theraband,
4. isometric rotator cuff external and internal rotations with arm at side
5. isometric shoulder abduction, adduction, extension and flexion with arm at side. -Soft tissue treatments for associated shoulder and neck musculature for comfort

• cardiovascular training such as well arm cycling, biking for Active Recovery

Weeks 2 – 4

• Soft tissue treatments for associated shoulder and neck musculature for comfort.
• Gentle pulley for shoulder ROM 2x/day in limited ROM <90*
• elbow pivots PNF, wrist PNF
• isometric scapular PNF, mid-range

Weeks 4 – 8

• M.D. visit at Week 4 post-op and will usually be progressed to a more aggressive ROM and strength program.
• At Week 4: start mid-range of motion (ROM) rotator cuff external and internal rotations active and light resistance exercises (through 75% of ROM as patient’s symptoms permit) without shoulder elevation and avoiding extreme end ROM.
• Strive for progressive gains to active 90 degrees of shoulder flexion and abduction.

Weeks 8 – 12

• Seek full shoulder Active ROM in all planes
• Increase manual mobilizations of soft tissue as well as glenohumeral and scapulothoracic joints for ROM.
• No repeated heavy resisted exercises or lifting until 3 months.

Weeks 12 and beyond

• Start a more aggressive strengthening program as tolerated.
• Increase the intensity of strength and functional training for gradual return to activities and sports.
• Return to specific sports is determined by the physical therapist through functional testing specific to the patient’s demands
• completion of Sports Test I for initial return to sports and progressive sport-specific training

NOTE: All progressions are approximations and should be used as a guideline only. Progression will be based on individual patient presentation, which is assessed throughout the treatment process.

Don’t Know Why Your Shoulder Hurts? Use our Shoulder Pain Symptom Checker to learn more about your symptoms and possible injury conditions. 

Download a Guide to our Shoulder-Saving Procedures

Explore all your options. Learn about procedures that can help you return to sports & delay or avoid an artificial shoulder replacement.

Clavicle Fracture – Physiotherapist

Clavicle fractures are very common in adults (2-5%) and children (10-15%) and account for 44-66% of all shoulder girdle fractures. This is the most common fracture among pediatric patients. Most often, a clavicular fracture is caused by a fall on the lateral side of the shoulder. X-rays confirm the diagnosis and help in further examination and treatment. While most clavicle fractures are treated conservatively, severely displaced or comminuted fractures may require surgical fixation [1].

Contents

Clinically relevant anatomy

The clavicle lies under the skin between the sternum and shoulder blade and connects the upper limb to the body. [1]

The clavicle, the first of the bones in the human body, begins to ossify in the connective tissue membrane directly from the mesenchyme as early as the fifth week of fetal life. Like all tubular bones, the clavicle has both a medial and a lateral epiphysis, but lacks a distinct medullary cavity. The epiphyseal plates of the medial and lateral epiphyses of the clavicle do not fuse until the age of 25. The clavicle differs from tubular bones in its characteristic S-shaped double curvature, convex in the medial direction and concave in the lateral direction. This shape allows the clavicle to serve as a support for the upper limb, as well as to protect the axillary vessels and the brachial plexus and ensure their passage from the medial side. [2]

Etiology

Young patients suffer fractures due to moderate or high-energy injuries such as car accidents or sports injuries, while older people suffer from low-energy falls.

Traditionally, the cause of the fracture was considered to be a fall onto an outstretched arm, but it has been found that most often the clavicle is injured as a result of applying a direct compressive force directly to the shoulder. [2] Approximately 87% of clavicle fractures result from a fall directly on the lateral side of the shoulder. [1

Mechanism of injury.

1. Fall on a straight arm.
2. Shoulder drop.
3. Direct blow to the shoulder.

Epidemiology

Clavicle fractures account for 2% to 10% of all fractures. Clavicle fractures [1]

• Found in 1 in 1000 people per year
• Are the most common fractures among pediatric patients
• Approximately two thirds of all clavicle fractures occur in men.
• There is a bimodal distribution of clavicle fractures, with 2 peaks occurring in men under 25 years of age (sports injuries) and patients over 55 years of age (falls).
• The middle third of the clavicle breaks in 69% of cases, the distal third in 28%, and the proximal third in 3%. [1]
• They account for up to 10% of all sports-related fractures and have the third longest return to sport, with up to 20% of athletes with such injuries not returning to sport. [3]

The clavicle is the only bony link between the upper limb and the trunk Due to its superficial subcutaneous location and the numerous ligamentous and muscular forces applied to the clavicle, this bone breaks easily. The middle third of the clavicle is the thinnest area that does not have ligamentous attachments, so its fractures are most likely. [1]

Classification

Clavicle fractures are usually described according to the Allman classification system, which divides fractures into 3 groups based on location. The system was later revised by Nier (Group II was further classified into 3 types). [1

1. Group I: Fractures in the middle third of the diaphysis (most common),
2. Group II: Fractures of the distal or lateral third. Frequent site of nonunion.
3. Group III: Fractures of the proximal or medial third.

The Robinson classification was more specific for different types of fractures in the middle third, while the Craig classification was for fractures of the lateral third. [4]

Clinical History and Physical Examination

The patient has the following symptoms and signs:

• The patient can hold the injured limb with a healthy hand.
• Patient may report clicking or popping sound when injured.
• The shoulder may appear to be shortened relative to the opposite side and lowered.
• There may be swelling, ecchymosis, and tenderness over the clavicle.
• An abrasion over the clavicle may be noted, indicating that the fracture occurred by a direct mechanism.
• With careful manipulation, the sound of crepitus can be noted from the friction of the ends of the fracture against each other.
• Labored or weak breathing on the affected side may indicate lung injury, such as pneumothorax.
• Palpation of the scapula and ribs may reveal associated lesions.
• Stretching and pallor of the skin at the fracture site may indicate an open fracture, which most often requires surgical stabilization.
• Non-use of the hand of the affected side is a neonatal manifestation.
• Associated distal nerve dysfunction indicates damage to the brachial plexus.
• Decreased heart rate may indicate damage to the subclavian artery.
• Venous congestion, discoloration and swelling indicate subclavian vein damage. [5]

Differential diagnosis

Diagnosis is based on the patient’s history and physical examination.[6]

The differential diagnosis of a clavicle fracture includes acromioclavicular joint injury, rib fractures, scapular fracture, shoulder dislocation, rotator clavicle injury, and sternoclavicular joint injury.

The potential complications of clavicle fractures, including pneumothorax, brachial plexus injury, and subclavian vessel injury, should also be fully assessed. [1]

Depending on the severity of the clavicle fracture, laboratory tests are ordered. If vascular damage is suspected, a general clinical blood test (CBC) should be performed to check hemoglobin and hematocrit values. If lung injury is suspected or detected, an arterial blood gas test and an exhaled posterior-anterior chest x-ray should be performed. Imaging studies are also performed to evaluate a clavicle fracture, such as:

• Clavicle and shoulder X-ray
• Computed tomography (CT) with 3-dimensional (3-D) reconstruction
• Arteriography
• Ultrasound scanning [5]

Medical treatment

Fracture of the clavicle is treated surgically or conservatively depending on the location (middle, distal, proximal), nature (displaced, non-displaced, comminuted) of the fracture, the presence of open or closed injury, age and neurovascular disorders. [3]

Traditionally, clavicle fractures have been treated conservatively with immobilization with a bandage and subsequent rehabilitation. For non-displaced fractures, such treatment gives satisfactory results, but for fractures of the middle part of the clavicle with displacement, it leads to an increase in the likelihood of re-injury, time to return to sports and the development of suboptimal shoulder function secondary to malunion and shortening of the clavicle with subsequent scapular thoracic dyskinesia. It has also been shown that conservative treatment of lateral displaced fractures in an athlete results in high rates of nonunion and subsequent impairment of shoulder function.

Thus, surgery is performed for lateral fractures with displacement in athletes, and is also recommended for fractures of the middle third of the diaphysis with complete displacement, shortening > 2 cm, or the presence of splinters. [3]

Surgical treatment

The main goal of this treatment is to achieve fusion of the clavicle in a normal anatomical position.

Indications for surgical treatment of clavicle fractures: [7]

1. Severe displacement caused by crushing followed by angular bending and severe stretching of the skin, threatening its integrity, and in the absence of a response to closed reduction.
2. Symptomatic nonunion such as shoulder girdle dysfunction, neurovascular disorders.
3. Neurovascular injury or impairment that progresses or does not recover after closed fracture reduction.
4. Open fracture.
5. Type II distal clavicle fracture (displaced).
6. Multiple injuries where mobilization is desired and closed methods of immobilization are not practical or possible.
7. “Floating shoulder”
8. Inability to tolerate closed immobilization, eg neurological problems of parkinsonism, convulsive disorders.
9. Aesthetic reasons
10. Relative readings include shortening of more than 15-20 mm and displacement of more than the width of the clavicle.

Surgical procedures include:[8]

• Internal fixation with plates and screws. (most common)
• Intramedullary (IM) fixation.

For displaced fractures of the middle shaft, removal of metal structures is recommended if intramedullary nails are used, but not fixation plates. While in case of a lateral fracture of the clavicle with a displacement, the removal of metal structures was carried out with fixation with a hook-shaped plate, rods, cerclage and tie wire, but not with fixation with plates that did not capture the ACJ, and with a suture. These methods of fixation are necessary for a lateral fracture of the clavicle, as they capture the acromioclavicular joint and various ligaments that can be damaged during a fracture. [3]

Physical Therapy / Rehabilitation

The main goal of rehabilitation is to improve and restore the function of the shoulder for everyday, professional and sports activities. The rehabilitation protocol may differ slightly in the first few weeks depending on the main approach to treatment, i. e. conservative or surgical.

Rehabilitation after conservative treatment

Non-operative treatment may take longer for fractures to heal. With conservative treatment, midshaft clavicle fractures usually heal between 18 and 28 weeks after injury. Therefore, it is necessary to regularly check whether the fracture site heals correctly or not. Thus, the rehabilitation protocol may also vary depending on individual comorbidities.

In the first few weeks (2-4 weeks) of an acute clavicle fracture, the POLICE principle can be used, which is explained below in the context of a clavicle fracture.

Protection

The patient’s shoulder is immobilized in a bandage or 8-band until clinical union is achieved. It is believed that the 8-bandage prevents or reduces the secondary shortening of the fracture during its healing. But it is associated with great discomfort and pain, including nerve compression with temporary paralysis of the brachial plexus and obstruction of venous blood return. [9]]Studies have shown that in the treatment of clavicle fractures, there is no difference between the two methods in terms of healing time and percentage of nonunions. Thus, a brace is commonly used, and immobilization in internal rotation for 2-4 weeks is recommended.[9] [1] The bandage is worn during the day, except for exercise and personal hygiene. The patient independently decides to leave it at night or not, but care should be taken. [9]

During severe coughs and sneezes, patients should also be careful (since respiratory excursions can cause collarbone movement) to avoid them as much as possible, and to learn active-passive coughing techniques.

Optimal loading

Therapy/Consultation within 1-2 weeks after injury:

• Use of a shoulder brace as mentioned above (must be worn most of the time).
• Self-mobilization is required to avoid stiffness of the elbow and wrist joints several times a day.
• Raising the elbow above shoulder height may be painful.
• During the first 1-2 weeks, the development of the range of motion of the shoulder is limited to pendulum exercises.
• Teaching correct neck position and range of motion.

Therapy/Counseling 3 to 6 weeks after injury:

• Decreased bandage wear time (use in independent position).
• Return to light daily activities using the arm and shoulder.
• During the first 6 weeks, active-passive movements in the shoulder joint are recommended with an amplitude of active movements in one plane with a deviation of no more than 90 degrees.
• Scapular mobilization exercises are included.
• Isometric Shoulder Exercise with Tolerable Resistance Starting at 4-6 weeks
• Heavy exercise should be avoided for a full 6 weeks.
• A gradual increase in the intensity of cardiovascular endurance training can begin with a brisk walk and a stationary bike.

Therapy/Consultation between 6 and 12 weeks after injury:

• As a rule, after 6 weeks with tolerable passive BP, active and active-passive range of motion of the shoulder in all planes is allowed.
• Progressive resistance exercises (isotonic) for the stabilizing muscles of the scapula, biceps, triceps, and rotators are given after 6 weeks.
• Arm stress should be avoided until clinical healing of the fracture.
• Sports and activities that require arm loading and use are usually suspended until pain subsides and radiological signs of progressive fracture consolidation are obtained, usually after 6 to 12 weeks.

Therapy/Counseling after 12 weeks or more:

Start a more intense strengthening program, cardiovascular endurance training as tolerated, and progressive athletic training.

• The period of return to specific sports is determined by the physiotherapist using functional tests based on the needs of the patient, according to which a specific progressive sports training is planned.[12]
• Preliminary activities such as muscular endurance exercises (upper body ergometer) and cardiovascular endurance exercises (treadmill, cycling) may be prescribed.
• Contact sports should be avoided for 3-4 months. Return to full contact sports requires that the athlete demonstrate radiographic evidence of bone healing, no tenderness to palpation, full range of motion, and normal shoulder muscle strength [9][1].

Rehabilitation after surgery

• For fractures of the middle third of the clavicle, the initial open reduction with internal fixation with a plate (fixation compression plate) and screws provides more stable fixation and immediate postoperative mobilization. [7] With surgical treatment, fractures heal faster than with conservative treatment. Thus, the duration of immobilization is shorter compared to conservative treatment, and mobilization and strengthening exercises can be prescribed earlier. A program similar to conservative treatment to increase the intensity of exercise can be prescribed, but much earlier.

Return to sports

According to a systematic review by Robertson and Wood in 2016, most patients with acute clavicle fractures return to sports, with about four-fifths of all patients able to return to their pre-injury level of sports activity. [3]

Studies have shown that the period to return to sport is from 6 to 12 weeks with surgery and 3-4 months with conservative treatment. [3] [1]

Conservative treatment of displaced midshaft fractures has been shown to reduce the percentage and increase the time to return to sport compared with surgery. Conservative treatment of displaced midshaft fractures can lead to re-fracture (more than half of cases) and delayed surgery (more than a quarter of cases). In terms of surgical technique recommendations for midshaft fractures, both plate fixation and intramedullary screws demonstrated nearly 100% recovery and similar recovery times. [3]

For lateral displaced clavicle fracture, surgical management is standardized and shows an increase in percentage and a reduction in return time. Non-ACC plate fixation and suture fixation provide better outcomes for athletes than other methods of fixation, which is likely due to preservation of ACC function. A lateral fracture of the clavicle is more difficult than a fracture of the middle shaft, so the outcome of the latter is better. [3]

Conclusion

• Patients with collarbone fractures are best referred to an interprofessional team that includes an orthopedic surgeon, an emergency room physician, a general practitioner, a nurse practitioner, and a physical therapist.
• Immediate orthopedic consultation should be performed for patients with neurovascular disease, open fractures, skin stretch, or any skin tear near the fracture.
• For non-displaced fractures, non-surgical treatment is the first choice.
• While surgical treatment is generally accepted for lateral displaced fractures in athletes and is recommended for midshaft displaced fractures. Surgical treatment results in improved percentage and time of return compared to conservative treatment. [3]
• Fracture healing may take 8-12 weeks with a good outcome for most patients. However, some patients may experience chronic pain and limited range of motion of the shoulder joint. [1]
• In acute cases and cases of postoperative nonunion, an early mobilization rehabilitation protocol may be recommended [11].

symptoms, causes, signs, types and methods of treatment of fractures in the Center of Surgery “SM-Clinic”

General information

Classification

Symptoms

Diagnostics

Operations

Expert opinion of a doctor

Rehabilitation

Question answer

General information

A clavicle fracture is a pathological condition in which the integrity of the clavicle is broken. The key symptoms of injury are acute pain, tissue swelling, and limitation of motor functions. The diagnosis of a clavicle fracture is established on the basis of an internal examination and a complex examination by traumatologists or surgeons.

A clavicle fracture is one of the most common types of shoulder girdle injuries. Most often, it is faced by children, adolescents, the elderly, as well as those whose activities are associated with increased physical exertion (athletes, dancers, representatives of extreme sports and martial arts).

The cause of a clavicle fracture can be direct blows to this area, falls from various heights, compression of the body when it hits a blockage, etc.

Classification

Symptoms

Diagnostics

Physical examination and x-ray examination remain the main diagnostic measures for suspected such an injury.

• Visual examination allows the doctor to determine which symptoms of a clavicle fracture predominate, whether there are visible tissue damage; assess the general condition of the patient and the need for emergency surgery.
• X-ray helps to explore the damaged area: to view the fracture zone, the direction of displacement of the fragments, to identify internal pathologies caused by the fracture.

As an additional diagnostic, a basic set of laboratory tests is carried out, in complex cases, CT or MRI is used. With signs of damage to nerve fibers, a consultation with a neurologist is indicated.

Operations for fractures of the clavicle

The method of treatment of a fracture of the clavicle is selected, depending on the characteristics and severity of the injury. Conservative tactics are appropriate only in the case of simple closed injuries without changing the position of bone fragments and other complications.

Surgical treatment is aimed at restoring the integrity of bone structures and full-fledged functions of the limb. Depending on the type of fracture, several options for surgical interventions are used.

Osteosynthesis

After manual comparison of the bone elements, pin, extra-osseous or intraosseous fixation of the fragments is performed.

Open reduction

It consists in the connection of individual sections of the bone with subsequent external fixation.

Closed reduction

It is carried out with the help of special devices that, without incision of soft tissues, provide anatomically correct position of bone structures.

In most cases, after the end of the operation, a fixing bandage or plaster is applied to the damaged area, which ensures complete immobility of the clavicle and accelerates the fusion of bone tissues.

Medical expert opinion

Rehabilitation

Q&A

Yes, as with any injury. To avoid damage to the collarbone, you need to be careful about the choice of seasonal shoes, avoid falls, bruises, follow safety precautions when playing sports and training.

No, this is a delusion. On the contrary, the area of ​​the fracture, even with the fastest and most successful recovery, will forever remain a “weak link”, which can again be injured under appropriate circumstances.