A Painful Shoulder Finding Six Weeks Before a Fitness Test
A 45-year-old career firefighter and paramedic with 18 years on the job works 24-hour shifts and must pass an annual physical ability test in six weeks: hose carry, ladder raise, and a stair climb with a high-rise pack. He booked a "movement check" because his left shoulder "catches" when he reaches overhead. The catching has been present for about three weeks, is worse after overhead work, and comes with no numbness, tingling, or night pain. He has had no surgery and takes no medication.
Screen results: shoulder mobility 1 on the left with pain reported at end range during the active screen, 2 on the right, and pain reproduced on the impingement clearing test on the left. Deep squat 2; hurdle step 2/2; inline lunge 2/2; active straight leg raise 2/2; trunk stability push-up 2; rotary stability 2/2. No pain on any other screen or clearing test. He asks: "Is it serious? Can I just push through it until after the test?"
1. How do you score the shoulder, and what exactly do you do, say, and document? Include what you deliberately do not say.
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Score: 0. Pain anywhere in a screen overrides the range-of-motion criteria. There is no "1 with pain" or "2 with pain". The impingement clearing test reproducing his symptom confirms this is not simply a range-of-motion finding, and the composite score loses its usual meaning in the presence of a 0 - you cannot read a total as a movement profile when one item is a pain flag.
Do: stop the shoulder screen there. Do not repeat provocative testing to "confirm" what you already found. Refer him to a qualified healthcare provider - sports medicine, orthopaedics, or a physical therapist, whichever he can access fastest given his timeline. Make the referral on the day, not at the end of the week.
Say: "Reaching overhead reproduced your catching, and a second test I use brought on the same pain. That's not a flexibility result - that's a shoulder finding. It's not a diagnosis, and it doesn't mean something is torn, but it does mean a clinician should look at it before we load it overhead. Nothing here stops you training your legs and trunk."
Deliberately do not say: "impingement", "it's your rotator cuff", "possible labral tear", "your shoulder is unstable", "it's just tightness, we'll stretch it out", or "you should never press overhead again". Naming a structure is outside the scope and will follow him into the clinic and into his head.
Document: the date, the exact tests, the side, the location and quality of the pain, that the clearing test reproduced it, the referral made, and that he was advised not to train overhead on that side until evaluated. Note that he was screened and referred, not assessed and diagnosed.
2. What can you train over the next six weeks while he is being evaluated, and what do you avoid given his occupational demands?
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Frame the priority: he has a physically demanding job and a dated test. The shoulder needs a clinician; his lower body, trunk and aerobic capacity are entirely available and are, in fact, most of what the test demands.
Keep training:
- Aerobic capacity and stair-climbing tolerance - his stair climb is the highest-value item and does not require an arm above shoulder height if the pack is carried at waist level or on a frame.
- Lower-body strength: trap-bar deadlift, belt squat, leg press, sled work, step-ups with hand support.
- Trunk work: carries, anti-rotation, dead bugs, core stability - all of it unaffected.
- Hose drag and carry work at waist height, if it is truly symptom-free.
Avoid: overhead pressing, overhead ladder-raise drills, throwing, pull-ups, and any rack position (front or back squat) that provokes the catch - a bar racked on the shoulder is an overhead-adjacent position for many people. Avoid loaded carries on the affected side until cleared, and be conservative about heavy suitcase carries on the unaffected side, which load the trunk asymmetrically.
Plan the timeline explicitly. Six weeks is short. Set a checkpoint at week three: if he is not pain-free and cleared for overhead work by then, he needs to speak to occupational health about an accommodation or a deferred test rather than discovering the problem on test day. Have that conversation early, while it is still a plan rather than a crisis.
Retest only after clearance. The re-screen happens when the provider clears him, he is symptom-free, he has full pain-free active range, and the impingement clearing test is negative. Then rebuild overhead loading gradually - half-kneeling press, landmine press, then full overhead - and watch for the catch returning.
3. Write the actual words you would use to communicate a 0 without catastrophising, and state your retest decision rule.
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The conversation, in order - information, meaning, then plan:
"I want to be straight with you about one result. When you reached overhead, you got that catching pain, and when I tested the shoulder a second way, the same pain came back. In my screening system that's a stop sign - not because something terrible is going on, but because pain is the one thing I won't train around and pretend I can fix.
Here's what I can tell you with confidence: this is a shoulder problem that needs a clinician's eyes, not a flexibility problem, and I'm not able to tell you what's causing it. It might settle in two weeks with the right advice. It might need more. What I do know is that the rest of your screen is unremarkable - your hips, trunk, and legs moved well, and nothing about your conditioning has to stop.
So here's the plan: you get the shoulder looked at this week, ideally by a sports medicine or physical therapy clinic. In the meantime we train everything below the shoulder, keep your stair climb and your engine going, and we don't do anything overhead on that side. Once you've been cleared, I'll re-check it and we'll build it back up carefully. If you're not cleared by week three, we need to talk about the test date with your occupational health people - that's a scheduling problem, not a you problem."
What this avoids: naming a structure, predicting a timeline you cannot support, minimising ("it's just a niggle"), and catastrophising ("your shoulder is damaged").
Retest decision rule: re-screen only when (1) the treating clinician clears him for overhead loading, (2) he reports no catching and no pain in daily overhead reach, (3) active shoulder flexion and abduction are full and pain-free, and (4) the impingement clearing test is negative. All four, not two out of four. If the clearing test is still positive, the score remains 0 and the referral stands - regardless of how good the range looks.