Shoulder Pain, Limited Flexion, and a Client Who Wants to Start Overhead Lifting

The findings cluster around the right shoulder rather than around the squat itself.

• Painful end-range flexion (145 vs 165 degrees) plus night pain is not a normal asymmetry. Night pain and pain at end range are reasons to have a physician or physical therapist evaluate the shoulder before loading it overhead.
• External rotation deficit of 15 degrees at 90/90 suggests a mobility or soft-tissue limitation that could change scapular and humeral mechanics. It does not tell me the diagnosis.
• Arms falling forward at about 100 degrees and a 30-degree forward lean during the overhead squat are consistent with limited shoulder flexion and possibly limited thoracic extension or ankle dorsiflexion. The heel lift supports an ankle or movement-strategy component.
• Bilateral winging and lumbar sagging during the push-up point to scapular stabilizer and trunk control limitations, but they are not diagnostic of a specific pathology.

My conclusion is not "the squat is bad." It is that he has an unresolved painful shoulder with range-of-motion asymmetry and night pain. I would refer for diagnosis and hold provocative overhead loading until cleared. In the meantime, I can train lower body and pain-free pressing ranges, provided the referral clinician agrees.

I would keep the reassessment short and repeatable, because the goal is to compare over time, not to build a diagnosis.

Measures to add or repeat:

• Pain at rest, at end-range elevation, and during the night on a 0–10 scale.
• Shoulder flexion and external rotation at 90/90, measured the same way each time.
• Thoracic extension in sitting or half-kneeling.
• Ankle dorsiflexion in half-kneeling, since the heel lift may be contributing to the forward lean.
• A pain-free push-up or wall push-up test with noted scapular position.
• A single-leg squat or overhead squat video from the same angle for movement comparison.

Documentation: Record the date, test order, pain score, range-of-motion values, and the exact load or body position used. Note that the empty-can test produced mild pain without weakness. I would avoid labeling the finding as a specific tendon or labral problem.

Reassessment timing: Recheck after the referral visit and then every two to three weeks if he is training. The reasoning is that a baseline is only useful if the conditions are reproducible. If pain increases or range of motion decreases, that is a signal to regress or return to the clinician, not to push through.

I would keep the hypertrophy goal but change the exercises and ranges that provoke the shoulder.

Temporarily avoid or limit: behind-the-neck pressing, wide-grip overhead barbell pressing, and any dip or push-up variation that reproduces end-range pain. These are not permanently banned; they are removed until pain and range of motion improve.

Substitute:

• Neutral-grip dumbbell press or landmine press in a pain-free range.
• Cable or band external rotation and scapular retraction work.
• Thoracic extension mobility before pressing.
• A push-up progression from an incline if the floor version causes winging or lumbar sagging.
• Lower-body training can continue, but I would address the heel lift with ankle mobility work and a heel-elevated squat if needed.

Programming logic: Hypertrophy still works through sufficient volume and progressive overload, not through one specific bar position. I would keep most sets at 2–3 reps in reserve and stop any set that changes shoulder position or increases pain above 3/10. Reassess in two to three weeks. If pain is unchanged or worse despite modification, send him back to the clinician rather than continuing to load.