Save Your Knees and Shoulders Without Surgery

Real quick, before we dive into this episode, I have a little sleep secret I want to tell you about. Look, sleep is crucial for your fitness, but it's crucial for just plain old everyday life and function. And I find I sleep great unless I have a migraine. And I've had more than my fair share since perimenopause all the way through postmenopause. My secret weapon was Blue Sky CBD sleep gels. Each gel contains 25mg of CBD and 25mg CBN for deep restorative sleep. Something about it helps to reduce inflammation, which I believe for me was key in helping me get to sleep. But the biggest thing is so many of the over-the-counter solutions, whether for sleep or migraines, can ruin gut health, and liver health. Neither one of those did I want to be problematic for me. So this option is recommended by healthcare providers worldwide and backed by thousands of happy customers, many of whom come from our Flipping 50 community. There is zero THC, so it's non-habit-forming. It's made by a trusted family-owned company that we all can feel good about. Third-party tested for purity and potency. And if you're interested, you too can try a sample for just $6. But even better, you can get 30% off forever with discount code FLIPPING50. That's FLIPPING50. Just go to flipping50.com/blueskycbd. We'll put that link in the show notes and you'll find it everywhere on Flipping 50 at My Favorites. What are you waiting for? Good night. Prepare to be mind-blown and have your optimism lifted up yet a little bit higher. My guest today is going to share what he knows and what you need to know about knee pain you may be experiencing, and we touch a little bit on shoulder pain at the end. But if shoulders are your issue, tune in anyway because what you will learn along the way about the knee will be directly relative to what you will learn at the very end about shoulders, and you want to hear it all so it will be relevant to you.

I'm Debra Atkinson, and you're listening to Flipping 50. I started this podcast over a decade ago to answer questions about fitness and menopause and beyond before you know to ask them. The goal: to help accelerate your results with the science and the practical application of proven protocols. While living your best life. There's no more powerful health influencer in the world than a midlife woman. It's not just you, but it's the 3 generations that you influence. My unique 40-year career, including being a university senior lecturer in kinesiology, an industry subject matter expert, an international speaker, to founder of the first and the only exclusively made-for-menopause-and-beyond fitness membership in the world, Every week I interview experts behind the science of optimal hormone balancing, fitness, and longevity, and share answers to our community's questions so you can have the vitality and the energy you want, need, and deserve.

If you have been sticking your head in the sand over knee pain, a little discomfort doing usual activities, or some swelling and inflammation, this is your episode. Or if you aren't sure whether you need physical therapy, whether you should get a referral, or you just need a massage or to lay off for a few days, this is your episode too. This episode may or may not have come from my own exploration of exactly these type of questions. I'm no stranger to physical therapy in terms of referrals to them or from them. Or in body workers for optimizing my own performance and recovery, but I am a foreigner to seeking support for any issues that I've got. Mine have all come from acute trauma or injury. I knew it, and the answer was obvious, but this was different. So my search was in place, but as serendipity often happens, my next guest appeared in my inbox. And so, as I often do, I'm sharing insights that I've received from him and the work that he does with you. And I think if you've got a knee or a shoulder issue or anything related to another joint, you also may walk away with some huge insight into what you learned once may or may not be serving your needs right now. My guest today is Dr. David Middaugh. He's a specialist physical therapist who helps people avoid unnecessary surgery while getting back to being healthy, active, and mobile. He coaches people online and has a clinic where people are treated in person. His contrarian treatment approaches are focused on addressing the root cause of problems like drum roll please, arthritis and tendon tears so that people have the most control over their health. I want you to stay until the end. So if you hear everything in this episode and it feels like this resonates, this gives me hope, this gives me optimism, this is exactly what it felt like I was waiting for because nothing else has felt like a fit, this. Then at the end, we'll share his online program and share with you what it is you can do to gain access for 50% off. So this isn't a sales pitch, but by the end, he made a very, very generous gift to our audience and community that you might appreciate. Dr. David Middaugh, thank you so much for being here.

Absolutely. Thanks for having me. I appreciate it, Debra.

And you know what, I'm not even sure as I think about this, how did I stumble across you? Because it could have been in a very personal and selfish study and search online. Because as I stumbled across what it is you're doing, I'm like, no, no, wait a minute, I need this. I then went out to find someone who is the local Dr. David Mittag, since you weren't in my neighborhood, and came down the rabbit hole. So I'm going to share with everybody what's going on for me, and inevitably they're probably already hearing about it. And, and don't want to turn this into the Debra Show, but I want to turn it back to you and talking about manual physical therapy. And I gotta tell you, that was the first time that I've ever heard that term, and I was like, wait a minute, I was looking for somebody who's got magical hands that I've worked with in Boulder, Colorado while I was there. I go back and work with them every year. If I'm there, I try and see them a couple of times, but I've never found that same kind of thing here. And I thought, okay, maybe this is as close, but I want you to describe it. And, and first of all, tell us how it is that you're 15 and you're doing this for a career.

Yeah, sure, sure. So manual physical therapy, I'll answer that question first. The idea is that it's hands-on work. Bodywork is another word that people use to manipulate the soft tissues like your muscles, tendons, ligaments, also to move the joints. We tend to be pretty good at moving the joints. And I use the phrase tend to be because in my industry, I'm a physical therapist, and really in the whole medical field, I think the word manual therapy is used loosely. Like if you, for instance, like a massage therapist could say that they do manual therapy and they wouldn't be wrong. They're technically right. There's different levels to this. The training that I've gone through, touching on my training, I have reached the pinnacle of what you can learn in manual therapy. So a lot of people think that I'm a chiropractor because I can do all those techniques like a chiropractor. Legally, I have to say I'm doing manipulations, not adjustments, but same thing. Joints are popping. And we're freeing up the motion. I can do soft tissue work like a massage therapist as well. And so I have all these tools at my disposal, but that's not the only thing because what I've trained in is the thinking, the biomechanical thinking behind how things should move. So I'll pair the hands-on stuff with the movement stuff. And what I focus on the most is fixing the root problem through the movement stuff. The manual therapy kind of just sets us up to be able to move better, to fix root problems of like knee pain, hip pain, shoulder pain issues. I started out going through my undergrad, got my bachelor's in exercise science. Then I did it. I finished that a year early. Then I did a doctorate in physical therapy, finished that right away. And then I went to my fellowship training, which was like another 5 years after that. And I just did it all back to back. That's why I still look like I'm 15.

Yeah.

Yeah.

Well, and I'm having an aha moment right here because I taught as a senior lecturer in kinesiology for 15 years and we had a lot of. That was kind of right as things— every year we came back and we, you know, the beginning of the year meeting was, um, we've, we've grown again by 700%, we've grown again by 800%. It was right when fitness was really taking off, you know, and we had lots of pre-PT and pre-med students who really wanted to be maybe in sports medicine, and they were coming through that as their undergrad. So I find that really funny that potentially you could have been one of my students and now I am like one of yours. So I'm like, huh, different ways. Somebody's got a funny sense of humor up there. But yeah, there's that. Um, but you are so talking our language. So I want everybody to hear this, and I hope that this is really resonating with you. This is, this is about so much more. And I think if you're here, you're over 40 or over 50, over 60, you're getting it even more and more easily the older we get that it's not just about like following a program of this exercise that many times, you know, with that much weight. It's about that movement needs to feel comfortable. It needs to feel like you're safe and not vulnerable. And if it doesn't feel good, we're reluctant to do it. We're fearful, we're afraid, and we probably then be become more vulnerable for injury even because of the thought, not even because of the movement. So I love what you're doing and, and how you're doing it. So first of all, what we've just said may also already have given you some insight into who do you go look for, you know, and/or where are they. And so literally, geography— where are you, Dr. David?

Yeah, I'm in Texas. I'm in El Paso, Texas. It's on the westernmost tip of Texas.

Have you ever thought about moving to Arizona? It's really nice over here. No, no, I have.

I've thought about moving different places, but I love El Paso. It's a great town.

Okay, well, I thought I'd try. All right, so I, I get what's different about physical therapists. I mean, what it is you're doing specifically, and I'd like to say, um, The pro that I've worked with in Boulder and loved works a lot very much like you do, and kind of combining all those things and really heavily focused on fascia, you know, and what is happening there. But I would assume that has to be a part of what you do too. You can't, you can't necessarily work with the muscle and the joint structure without addressing fascia. Right.

100%.

Would you mind just sharing for everybody here, like, what is the difference between, like, as you work with each one of those or address which one is really the problem here? I mean, how does that work in your brain?

Yeah, absolutely. I really think it's hair-splitting. It's, it's being a little, um, it's, it's difficult to only Affect fascia without affecting other stuff. The analogy that I like to give people is if you were to wreck a car and let's say you were to like run into a light post head-on with your car, hopefully, you know, nothing, you don't get hurt, but think of the damage that would happen to the car. The bumper would get bent in, the grill would be damaged. Maybe the, usually the radiator's right behind the grill that might get broken. There might be damage at different layers all the way to the engine. Depending on how, how bad the accident was. When you're thinking about manipulating the muscles in an area of your body, you have skin, then you have a layer of fat. Then below that is the fascia. And the fascia is very, very, very thin. If you think of like meats, like chicken is the, is the easiest one that people think there's that little see-through layer that you can kind of peel off the meat. That's the fascia. That's how thin it is. I mean, it is. It's like, like a plastic wrap around your muscle, basically. Then there's the muscle, and then within the muscle there's, there's usually different muscles and they're all encapsulated in fascia. And the reason why fascia became such a big deal is because we discovered maybe about 20, 30 years ago that fascia is full of nerve endings. There's like a connection with our movement and the fascia and how we interpret it in our brain. And so it kind of took off as like, we need to do fascial techniques and fascia-related treatments, when in reality, if you're getting a massage, you're getting fascial work. If you're rubbing yourself with a— if you're doing a massage gun treatment, you're doing fascial work. There might be spots where it's a little more caught up, if you will, like there's a trigger point or there's a knot. People use different words. At the end of the day, if some— if you feel something stuck on your leg, on your arm, wherever it is, You need to just loosen it. And maybe it's fascia, maybe it's a muscle, maybe it's joint related. We just need to loosen it at the end of the day. It's almost like going back to the car wreck and saying, well, your radiator's broken and so is the bumper and so are the headlights and so is the end. We need to kind of fix it all. That's, that's kind of how I see things is let's just fix the whole thing. Holistic.

So cool. Okay. So talk to me a little bit about, I mean, we teased here definitely with shoulders and knees and they are are probably the two most common problematic areas for adults over 40. You know, it's like you wake up in the morning and it's like, knees okay, shoulders okay, gonna be a good day, right? And, and, or not so much, maybe I didn't sleep because that shoulder. But it's, it's intriguing to me to ask you this question. It also feels a little naive and maybe a little bit more optimistic in asking, but Is it possible to heal osteoarthritis, which you and I both know that this is for listeners, the wear and tear kind of arthritis is you've used those joints really well, you've enjoyed them, and, and you've done your thing, or maybe you've had an accident and trauma caused to them. Is it possible to heal that osteoarthritis without surgery?

Great question. I answer this one all the time and it's such a controversial issue. And here's my— the best angle I have on it. We have to first figure out what is your definition of healed arthritis? Because if the definition I use is if you were diagnosed with arthritis, let's say you had knee arthritis, you got the X-rays, you're at the doctor's office and the doctor said stage 2, stage 3, whatever it is. Arthritis and you can see the bone spurs and the loss of space, maybe it's bone-on-bone arthritis. The first thought that people have, and even in the medical field, they say that's, that's permanent, that's done. But what I tell people is, yeah, it's true, the X-ray might be permanent. If you get an X-ray again in a year, it might look like that, possibly even worse. But what if you feel better?

I like you a lot.

Pain's gone. Yeah. What if you can hike again? What if you can exercise? Then I would consider that healed. Mm-hmm. But medical researchers, most doctors, people that maybe want to help you out with a knee replacement surgery are going to say, oh, progress from stage 2 to stage 3. I know you're hiking, I know you're cycling and you're back to exercise. I know you're at the best shape you've been in the last 10 years, but your arthritis is getting worse. So if you're feeling fine, I would say keep going because we have research now that shows that It, it is possible for you to have severe osteoarthritis and other things too, like a severe meniscus tear, severe disc herniations in your back, and have zero pain and high function.

Yeah. So, well, I'm gonna bring this up, and I just— I, I think listeners, bear with me if you've heard this, is, if you're a, you know, OG, you've heard this before. I did a Prenuvo scan myself last summer. So total body scan, they look at soft tissue, hard tissue, and they send it all. I got it back and I was like, I'm not sure I needed to know all of that, you know, because it told me I had a little degeneration here and here and here and here. And I'm like, you know, I was doing fine before I got that back. I thought I was being proactive and I thought this would be really geeky to find out and maybe be preventative and proactive. And then I was like, no, I think I made a mistake. I just didn't need to know that because I all along thought that's not going to happen to me. I'm going to stay active. I'm going to keep moving. I'm 60. Nothing's happened to me and I've done damage. I'm not doing that kind of damage anymore. And then I was like, wait a minute. So then this knee thing happened, right? So now I'm like, what? I planted that seed myself. You know, there is a little something to that. But I also feel personally, I feel very optimistic. I feel like still that doesn't happen to me. That happens to other people. And I think that's a good thing. I think some of that is, you know, the way you think in your mindset and what you expect also has to— I'm sure you've seen it. One way or the other, the outcome of patients has probably— how much is it affected by their mindset?

Oh, tremendously, tremendously. Because there's research being done on when the doctor tells a patient and, you know, has the X-ray and says it looks like it's bone on bone— keywords— knee arthritis or shoulder or hip arthritis, whatever it is. As soon as they plant those words in your head and tie it with your X-ray, You have this belief that every single step I take, every single thing I do with that joint is just wearing it down further and further. It's just a ticking time bomb before I need to have the joint replaced. The researchers are finding out that if they instead stop using bone on bone, that term, the term, and say this, this can— yeah, the term. And they say it's possible for you to get back to being active, to get back to feeling fine. If you do some exercise or do, do the right things. We can talk about that because I have— I'm very opinionated on which exercises. Um, great. If you do the right things, then you can get to feeling great despite having that X-ray. So there's— it's definitely big time in your head on how you think about this, the mindset you have.

Yeah, I love that. And I think for listeners, I— that is very important. And I have experienced that just anecdotally with different people reaching out to me been saying, you know, I'm bone on bone. And you know what that becomes is not a description, it becomes an identity, right? And that's where, uh, you know, you just, you don't want that for somebody. So yeah, yeah, so love that. Talk to me then about the right kind of exercise and, you know, where do we get in trouble? Because I think sometimes we can— we often think, and I find this to be true, I I know this anecdotally. So I know you have a huge YouTube channel. And by the way, we're going to put that link in the show notes to all of you who are listening, because there's gold to be found there on that. And, um, you know, I've got a significant— before I look at yours, I think significant following on YouTube. And one of the videos I put up probably more than a decade ago now is the most watched, and it has to do with knee pain. Right. And, but the obvious thing is people with knee pain go right to, I need a knee exercise, right? I need a knee strengthener. And, you know, I'd love for you to talk and lean into that a little bit about how true, or maybe that's not so true for everybody listening.

Yeah, absolutely. Talking about knees specifically, I'm going to get my knee model. Just to give us a visual aid here. So let me just introduce you really simply to the anatomy of the knee in case you aren't aware. Here's the thigh bone on the top. It's chopped off. This is the knee joint right here. There's a kneecap right there. The blue thing is a meniscus. And then the bone right here is the shin bone. And there's a little bone on the side called the fibula. The knee bends just like this. And then the muscles, which aren't on this model, but I'll tell you, you have the quad muscles, the muscles in the front of the thigh. Right here. They attach to this thing and they come in and attach to the kneecap and then come down. You have hamstrings back here and everybody who has knee pain usually thinks or is told you should go do knee exercises. And the first exercise that people think of or get pointed to is quad exercises. And in case that's you or you've told people to do that, here's the thing. Like it's no, Yeah, it's not what we should be doing. It makes things worse. And it's just superficial level thinking. It's just, it's just, you look down at your leg and you say, oh, this muscle connects to my knee, so I should exercise it. The assumption is that it's weak. And what I'm finding in the research is there are research studies of people who have knee arthritis and they're finding weakness in the quads. So they're finding this correlation, this connection between weak quads and the presence of knee arthritis. And they're just assuming right now, they're guessing that maybe if you strengthen the quads, you'll get better results with the knee arthritis. In fact, it'll improve. But what I'm telling people is there's big holes, big gaping holes in the research. And what's happening is the quads have been overused.

Yeah.

And as a result of that, they're causing knee arthritis. And then because of pain, it starts to go down, the strength.

Pick on me, pick on me. Okay, so I see this all the time, and right now you cannot go to social media if you're interested in fitness and not see this, but there are lots of people doing heel-elevated squats. Yeah. And I am like, why? Why would you do that? Unless, unless you have a shortened Achilles tendon and maybe plantar fasciitis. It's the only ever time I thought, well, maybe that's appropriate for somebody who wants to really do a squat and who can't otherwise. But talk to me, you're the professional, I defer to you. Heel elevated squats.

Like you said, you know, if you really want to get a squat in but you have some problems getting your feet down because of, of some condition like that, but I wouldn't even reason that if you have plantar fasciitis or shortened Achilles tendon there's probably some other problem at play that you need to address there to be able to get your feet flat when you're doing the squat. More often than not, when I see people do heel-lifted squats, you know, they're on a wedge or they have certain special shoes that have a wedge built into them, that kind of thing. They don't have the flexibility, and because they don't have the flexibility, what sets that up is that they have a muscle imbalance. That's what's causing the knee arthritis or a meniscus tear. In these people, and it's because their quads are too active. And as a result of that, it's compressing the joint, compressing the kneecap against the thigh bone, and it pulls the shin bone up into the thigh bone here. And that's what's grinding the joints and causing arthritis problems. But when you have this muscle imbalance present in somebody who's younger, doesn't have knee arthritis, it usually comes off as the joint isn't moving right.. And so you need to make modifications like get on a wedge in order for you to bring your bottom down into a deeper squat. Usually can't do that because of a muscle imbalance. Glutes are key here. When you have weakness in the glutes, that's when the quads like to get over-dominant. And when you get into that deep squat, like the— yeah, go ahead.

What percent of the population would you estimate has strong glutes?

Oh gosh, definitely less than 10%. Yeah, I'd say probably under 5% even. Yeah, you have to, you have to understand too, I'm seeing people with problems, so my, well, it's true, my picture of that is going to be biased as a result.

That's, that's true, that's true. Fair, fair question. Thank you for saying that.

But what I would say is if you have knee pain, there's probably a 90-something percent chance that weakness in the glutes is a problem related to that. That's like a root cause. And if you don't have outright weakness, then you have a coordination problem. Maybe you have good glute strength, but you're not using them at the right time and it's causing other muscles to take over.

So is that a, that a brain to muscle problem? Like it's the wires are not connected very well? Right.

Okay. That's absolutely right.

So we need to go backward as opposed to forward. Like we're doing all these deadlifts and squats, but we're still not firing the right muscles. So we're actually putting ourselves more at risk for injury, if that would be true, right? We look in the mirror and we think this is awesome, right? But it's not.

Okay.

Right.

You have people that have big quads and they're proud of them. And, you know, that's pretty cool to put on that muscle. But then I ask them, can you activate your glutes? Like, can you— standing, sitting, whatever position you're in— can you tighten those muscles back there without your thigh muscles also tightening? And most of the time, people in my office have knee pain, they can't do it. So what's happening then is every time they go do an exercise where they're supposed to be using their glutes and they can't even fire them at you know, doing a sitting down in a chair, what muscle do you think's taking over and acting too much? Usually those quads.

So we've talked quads, we've talked glutes, but there's a muscle group that I kept thinking you're going to mention we haven't talked about yet. How about hamstrings? Where do those fall when you're assessing people who do come in and have problems? What's going on with that?

Hey, this is Debra Atkinson. I love creating the Flipping 50 podcast for you, and I have for over a decade. I also love helping midlife women shift not only their physical energy but their beliefs about what effective exercise looks like and how much it can positively and powerfully impact your life. How you menopause and exercise in menopause determines how you live not just now, but decades from now. If you're not exercising right now, you're getting tired, not stronger, or you think you don't have time or the energy to exercise, do a 5-day flip with me. I'll send you one short video a day for 5 days. It's just 15 to 20 minutes long, so you can see exactly how I plan out a fitness plan for myself and for thousands of clients I've worked with. You can get this at flipping50.com. Right now, what are you waiting for?

Let's start Flipping 50 together.

Yeah. So hamstrings usually get thought of as the muscle you should be working out that oppose the quads. So hamstrings, for people that don't understand muscles here, quads are on the front of the thigh right here. They connect to the kneecap. Hamstrings are on the back of the thigh and they cross the knee joint and attach to the kind split and go to the sides of the bottom half of the knee on the, on the top of the shin bone. Because they cross the knee joint, the hamstrings also have the ability to add compression into the joint. So if you get them really strong, they're pulling the shin bone up into the thigh bone and compressing it. And that's why on an X-ray, when you look at, at the X-rays of somebody with knee arthritis, they'll have decreased joint space because all these muscles are just squashing the joint into itself.. And then if it's there long enough, you get bone spurs or they call them osteophytes. These are overgrowth of the bone because it's just been smashed for a long time. Just like if I smash my face, my cheek will start to fold over like that. Same thing happens with the bone. You start to fold it over a little bit over years, of course. So I don't tell people to work out their hamstrings. I tell them to focus on their glutes because if you can walk with your glutes, if you can do squats and other exercises with your glutes, your hamstrings will still work, your quads will still work. They'll— they just need to work secondary. But you need to make— what I tell people is you need to be primary at using your glutes. You need to be glute biased with all your activities. That's going to set you up to kind of knock down all the dominoes and set yourself up for good movement and good joint health in your hips and knees.

Glute bias, it's my new word. I'm going to ask you a question because We're talking to— so imagine every listener here is probably your mom and your grandma. So it is, you know, a woman over 40, and we've got probably more women even over 50, more over 60. We've got some women who are bumping into 80. We have a great, great audience who wants to, you know, take care of themselves now for maybe the moment they're in, but also prepare for longevity for the decades ahead. And so there's a couple things going on. We're working on how do we, um, help ourselves stabilize blood sugar, reduce insulin resistance, avoid sarcopenia and osteoporosis. So, you know, we do want them working all the major muscle groups that we can, but obviously, case in point with you here, without causing problems. How do we, how do we manage that, David?

One of the simplest things that people get told to do all the time is to go walking. If you especially have knee arthritis and walking's an easy recommendation, right? For somebody with diabetes, somebody who's trying to maintain their muscle or even build some muscle is to go get some movement. I think walking's fantastic, but for somebody with hip arthritis or knee arthritis who is not yet glute dominant, they're quad dominant because they just haven't even thought of this. Or maybe they got told to do exercises that involve their quads more. I mean, if you go on a walk, a brisk walk, like where you're trying to, you know, put some effort into it, almost going to start to jog if you go a little faster.

Big dog, not a little dog.

Yeah, right. You'll quickly feel your muscles working, you know, within 5 to 10 minutes. And if you pay attention in that moment to which muscles burn most and you feel like it's your thigh muscles, especially the quads, but even the hamstrings, then you're, you're quad muscle dominant, your thigh muscle dominant. And although that's great for diabetes, you know, for keeping your blood sugar in check, long-term you're slowly feeding into a muscle imbalance that's adding more compression through your joints in a negative way. But if you can make it glute dominant and feel your glutes burning more so, and you just have to think about using your glutes, and I talk about this all over YouTube, um, you're still going to use the big quad muscles and the hamstrings. In fact, I think you're going to get better distribution of all the muscles. You're going to use them all more evenly, but you have to think to use your glutes because we don't use our glutes. We sit on them a lot, especially in our American culture. You know, we tend to sit. So you need to turn them on and not just count on your quads to do all the work, all the calorie burning glucose, you know, sucking in the glucose to the muscle. All that work. It needs to be from all your leg muscles, but make it come from the glutes and you're setting yourself up for overall health because you're helping your joints too.

Love that. So if somebody is experiencing knee pain, what do you got for favorite glute exercises? Maybe the Wi-Fi signal's not very strong. What do you do to turn it on?

So people love to try to jump into walking. And I'll tell them, stop walking, stop walking, which is so contrary to, you know, doctors say start on a walking program 10 minutes a day. If you can work up to 30, great, every day or however many days a week. I tell people, just turn on your glutes first. Sitting down in the chair, lying down on your, on your bed and wherever you want to be standing. Can you figure out how to make your glutes contract apart from your thigh muscles? It's not really like an exercise, like you're going to be in the gym and break a sweat. It's more gaining mental control over your muscles. Because if you cannot do that, Debra Atkinson, everything else is going to fail after that. If you go into the gym to do bridges or you start to do squats, or even if you get on a, like a glute machine at the gym, you're going to compensate. You're going to use other muscles if you don't have conscious control over your glutes. So my opinion, that's the number one thing. And it comes down to literally— let me just be as clear as possible— contracting the glutes and holding it for 10 seconds and concentrating on not letting your thighs also contract and take over. And what I tell people is go 100% the first time, like try to contract it as hard as you can, 100%. If you feel your thigh muscles working, then back it down to 70 or 50 or maybe even 10 or 1%. And hold it there because you have your— what's happening in that moment when you hold is the nerve signals going to your glutes. It's called the motor unit, by the way, for those of you guys that know this stuff. And you're waking up dormant muscle cells. And when you're doing the hold, you're going through something called tetany. Big words for basically you're just calling— you're making the nerve call all the muscle cells and say, hey, wake up, we haven't been used in a while. And then they all start to wake up. And the longer you do the holds, a 10-second hold is usually about right. You do repeated reps like that, you get a better contraction over time. And then you have to separate it from your quads. And then the, the final part before you get into the more advanced stuff is you have to be able to fire the left butt cheek apart from the right butt cheek. Some people do it naturally. I know it sounds silly. No, we'll do it naturally and they turn it into a dance and they, they, you know, it's a party trick for them, that kind of thing. But there are people that cannot do it.

Who do you party with?

You know, it's probably something done in private with, with people, you know, that, hey, look at this, check this out, what I can do. But if, if you can't do that, then how are you going to walk? Because when you walk, what should be happening is when you bear weight on one leg, like say your right foot, your right glute should clench a little bit. And then when you switch to your left leg, your left glute should clench a little bit, and it should be alternating as you're walking.. And if you, if you can't isolate the left from the right, I have people literally trying to walk and they're contracting both glutes every single time. It's going to fail. And then people run into this situation where they say walking hurts, but the doctor told me to do it. The physical therapist told me to do it. Everybody on the internet. And there's research studies that show that it helps with knee arthritis and weight loss and diabetes management control, all that stuff. But there's some technicalities here that the research doesn't know about in mainstream medical. Does not understand yet.

That's what I'm telling you about with the muscle imbalances. Yeah, wow, definitely nobody's covering this, so super helpful. And I think, you know, just the, um, clarification that if I summarize what you've just said— so a couple of things that are long existing, you know, the quad to hamstring ratio must be off, your hamstrings are, are weak, and that's why there's knee issues. I just came from an appointment, I've been told that more and once sitting in that office, you know, that you probably have weak hamstrings, I can refer you to somebody. And of course, as strength and conditioning coach, I'm offended, but that was my ego talking, not anything else. But it is the glute. I mean, for sure, I know that, you know, my right glute is just like checked out, gone to Tahiti without me, you know, and the left is just fine. And it is amazing. I love unilateral work. For that reason, you know, because otherwise you don't know. You don't know what you don't know. Um, talk to me about— there's so much I feel like we could still stay with glutes, but I want to make sure we leave a little bit of time for shoulders. And I think shoulders are so much more complicated given there are so many more movements that they're responsible for, and we need them every day. We need them just to, to function in our work. But talk to me about issues that you see most commonly with shoulders, and especially if you can, isolating females midlife and older and what you, what you've seen.

Yeah, absolutely. So like I've described a muscle imbalance between the quads and the glutes in the lower body and how that can set up things like hip arthritis, knee arthritis, meniscus tears, even other conditions, all your all the major hip and knee conditions likely related to this muscle imbalance. There's a similar muscle imbalance up in the neck and shoulder, and the weakest muscle is your upper trapezius muscles, usually called the trap muscle. It's this one right here that spans from your neck out to the corner of your shoulder. I'll show you on my skeleton here, because if you actually work the muscle out, it actually attaches to the base of the skull and all these little bones right up here in the neck. And then it fans out into the corner of your shoulder, right in this area. That muscle is responsible for kind of two types of motions in the shoulder. One is what we would call rotation, upward rotation of the shoulder blade. So I can't show you on this skeleton because it's screwed down, but the shoulder blade can actually rotate upwards this way, rotate in both directions.. And then also elevation, which is shrugging, right? So when you reach up overhead, let's say you're gonna reach up for something, you know, above your head, your shoulder blade should elevate or shrug and also upward rotate. What everybody out there is doing. Well, I mean, you know, not everybody cuz some people don't have shoulder problems, but people with shoulder problems, the weakness that I'm talking about, the upper trap thing, is there when they reach up, they don't engage their upper trap. It's like your glute that's gone to Tahiti. Their traps have gone to Tahiti. What should be happening is that you see it. I'm just shrugging my shoulder. You have no idea, Debra. I go to the gym and people are picking up very heavy weights, barbells, and they're reaching up overhead and they stop right here and come back down. That's their rep. When they should be shrugging with the upper trap. Yes, because that's part of the full range of motion. And so when they train like that, other muscles are getting all the work. So just like what I talked about with the glutes and the quads, if your glutes are shut down, quads like to take over and that causes problems in the hip and knee. What happens over here is now your deltoids take over and your rotator cuff takes over. Yeah. Rotator cuff are tiny muscles. There's 4 of them. And the one that gets torn the most, because rotator cuff tears is one of the biggest problems that affects people, women especially once they hit 50, that's like the rotator cuff tears, the rates go through the roof and they're having rotator cuff repair surgeries. And then usually it sets up a second rotator cuff tear because there's a root problem that hasn't been fixed, weak upper traps. And then it sets up shoulder osteoarthritis and eventually a replacement, a replacement in the shoulder. And it's because of these weak upper traps. If you simply learn how to shrug every time you reach up and make it smooth, because what I tell people is once your hand passes, like your thumb or palm passes about your eyes, you should start shrugging already. And any time you reach up overhead, you should be maximally shrugged. That's normal motion. And then maintain a bit of the shrug until you come back down, gradually reduce it. And then once your hands back at your face level,, then the shoulder blade should come down. If you move like that, you are protecting your rotator cuff. You're protecting the ball and socket joints. You're doing so much good. And the reason for it is because when you shrug and upper rotate, when you're using your upper trap appropriately in the shoulder, the ball and socket joint, the socket is really small. That's why it's more complicated. Like you said, it can move so much more. Yeah. But when you shrug and upper rotate, you rotate the socket into an upward position like this. Which preserves the shoulder joint. If you don't shrug, then you're keeping the socket faced outwards more so. And that's when you start to compress tissues and overuse the wrong muscles. You're just not moving correctly biomechanically. But if you learn to use your upper traps appropriately all the time, you save yourself a whole lot of headache. You heal rotator cuff tear and you avoid shoulder replacements.

Talk to me about this. So do you notice this when, when men versus women come into your office? I have a lot of women— I've worked primarily with women for probably over 40 years, and, and inevitably women carry their tension here. Their upper traps are over-firing when they're not lifting. I mean, they're, they're just like, like right now, right? They're, they're elevated and they don't know, you know, what is a resting position and dropped and open and kind of just positive posture and retracted. How is that related, or is it Is it even related? Is it unrelated to exercising correctly with it?

I think I have to ask the question because there's, there's some, um, there's different shades to this. When you talk about tension in the upper traps, which is a common thing that I hear from patients, women especially, for sure. And I, we see more women than men here in my office and online. And, you know, they related to life and all this and that. And I tell people always, like, I understand life is stressful, but life is stressful for everyone. There's varying degrees of stress. And, you know, it's whether you're very wealthy and have all the needs of life, you see those people stressed out. And whether you're very not wealthy and don't have your needs met, those people get stressed out too. So stress is relative. Everybody goes through stress. Is it truly carried in your shoulders? I have to— I look at it biomechanically. And what I see, going back to my muscle imbalance concept, is if you have weak upper traps, think about those trap muscles, right? They connect out to the shoulder. And then what's dangling off to the side here? You have your arm, right? Your arm, depending on your size, is a good 20, 25 pounds. You know, it's a significant percentage of your body weight. And if your traps are weak and your arm's hanging down, that trap's getting stressed and tensioned. So one test that I'll do with people that does amazing things, and you might do this yourself, or, you know, if you're watching or if you want to try it, Debra, is let your arms dangle at your side and then turn your head all the way to the left, turn your head all the way to the right. And when you turn, just feel the tension stretch, just pay attention to what's going on in your neck and shoulders, your upper shoulders. And you usually feel some tension. You'll feel like when you get to the end, like things kind of tighten up and stretch. Then if you can lean like on a desk or armrests near you, if you're somewhere like I'm standing in it, if I lean on the table and just lean in enough to get your shoulders to go up, what we're doing here is putting slack on the upper traps. Then with that slack put on, turn again, and you'll probably notice you can go so much farther and with less tension. So we've proven here is that tension and stress that you felt that changed after doing this test is probably more so related to a weakness in the muscle and its inability to hold up the weight of your arm and shoulder, maybe chest, all that stuff.

And what needs to happen as a result is we need to get stronger upper traps. Wow, that was an eye-opener right there. Where have you been for 40 years, right? Okay, talk to me a little bit, because I know not everybody is gonna get to Texas where you are. Is there a way to experience— so your YouTube channel is one place. How could listeners experience a little bit more of this insight for themselves?

Yeah, definitely. And on our YouTube channel, we have playlists by body parts. We have like a rotator cuff tear help playlist, knee arthritis help playlist. So if you want to just see all the videos, we've organized them for you there. We also have online programs that go deeper and they're more organized and straightforward and very thorough. And the way that I describe those, it's as if I'm with you thoroughly, exhaustively teaching you everything you need to do so that you can fix the root problem of the, the given issue, a knee arthritis problem, a rotator cuff tear, hip arthritis problem. And, um, and those are on our website, which you can find links to that on our YouTube videos.

That is awesome. By the way, everybody, we're going to make sure that we put a link in there. And what he didn't say very humbly is that, yeah, he's setting up a 50% discount for a one-time purchase for you. So this is either one-time purchase, or if you wanna join, there is a membership, I understand, and you can use code FLIPPING50. I know you're either walking correctly using your butt, by the way, or you're lifting or you're commuting, so we've got you covered. This will be in the show notes where you can get it. We'll share this with those of you who are on our social media list, you're probably, or our email subscriber list, you probably already got it or listening here, you'll make— we'll make sure you get it. Dr. David, thank you so much for your generosity and sharing the nuances of manual physical therapy with us today.

Absolutely, Debra. Thank you for having me.

Glad to be here. Thank you so much for listening. To listen and access a decade of episodes and the show notes, visit flipping50.com, where you'll be able to find all of our our prior episodes, and I made it easy for you to make the most of your listening time by selecting 5 specific areas most commonly high priorities for our community and giving you top 10 lists if you let me know you'd love them. If you know a midlife woman or a soon-to-be one who wants to optimize her midlife energy and time with the right exercise and lifestyle changes and a mindset shift about just what is possible, share this podcast with her and I thank you. There is no more powerful health influencer in the world than you, midlife woman.