Podcast #136: Gluteal and Rotator Cuff Tendons with Byron Miller

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https://podcasts.apple.com/us/podcast/jacked-athlete-podcast/id1462537296?i=1000700292416

“During clinical [in PT school], I developed a raging case of elbow tendinopathy. It was because I was doing a lot of manual therapy, writing a lot of notes and lifting and doing jujitsu. And it was just way too much… I’m in PT school, but I didn’t know how to manage it.”

Glute tendon pain: “As to why they called it a bursitis… why were they wrong in the way that they were wrong? I feel like maybe we didn’t really have another structure to be able to say gets inflamed… And in the shoulder, something similar… It’s like, all right, we know these can get inflamed, so let’s say that.”

Glute Tendon isometric: “There was some supine isometric hip abduction into a belt. So not a TheraBand, but an immovable object… pushing directly out.”

Glute med tendinopathy: “I had my own case. My driver was really heavy sets of reverse lunges and step ups after not having a ton of exposure to that, plus being a side sleeper. So way overdo it and then the whole night have it compressed the next day, wake up and then it’s hard to offload it going forward.”

Glute med tendinopathy: “I do think that that hip angle does matter and it’s also why maybe if somebody was very weak and you end up with that that Trendelenburg or that hip drop that that you get much more compression with every step and that could be a driver as well in those folks who had a significant reduction in capacity of those muscles that would when they go to do the things that require that maybe they’re going to experience more compression because they don’t have stability of the hip.”

“Overly complex exercise leads to lack of adherence, which is the thing that’s the most important in tendon rehab. You need that consistent loading. So I like to really simplify things.”

Glute med tendon isometric: “I’d use a hook lying abduction into a belt. So like hips neutral. So that there’s no potential compression or shortening of the muscle. And then we’re pushing out. I’ll usually give people a force percentage, just a subjective. And that’s usually determined by symptoms and how much it’s provoked by what we’re doing. So initially we will just be in that hook lying position, pressing out maybe if somebody’s really flared and we’re going to say 30%. And we’re going to see what that response is in the moment.”

“I am not using isometrics to try to decrease their pain right then. I’m actually trying to introduce loading. I’m trying to improve the tolerance of the tendon to loading. So initially I think about things in terms of tolerance and then later I’m thinking about capacity. So with this initial isometric loading, maybe somewhere between three by and five by 45, pressing out at 30 to 50%.”

After isometrics for glute med: “From there, I like to get on feet ASAP after that, because I think that’s actually where Glute Med is going to be acting…. So maybe in the different phases of gait. So I like a tempo step up, or maybe you would call it like a lateral step down. Something like that where I have the ability to control that, that stepping down over three seconds, maybe a tap and then coming up over three seconds and a hold at the top. So I’m getting good time under tension for that glute med throughout that whole set. I’m doing that and then maybe split squats, something like that. That’s usually going to be what I’ll progress to for my strength movements after we move on from isos, but also continuing to run those isos.”

Glute med flaring positions: “people just hanging out on their hip, that’s flaring. Crossing your legs is flaring, sleeping on your side is flaring, sitting in a seat where your hips are below your knees is flaring.”

Glute Med: “Most people can tolerate bilateral lower body loading. So they’re usually doing okay with like a squat to 90 degrees or, you know, deadlifts or RDLs to normal amount, like maybe not to one rep maxes or things like that, but they’re usually well tolerated because there’s not a lot of like frontal pain, plane loading. So most folks are able to maintain those while we’re running the ISOs. And then once those symptoms come down, that’s when I’m going right into step ups and split squats.”

Tendon tolerance vs. capacity: “a lot of times you’re able to do a lot in the moment… So you can go play all types of basketball. You can do all types of stuff. You have a ton of capacity for that thing, but the next day you can barely walk. The symptoms are crazy, right? So you had the capacity for it, but the tissue doesn’t really have the tolerance for it yet. It’s able to do it in the moment, but it is really telling you, dude, if you keep this up, we’re going to break down.”

“So initially, I’m kind of thinking about those isometrics as I’m trying to, it’s like a little bit of poking the bear. It’s a little bit of, let me give it the thing that’s flaring it. So I’m not trying to have symptoms come down. I’m actually telling people, I’m finding the symptoms going up two points in that. And then it’s coming back down by 24 hours later. So I’m establishing tolerance to a certain amount of load, even though it’s not that much.”

Daily isometrics: “I don’t for all of my tendons, but like for these ones where I’m thinking about a tolerance establishment versus capacity building, because I think if you’re like doing those really intense isometrics, maybe that’s something that I’m thinking more on trying to build capacity and maybe I need to like wait some time. This is more like, let me just get this thing less grumpy. And if I can annoy it and have it come all the way back down in 24 hours, I would rather go ahead and hit it again and just really quickly accelerate that tolerance building process.”

“For that hook lying, we will very quickly progress that into a bridge so that I’m getting active hip and it’s less flexed hip. So it’s more of a neutral hip position that we are abducting on. That’s a progression for that pretty quickly. Sometimes that happens the first time I meet somebody. If they already have tolerance to the fully bridged one, then that’s what will run, not just all the way down in the hook line.”

“If somebody’s really tall, we’re gonna have conversations about sitting surfaces because if I had some guy that’s like 6’3″, most of the time when he’s sitting on a normal seat, the knees are gonna be above the hips. And that’s gonna result in a wrapping around of that glute med and you are gonna get compression in that. So I’m gonna tell that person to try to like at home, get a pad… And so now we’re gonna not get those compressive issues. If somebody has like a history of crossing their legs, we’re not gonna do that for a little while. Gonna ask them if they’re side sleeper or not, if they are, just having them go to the other side is not sufficient actually, because you still end up with that femur adducting because it’s in space. And so then you end up with that compression wrapping over. So I have folks put a pillow between their legs, but also one that is blocking at the foot as well so that there’s not that external rotation that’s occurring. So the thing is like completely neutral. So you’re on the non-effective side with like two pillows… That seems to be really, really helpful. And that one I have found to be pretty important because if you’re loading it every day and then compressing it all night, my thought is it never got time to do what we know it needs to do, which is rest, recover, rebuild, reestablish homeostasis, all of that stuff.”

“A lot of times folks with glute med, they’re going to notice that a certain step count or stride length, those things are matter.”

“I’ve had some folks that were like on treadmills walking at really high speeds. And that’s one of the things that was really flaring it up. So we just back that off.”

“Or some folks that really love to walk and are hitting more like 15 to 20,000 steps a day. We’re seeing, that’s probably a driver as well. And we have to bring those down. And then you just try to establish the highest floor possible so that they’re not losing that capacity.”


“Once it’s doing well and you’ve established some tolerance to loading, especially like a weighted step up, then you can usually reintroduce a normal return to run program.”

“And the most clarifying case for me was an individual, he’s a guy in his mid-20s. He was a carpenter. But he also played his recreation was disc golf, but he didn’t do any of that anymore because his shoulder hurt so bad. When he first came in, he was actually holding his shoulder because it hurt so much to just walk with it. And he’d been dealing with this for multiple years and his shoulder would get so flared up from work that he could barely do anything and it was really, really significant. So he’d seen multiple PT’s, he’d had at least one injection and I was… I was like, is exactly the case and this is a great opportunity, so let’s try this. We ran this with this guy and just doing ABduction, progressing from that isometric to the isotonic, to isotonic with weight, he was able to get back to playing disc golf without pain. And I was blown away. was like, wait, we did one exercise, that’s all we did. We didn’t even ever do anything like plyometric for the shoulder and he got completely better doing that.”

“It became clear to me that loading was really, really important. And so that’s been kind of a cornerstone of what I do now and making sure that we are like just getting some dedicated loading to that rotator cuff as a way to cause that adaptation versus maybe like a ton of extra exercises.”


“The rotator cuff is basically acting at all times to stabilize the shoulder and to keep it in the socket. And so in a position of like 90 degrees adduction, there is very significant rotator cuff working to resist the shearing force of the humeral head as well as to keep it in. In my experience, you’re going to get infraspinatus, supraspinatus pretty well. The one that maybe you’re not going to get that well, you might need to do a different movement, or the two I would say. Biceps tendon, I’m probably going to be thinking more biceps flexion, like we need to work here.”


Rotator cuff compression: “especially side sleepers. It’s a really significant issue for a lot of them. That often is going to be the most painful time of their day. A lot of them just learn that they can’t sleep on that side at all.”

Biceps tendon: “I find that extreme shoulder extension position all the way back here is the most flaring thing, maybe even more so than overhead.”

Rotator cuff: “I think that you’re gonna get a ton of loading because of the moment arm. It’s just so far away. So you don’t actually need a boatload of weight to get a good amount of force at the shoulder.”

“I don’t think being strong is enough. Because I think that most folks don’t do anything fast with their arms. And if you go from just lifting to playing softball, there’s a high likelihood that, you haven’t thrown in like three years, I can really see that causing an issue.”


“We don’t know what’s going on in the shoulder. Our tests can’t even differentiate what rotator cuff muscle we’re looking at. And therapists can’t agree on scapular dyskinesis either.”


Rotator cuff tears: “I don’t care. Yeah, it’s really interesting because it might be the place where they have the most research. It’s similar to the back, you know, they have all these asymptomatic findings in the shoulder, just boatloads of asymptomatic tears, asymptomatic issues. And I’ve had experiences of MRI confirmed full thickness tears that we rehab just fine and we don’t really do that much differently.”

Shockwave/Injections: “I’m not a big fan. I’ve seen a lot of bad stuff. Stem cells, I’ve seen stem cells be extremely flaring. People have really bad responses to those… So to me, it’s like all of these things have potential risks to them. I’m also familiar with other people getting injections in other areas and it going very poorly.”

“In my experience, those things are not positive. And also I’m sure as many folks have talked about, like they just set up this incorrect expectation that that’s going to fix things. But we know that if this is driven, at least in any capacity in a tendinopathic stance, we need loading to improve it. And so they end up not getting better over time. And when they go to load it, it just returns to the same situation.

Website: https://www.tendonrx.com

Instagram: https://www.instagram.com/tendonrx/

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