The Most Painful Shoulder Conditions:
Many folks think that severe pain means something must be torn.
But... in patients with one of the three most painful shoulder conditions, there's nothing torn at all. After 30 years, it's safe to say that the three most painful shoulder conditions I see have nothing to do with a rotator cuff or labral tear.

These patients are often in far more pain than someone with a massive rotator cuff tear, and I can usually identify them before I even begin the examination because of how they hold themselves, how miserable they look, and how they move into the exam room.

I have probably written more about tendons in the past year than most surgeons have written in their careers. I do this because tendon disorders are among the most common issues I see in the office.
You will need to know this stuff at some point.
Also... Don't think that because of severe pain, something is torn. Let's do this... Most tendon pain is not caused by a single traumatic event. Tendinopathy is the most common cause of tendon pain. It is a failed response to loading over time. Simply put... Your tendon was asked to do more than it was adapted to handle, and the rate of breakdown exceeded the rate of repair.

This can happen to someone sedentary who tended to their garden in the spring... or a runner whose achilles was used to 20mpw, and now they decided to run 40mpw.

The tendinopathy process occurs on a spectrum... from a reactive stage that is usually reversible to a degenerative stage where the tissue has changed structurally but can still be managed effectively.

The Frozen Shoulder... a thread.
A frozen shoulder is one of the most misunderstood conditions in orthopedics. It is not purely a mechanical problem. It is a metabolic one. The shoulder capsule becomes a target of systemic inflammation, hormonal disruption, and glycemic dysfunction. Most people, and some surgeons, still treat it as if something is stuck and just needs to be loosened... Properly managing this and the contributors is essential to resolving it. Perimenopausal women are disproportionately affected, and we need to look at the receptor-level interactions.
Estrogen acts through GPER to suppress the PI3K/AKT signaling pathway, thereby preventing fibroblast activation and blocking progression to fibrosis.
When estrogen drops, that brake is removed. A Duke Health study found that postmenopausal women not on HRT had 99% greater odds of developing frozen shoulder compared to those who were.

Once we start falling… serious health issues are just around the corner.

We don’t fall because we stumble… we mostly fall because we can’t recover.

An important thread... I have spent three decades across an exam room table from people who are trying to figure out why their body stopped being the thing they could count on.

Are Most Rotator Cuff Tears Actually Tears?
This topic is far, far more complicated than most think... and it's certainly far more complicated than the discussion in most office visits portrays.
1/
If you have a rotator cuff tear on an MRI report, almost everything you have been told about it is more wrong than right.
A short thread on what the cuff actually is, why most "tears" aren't what you think, and why surgery is rarely the right first step. 2/
The rotator cuff is a stabilizer, not a lifter. The deltoid does most of the work to lift the arm. The cuff keeps the head of the humerus centered while the deltoid does the work.
That distinction explains why a cuff defect or "tear" is often compatible with full or nearly full arm function.

Knee Osteoarthritis... Why Rest and Wait For Surgery is Not the Answer
1/
You have more agency than you have been told you do. The X-ray is not the verdict. The trajectory is not fixed. There are many things you can do... and they will influence the trajectory of the disease course more than any injection or medication will.

A short thread. 2/
The X-ray is a poor predictor of your symptoms.
I have friends with bone-on-bone changes on their imaging who run and lift with me. I have patients with mild radiographic findings who can barely climb stairs. The correlation between imaging and pain is famously weak.
The X-ray describes the structure of the knee. But... Function isn't defined solely by structure.

APOE Status and Dementia Risk...

APOE4 is the strongest common genetic risk factor for late-onset Alzheimer's. About 25% of the population carries at least one copy.
It's a risk modifier... not a guarantee. And the levers that change the trajectory are mostly things you can actually do something about.
A short thread... 2/
The basics.
APOE comes in three versions: E2, E3, and E4. You inherit one from each parent.
E3/E3 (60% of people): average risk
E3/E4 (~22%): one copy, 2-3x lifetime AD risk
E4/E4 (2-3%): two copies, much higher risk, often a decade earlier
E2/anything: usually below average risk.

Knee Osteoarthritis Thread 4: Metabolic Health and the Knee.
Your metabolic health will directly impact how your knee feels more than you can imagine. Your metabolic health directly influences how quickly your arthritis progresses and how your cartilage responds to the stress it's under.
This is the part of the knee OA conversation that most patients never hear. Here's a useful fact to set the stage for this discussion: Hand osteoarthritis is far more common in people with obesity.
Hands don't bear weight. So if OA were purely a mechanical wear-and-tear issue, this wouldn't make sense.
But... It does make sense if OA is driven, in part, by systemic inflammation, which circulates everywhere, including into non-weight-bearing joints.

I'm a 62-year-old orthopedic surgeon, trail runner, climber, and cyclist. This is my Midlife Athlete's Playbook. I've combined what I've learned from 30+ years of treating active adults, and from training through my own 50s and 60s. The physiology of aging is real, but most of the decline people accept is optional. Aging brings real physiological changes. But lack of specific age-appropriate training brings far worse ones. A few things I've learned from three decades of treating active adults and from my own body.

Coming Back After Injury, Surgery, or Illness... Why It's Easy To Set Yourself Up For Breaking Again.

1/ I've helped hundreds of athletes return to activity after injury, surgery, or serious illness.
The return is almost never linear.
The sooner you accept that, the better the return will be.
A thread on the actual data — and how to try to come back without breaking yourself a second time. 🧵 2/ Most returning athletes underestimate two things:
How fast you detrain.
and...
How uneven the losses are across different systems.

Your aerobic base, strength, tendons, bone, and metabolism all lose capacity — but not at the same rate. And they don't come back at the same rate either.

Knee Osteoarthritis: Thread Number 3
The most powerful intervention for knee osteoarthritis is not a pill, not an injection, and not a surgery. It's not PRP and certainly not stem cells.
It is the muscle above and below the joint.
If you have knee OA and you are not doing targeted strength training, you are leaving the most effective treatment on the table. 🧵 Every time you take a step, force travels through your body. Strong muscles, especially the quadriceps, absorb a substantial portion of that force before it reaches the joint.
When those muscles weaken, the joint takes the full load. More load, more inflammation, more pain, faster progression.
Muscle is the knee's primary shock absorber.

Knee Osteoarthritis... Thread #2 !
Your knee hurts. Your instinct is to rest it. Please don't.
That instinct is very often wrong — and following it makes osteoarthritis worse, not better.
Movement is one of the best evidence-based primary treatments for knee OA. Here's why. 🧵 Most people mismanage their diagnosis of knee arthritis. It's not their fault... They make wrong assumptions... and they narrow their lives further.

Start here, though.... This was the first thread... ideally, you consume these in order ;-). Then again... it might be a lot to ask people to read that much ;)

https://x.com/hjluks/status/2042550149864476722?s=20

Don't Let Your Lives "Narrow"!!
I've been an orthopedic surgeon for 30 years.
The thing I watch happen to people, more than any injury or surgery, is refer to as the narrowing.
Most of my patients have no idea it's happening to them. They think it's just aging. It's not. 🧵 The narrowing is the slow shrinking of what your body will let you do... or what you assume your body can or should be doing at your age.
You used to carry four grocery bags. Now you take two. You used to sit on the floor with the grandkids. Now you sit on the couch and watch. You used to take the stairs two at a time. Now you hold the rail.
If you're under 80 and you lie down for an injection... you shouldn't need a two armed lift to sit back up. Granted... in some instances you will... but I'm speaking about the "healthy" 60-70 something that can't because they never recognized this loss of ability and never did something about it.

Osteoarthritis Of The Knee... Thread #1... of 4
"Bone on bone."
"Your cartilage is worn away."
"You have the knee of a 90 year old."
I've heard these phrases bantered about thousands of times in 25 years. They are very common explanations patients get for their arthritic knee pain.
They cause harm.
Xray findings do not correlate with symptoms... they just don't.
... and those descriptions lead to decisions that might not be the proper treatment at that point in time. 🧵 Patients fear the phrase bone on bone. They think that's the end.
Heck... I run with people who are bone on bone. I've replaced knees in people who aren't bone on bone. The diagnosis of severe arthritis is a clinical diagnosis... not a radiographic diagnosis!!

But, often, after hearing those bone on bone words, the patient goes home believing their knee is a machine with completely worn-out parts, and that any movement will grind it down faster.
But... we know that's not true.

Tendon pain is the most common reason people come to see me.
Most of it is self-inflicted — from doing too much, too soon, or from doing too little for too long.
Let's review what most people (including many doctors) don't understand about why tendons hurt and how to fix them. 🧵 Tendinitis is a myth (mostly) When your tendon hurts, most people assume "tendinitis" — inflammation, swelling, immune cells.
That's not accurate for most adults with tendon pain.
Under the microscope, those tendons rarely show the classic signs of inflammation. What they show is something different entirely.

Why I Train This Way at 62
1/ I’ve been an orthopedic surgeon for nearly 30 years, and over that time, I’ve watched something happen to many of my patients that isn’t dramatic or sudden, but ends up being far more consequential than any single injury or diagnosis. 2/ Their lives narrow. Not all at once, but gradually. The trips they stop taking, the hobbies they quietly give up, the activities they once enjoyed but no longer feel capable of doing. It’s rarely a conscious decision. It’s a slow loss of capacity. And they normalize all of it.

Viruses and Joint and Tendon Pain
You had a cold two weeks ago. Nothing serious. But now your knee hurts more than it has in months. Your achilles is flaring. Your easy run felt like a half-marathon. You didn't do anything wrong. Here's what's actually happening... I've been an orthopedic surgeon for nearly 30 years. One of the most consistent patterns I see: patients come in with a flare of their knee, shoulder, or tendon pain — no new injury, no change in activity — and when I ask if they've had a recent illness, the answer is often yes.

I hear this every week in my office:

"Doc, my heart rate hits 150 during squats — that's cardio, right?"

No. And if your cardiologist hasn't explained why, keep reading. 🧵 A high heart rate during lifting is due to cardiovascular stress... No one is disputing that.

But cardiovascular stress and aerobic adaptation are not the same thing. The type of load your heart sees during a heavy lift produces a fundamentally different physiological response than sustained aerobic exercise.

Having been an orthopedic surgeon for 30 years...5 things I wish someone had told you before you walked into my office — in atraumatic joint and tendon pain.

Most of you will present with atraumatic joint and tendon pain... traumatic injuries are far less common in adults. And no... you didn't "sleep wrong." Your MRI is not your diagnosis. It's fine to get the MRI. But what comes next is what really matters.

Meniscus tears, rotator cuff changes, disc bulges, and labral tears— we find these in people with zero pain all the time. By midlife, they're nearly universal.
The scan shows what's there. It doesn't explain why you hurt. Those are two different questions.
You need to be listened to and examined. That's the only way to correlate the MRI findings.

Pain on the outside of your hip is one of the most common problems I see in my practice.

Walkers get it. Runners get it. People who've never been to a gym get it.

For decades, we called it bursitis and injected it. We were treating the wrong thing. The problem is almost always the gluteal tendons — the gluteus medius and minimus — not the bursa.

Think of it like the rotator cuff in the shoulder. The bursa gets irritated, but it's reacting to what's happening next door.

Both can hurt without a tear. Both can show tears on imaging and cause no pain. Both respond to progressive loading — not rest.

I'm a 62-year-old orthopedic surgeon, trail runner, and cyclist. I've also spent 30+ years watching people give up on their bodies too soon. And watching too many lives narrow.

Athletic performance doesn't have to decline sharply in midlife. Most of what drives that decline is addressable. We yield too much to age. Yes, aging brings changes. Lack of training brings far worse changes.

A few things worth knowing — The Midlife Athlete Playbook 🧵 After 30, you lose roughly 1% of muscle mass per year without resistance training. By 70, that loss compounds significantly.

Skeletal muscle doesn't care about your age — it responds to load. Consistent resistance training at any age builds and preserves it.

If you're not lifting, start. If you're already lifting, don't stop.