Jared Powell (00:11):
Welcome to the Shoulder Physio Podcast, a podcast dedicated to exploring meaningful topics in musculoskeletal healthcare. I'm your host, Jared Powell. Before we begin, the primary purpose of this podcast is to educate and inform the views expressed in this podcast by myself and any guests are information only, do not constitute professional advice and are general in nature. If you act on the basis of any podcast episode, you should obtain specific advice from a qualified health professional before proceeding.
Jared Powell (00:46):
Today's guest is Neil Millar. Neil is a professor of orthopedic surgery and consultant orthopedic surgeon specializing in shoulder surgery and the management of complex tendonopathy. I've finally succeeded in enticing a shoulder surgeon onto the show, and I tell you what, we get along much better than you might expect. In fact, it is refreshing and reassuring to hear Neil's approach to shoulder surgery. Neil is a classic clinician scientist maintaining a clinical caseload and leading a research lab simultaneously. Neil has recently published a great paper in nature reviews on the topic of Tendonopathy, which I strongly encourage you to read. Neil promotes the abolition of silos in tendonopathy management and urges, physios, sports physicians and orthopedic surgeons to work together. How lovely. This is probably one of the most clinically applicable podcasts I have recorded to today, and I reckon you'll get a lot out of this one before we start the podcast, a quick note from our sponsor, Clinico Clinico is a practice management software that's used by 65,000 practitioners worldwide.
Jared Powell (02:02):
It's great for busy physios, which is why it's an endorsed partner of the Australian Physiotherapy Association and the Charted Society of Physiotherapy. In the uk, you'll find everything you need to run a successful physio practice in one place, like treatment notes, digital forms, online booking tools, customizable body charts, and much more. Clinico meets privacy legislation for Australia, the uk, the US and Canada. So wherever you base Clinico will help keep you compliant. Charitable donations in giving back are a big part of Linco. A minimum of 2% of all CLINICO subscriptions are donated to charity each month, which means more than 1 million Australian dollars in total has been donated since Clinico was founded. Shoulder Physio Podcast listers can get 60 days for free. Signing up takes less time than this message. Visit clinico.com/shoulder hyphen physio. Without any further delay, I bring to you my conversation with Neil Millar. Professor Neil Millar, welcome to the show.
Neal Millar (03:02):
Nice to see you. Thanks for having me, Jared.
Jared Powell (03:03):
No worries. So you are, you are speaking from Glasgow over in Scotland and I'm, I'm down under here in Australia. So through the wonders of the internet, uh, we get to chat and, and talk about all things tendons, which I know is a, is a passion of yours. Before we get into the nitty gritty though, Neil, I want my listeners to know a little bit more about you. Describe your Monday to Friday as best you can, and also some hobbies that you perhaps might enjoy if you get some free time.
Neal Millar (03:33):
Uh, yeah, so, uh, thanks again for having me. I suppose so, I mean, to start off I'll apologize. I am an orthopedic surgeon, but we'll try and get past that in the podcast. Um, you're,
Jared Powell (03:43):
We have to stop the, stop the,
Neal Millar (03:46):
Yeah, exactly. That's enough. So, um, my, so I'm a chair orthopedics in Glasgow, mainly a shoulder surgeon, but I do lots of other tendon type surgeries. So Monday's my operating day all day. I usually do routine cuff repairs, instability, shoulder replacements, Tuesday, Wednesday I normally have in the lab or I'm traveling, um, uh, most of the time now. And then Thursday I do a fra, an upper limb fracture clinic, which was, I, uh, didn't used to do but because of covid I took on and actually I secretly enjoy but don't tell anybody. And then on a Friday I have my normal clinic and my clinic really is a complex tendon clinic that makes you quite depressed by the end of it. So I look forward to Friday evening for a glass of wine. Um, hobby wise, so I've got four daughters, so I don't really have any hobbies cause I'm just so bloody busy with them. Um, uh, but I do, you know, I enjoy DIY and things like that. Gardening. You may. Uh, so, um, that's my main sort of hobby, but I have no free time and I don't really speak in the house cause there's five female voices.
Jared Powell (04:50):
As it should, as it should be Neil. So, as it
Neal Millar (04:52):
Jared Powell (04:53):
, I, I wanna get back to your, your working week cause it sounds quite varied and diverse, which is, I'm gonna say unusual for an orthopedic surgeon from my experience anyway. How did you get into the, the, the complex tendon clinic and, and all those other sort of
Neal Millar (05:07):
Things? Uh, I, yeah, so I, I mean my journey really, I went to Sydney in as a med student and then back in, uh, 2005 and six to work with George Morrell in Cora in Sydney. And he is a, an atypical orthopedic surgeon. He has a basic science background, but operates. And I think that inspired me to want to do that in my own practice. Cause I thought we, we both thought at the time that tendons, the basic science was really, it wasn't done to a level that you would expect of cancer biology or cardiac disease. We were really way, way behind when I came back and the post here, I found that pa patients with multiple tendonopathies or problematic tendon patients were getting a bit of a rough deal. Uh, so we set up myself and a rheumatologist, uh, set up a sort of complex tendon clinic.
Neal Millar (05:57):
So that was for people who were a calin to physio or a calin to other treatments who basically had lost their way as well as patients with mul, you know, the borderline, um, spondyloarthropathy type arthritic patient with multiple tendonopathies that were probably mechanical. And then also we, I also do a lot of fluroquinolone with toxicity patient work. So that now has meant that we actually, I run UK wide. Uh, we also take some patients from the states and, and Europe, sometimes a UK wide sort of complex tend clinic where we're funded to see the, the ones that are really struggling in a field, uh, mostly every other management. So they're taxing, I would say they're, I always say when I'm giving a talk, if anybody asks you to set up a complex tele clinic, run outta the room because it, it, it, it takes a lot. But I find it very rewarding because I think these patients, um, have had per advice, per treatment sub most of the time. And actually you'll never hear an orthopedic surgeon say this again, but a lot of the bio social aspect of it needs to be explored with them to get them back on track to a rehabilitation program. And so I, I quite en enjoy that and I think there's a need for it. Um, but yeah, that's, it's not without its challenges. Let's put it like that.
Jared Powell (07:20):
Neil, you've become my favorite orthopedic surgeon by simply uttering the bio psychosocial framework, which I, you're right, I've never, I've never heard before. And I, I love how you've, you've chosen the challenge of doing this complex tendon clinic when you could make a perfectly good living out of just doing your cuff repairs and your, your normal whatever. Hopefully not a lot of subacromial decompressions these days, but certainly there's a lot of shoulder surgery work out there, so, so kudos to you for doing that. Is it something that you would, you would like to see perhaps a bit more of in orthopedics, like orthopedic surgeons going outside their comfort zone and looking at more complex pathology?
Neal Millar (08:00):
Yeah, I think, I think, I mean, I, at the end of a lot of my talks now, who I give to some, I give talk surgeons, I, I sort of say, look, the mucosal disease treatment is changing, not just in, tend it away in other diseases that we treat a lot and it's changing towards a biologic or drug related era that we can probably manipulate disease other than operating on people. And you're either going to embrace that and get on the train or you're gonna be off the train and someday else is going be prescribing those drugs and looking after your patients. Uh, we know orthopedic surgeons, you know, type A personalities, you know, can be pains in the. But if you, you're smart enough, I always say to them, you're, you've got the level of intelligence and interest in that. You should embrace this era with other, you know, like physiotherapists, like sports physicians.
Neal Millar (08:53):
And understand that you having these patients in your office and treating them with a drug, you're still going to improve them. They're still gonna need to see you. You need to start, adapt and move forward. Because if you're just gonna operate, we can all do cough repair and all do a hip replacement. But the, the, the disease, the way we treat patients in all diseases, cancer, cardiovascular, you know, pancreatic cancer, we're changing towards a personalized, uh, era. And we need to, as I say, we need to pivot and be there. And if we don't, we're just, we will get left behind. And rheumatologists, sports, physicians, physiotherapy, prescribing will take your patients. And that's, that is the reality of the world moving forward.
Jared Powell (09:37):
Yeah, yeah. So jump on or, or get left behind. Yeah, that's a good incentive. So yeah, before we get into the, to the, the, to the tendon chat, I wanna ask you very quickly, what book are you reading right now? Neil and TV show, more TV show,
Neal Millar (09:51):
So's book. I bought a book in the summer. I still have a good ride to be today . Um, but I'm watching, I'm obsessed and I, I dunno where this has come from. I'm obsessed with the Yellowstone. I just, I have no idea because I'm not really into horses, but I i I just can't stop watching it. I literally was, I was taking one of my daughters to hockey the other night and I have half an hour where I hour I have to wait in car with my four-year-old listening to Frozen. But I'm on watching Yellowstone. It is, I dunno. So maybe, maybe you'll find me with the steps and rope some, I dunno, next year. And I've given up tendon. So that's,
Jared Powell (10:28):
That's, you'll be in Montana on the, on the Dutton Ranch? Uh, yeah, I, I'm with you. I've watched, I've watched all of it, I think, and it's, uh, it's uh, maybe it appeals to a life that we want to live. You know, you're out there, you're on the land.
Neal Millar (10:41):
I think, I think that's maybe, I think it's so abstract to being an orthopedic surgeon, you know, it's so out there that I think I could just go and do that. I could just go and do that.
Jared Powell (10:51):
Screw all these complex tendons I wanna go. Exactly,
Neal Millar (10:54):
Exactly. I'm gonna go and rope a horse or something. .
Jared Powell (10:58):
Alright, I'm sorry mate. I'm gonna bring you back to tendons. So, so Neil, where are we with tendons in terms of the genesis of, of tendonopathy? Is it, is it a simple model of overload without adequate repair time? Or is it something more multifaceted and rich and complex?
Neal Millar (11:16):
I, i look, I, I think I, I think tendon research is in a very good place in that we have now reached the stage where we are doing X well, excellent basic science alongside better, not wonderful, but better clinical trialing. And I think that has revealed that this is just mechanical loading. Clearly that's a part of it and probably a very large part, but, but there are many other, it's multifactorial. There are many other avenues that drive this disease. And you need to consider, you know, inflammatory mechanism, atic mechanisms, uh, you know, environmental reasons. You know, look at the, the look at diabetes and metabolic disturbance. We haven't really gotta the bottom of that, although we know it's a factor. Smoking and, you know, you know, socioeconomic deprivation and high patients who have a crappy life get, tend have a crapp bear life. You know, so it's, it is a, it is a multifactorial disease.
Neal Millar (12:13):
And this old ad is that it's just, you know, I'm, I don't prescribe to it. It's just mechanical loading. Why clearly that's important to certain subgroups. And this is why like Berger's work is that, you know, finally we were talking about subgroups and precision tended up a few years ago. She's now nicely highlighted that in a group of, you know, Achilles patients, you know, looking at what, who, and what might respond, you know, these activity dominant psychosocial and then structure. So look, there's a lot of, um, sometimes I find there's a lot of moaning in the 10 in the community. Um, and I think that's because it's diverse. There's orthopedic surgeons, there's physical therapist, therapist, there's a lot of different groups. Sometimes maybe if we just talk to one another and better, I think we could probably figure out a lot of this multifactorial and treat our patients better actually. So look, you could take the tactic. Well we, what have we discovered tendinopathy? Have we just revealed more complexity? Yes. But by revealing that complexity, we are ultimately gonna treat the patients better. I think.
Jared Powell (13:16):
Yeah, you're right. We do tend to, between professions, physio, orthopedics, sports, physician, rheumatologists, whoever you may see, we tend to compete in terms of how we're gonna manage these tendons. And it, and it really frustrates me. And it's also, it's different in terms of who you go to. I don't know what it's like over there, here in Australia, if you were to go to a sports physician for a grumpy achilles, you might be a suggested exercise, but you're quickly gonna find yourself sort of recommended some type of injection, be it a yeah p r p be it a cortisone, be it a high volume injection or whatever it may be. And that's, that's frustrating for me. And this is why I liked your paper in in nature, the primer on, on Tendonopathy, cuz you kind of had a few people from different backgrounds, uh, contributing to the paper. So do you think the management of an individual with a tendonopathy would be better if most professions who come to see people with tendonopathy were giving similar advice rather than totally disparate advice? Yeah,
Neal Millar (14:19):
Yeah, I think that's, I mean, that could be pretty brutal and say, you know, a lot of, part of the problems with tendons is it's highly prevalent and therefore people can make a lot of cash outta it. And by that, I think that is a driver for substandard early treatment, I think would, will not set just the sports physicians. Cause equally, if you go to clinic in New York with a cuff or, or a patella, you'll end up with a PRP injection if you see a surgeon. So we're not just, we'll not have a go just the sports physicians, but we could. But we, um, I think, think, yeah, I, it astonishes me when I see a complex patient about how crap the treatment has been, and I'm gonna get at physios here as well here in that there's no standardized logical thought process sometimes in, in the, in the early phases.
Neal Millar (15:07):
And you flip around with different, multiple different exercises, different interpretation of what the patient's feeling. And that's why we come up, that's why I actually wrote that paper and got together, you know, a good group of physiotherapists, sports physi, you know, a diff you know, the people we treat group of people who really treat this disease. And that's why we come up with a framework of get the diagnosis right. Spend time with your patient at the start, listen to them, you know, are you missing something like a a spondylopathy? Are you missing that they're grossly depressed that they lost? So, you know, listen to them, educate them, acknowledge them, think about their fear mechanisms and then start a loading program that evidence, so is so in the favor of that start something sensible and logical tailored to that patient. Is it isx? Is it eccentric?
Neal Millar (15:56):
What have they tried before? Energy, you know, talk to them. That's the most important. And remember 99% of the time the patient usually is right and will give you the indicators of what they need. Then if the loading program isn't working, you know, sit down, you can change it. But do not rush in with unproven adjunct therapies early. Because a lot of the time that is what the killer can be. You can have a PRP start gtn too early when actually their cusp that their loading program just needed, they just needed a couple of sessions of is, you know, ISO or you know, you know, just something a little bit different. So it frustrates me that it still happens. Um, I think it's getting, I think it's getting better and I think it will get better as no more novel treatments come on board for recalcitrant uh, treatments.
Neal Millar (16:47):
Cuz all of these treatments that we're developing, um, will only be for secondary. These are not gonna be something you're gonna walk into your clinic and be given a biological drug. These are for patients who maybe six, 12 months down the line aren't responding and need to need some sort of adjunct to help, you know, dysregulated inflammatory response or a dysregulated whatever. So yeah, I, I, I, I sent, I can understand your frustration, but I think all we can do as a group is continue to educate that load management should be the first port of call. But there's a lot of, there's a lot of heavy lifting around load management and you have to appreciate that and they get the patient to accept that. And that's not always easy. I mean in glad a typical Glasgow patient, if they come in with an achilles tendon, as I always say Achilles tend, I say, look, you need to do these 15, you know, need to do these exercises for 12 weeks.
Neal Millar (17:44):
Repetition an usually ends within. And that is because it's hard, it's hard in life now to commit to exercise regimes. And maybe we need to say, right here's a bit of load management, but walk 7,000 steps a day for four of seven of the days. Maybe we, a lot of the time focus wholly on the set of exercises when actually generic health plus a bit of exercise might be. So, and that's what we do sometimes in the complex tendon clinic because we can't give them, we can't load them always how we want to because they're just not conditioned. And therefore we switch that around, say, right, you know, first week you're gonna do 2000 steps, third, second week we gonna do three, we're gonna take this slowly, we'll add in a, you know, an asymmetric at week three and and that's what we do. And it's time consuming, but it can help the patient.
Jared Powell (18:38):
Hmm. I, um, I agree with you having a go at physios too, so thank you for that. We'll tee off on each other in every profession, but, um, the, the physio you say, you say at large it might be getting better or that's your sense. I'm not so optimistic. I still see some horrific physio around with people getting friction massage on their Achilles for six months, you know, or dry needling into their, which you know, it is what it is. It, it might be a fine adjunct, no exercise or just a calf stretch and a cal rub. And, and then same with rotator cuff related shoulder pain cuff tendinopathy, which is my area of interest. You get people just getting an upper trap massage and then a peck stretch, you know, and it's just, it's woefully inadequate in terms of trying to change the capacity of that tendon. So I, I'm a PEs it's still bad.
Neal Millar (19:32):
I'm trying to be optimistic. Look, I could wax lyrical about physiotherapy regimes I've seen. But look, it's, I would argue that it's not easy being a, you know, not easy being a physiotherapist, actually, it's not easy. Um, it's sometimes not an attractive career. It's hard work and therefore you've got to cut, you know, they're not doing it intentionally. I think the onus should be on people like me helping and educating and maybe putting things out there to help them with patients. But I agree, they're, you know, physiotherapy trials are hard. We're not great at trialing in this indication. And so, look, I have, I'm not as pessimistic as you, um, but I, I agree there are some waffle things done, but maybe, you know, let's not forget that it is, it's a tough, like here in the UK at the moment, a band by newly qualified physio therapist is paid crap. Do they have the, do they have the drive and ambition to span 45 minutes with a patient when they're getting, you know, there's a lot of other issues around physiotherapy we could go into. Why maybe that profession, why, why that, why people are moving more quickly? Adjuncts, you know, I, I can be kind with physiotherapy too, , so it's not Yeah,
Jared Powell (20:51):
You're right. I I was, I was playing devil's advocate. It's, yes, there are many forces which are, uh, sort of leading to that low value care or perhaps a lack of critical thinking or a, or a lack of passion, frankly. Because if you are grinding through the week and getting paid nothing, and I worked in London for a couple of years and I got paid half of what I get paid here in Australia doing more hours, which was criminal. Um, yeah, it's tough to find that passion to translate that into clinical care, you know? But I still think that if you are, you've chosen to go into it, it's a profession and it's a, it's a, it's a profession that's founded and based in science and critical thinking. Yeah. Then if they listen to this podcast, there should be some improvement there at, at scale. Yeah. So I wanna, I wanna get more sp Okay. Do go on mate.
Neal Millar (21:41):
Yeah, no, no, no, no, go ahead. No, you're fine. I
Jared Powell (21:43):
Wanna, I wanna get specific here for a minute cuz I, we're just gonna, we're gonna run outta time. I can see where we're gonna go here. I want to talk about, so I'm an Australian physio and I was trained roughly around the time this continuum model of tendonopathy was proposed by Jill Cook and Craig Perham around 20 2009, 2010, which was a really a appealing and elegant and and attractive model actually. I found that it highlighted the stages of a tendonopathy, it also showed how you would manage various stages of the tendonopathy and then also actually showed that the tendon was adaptable and, and could perhaps change, you know, it could be reactive here, but we could get it back to normal, so on and so forth. So I wanna ask you, cause I haven't really read about it for a, for five or six years, how's that model sitting in, in contemporary tendon research?
Neal Millar (22:33):
Look, I think there was always a place at, at the time it was, yeah, it was fields leading. I would argue that I didn't really, you know, it, it said it was looking at the basic science aspect of it, and it did, it did at the time, but the basic science at the time was crap, right? So you're putting, you're, you're developing a model and I, I get that it was what the theory et cetera around it, but the basic science really was not great and the understanding was not great at that time. And so it gave a very, I think it got a reasonably prescriptive, but I think the, the field needed at that point, I think it's moved for me, it's moved on from there. I think it's a useful, I mean they updated it, uh, recently and I think it has a place, it certainly has a place, but this, this science has moved on quite considerably here.
Neal Millar (23:19):
We now know that we probably should be targeting in, in, in, in early disease. There's mechanisms we can be targeting quicker with maybe drugs in certain subsets of patients rather than being wholly physio and loading management centric. And we need to be ready to adapt to that. Um, so look, it's always going be out there in the, and I think it is useful as a, as a, as a guide. Um, I'm, I'm not, you know, reactive tendonopathy, I never really liked that word, but you know, it's more that, that for me that's the initial, you know, molecular insults that are actually really important then leads on to dis dysregulation or disrepair. They, they talk about, and then this, I don't like the word degenerative tendonopathy because it belittles it, it's a bit like a way wear and tear. It really doesn't explain the complexity of, uh, the disease.
Neal Millar (24:10):
Degenerative tendinopathy really led on to the whole thing that there was no inflammation. And, and, and that argument, which, which I suppose irritated me because we were discovering so many different things at the time and it took us, we have this, I'm just back from Dallas at the Orthopedic Research Society and I was giving it, I know it took us really 10 years to, to change the, or get into the field that actually inflammatory mechanisms here are pretty important. Not inflammation, not clinical inflammation. And, and therefore, so I think we're modernizing and, and I, so I, so look, I think it was good at the time. I'm not wedded to it now. And I think that over the next, I think the next five years with a lot of the work coming out in clinical trialing in the subsets of patients that Karen has highlighted, I think more trials with more good physical therapy trials will look at those subset of patients and you'll know when somebody sits in front of you for the first time after a questionnaire and a chat with them, you, you, you'll see them as a psychosocial dominant patient and you'll tailor your treatment to that.
Neal Millar (25:17):
Versus you'll see somebody who maybe is an, has an infl, you know, is going to be recal recals to load and maybe you want to add in a molecular adjunct much earlier cause they're giving symptoms or signs. So that's where I think as a field we'll change or move away from a, from a a mo I'm not, I'm not a big fan of models anyway, but that's, um, that's where I think we are Now,
Jared Powell (25:42):
Do you mind if we linger for a bit on, on inflammation? So I, I, I remember when I was over in, in London working, I met up with Jonathan Reese who, who wrote a paper on inflammatory
Neal Millar (25:54):
Or I know Johnny Re Yeah, Johnny and I share a lot of complex, he did the London one.
Jared Powell (26:01):
He, he's a lovely chap and we, we met a lot of times and shared patients, um, with Tendonopathies. And I read this paper on Cuz Cook and Purum. I was like, nah, there's no inflammation in in Tendonopathy. What is this? It's all a big myth. And then I read John's paper and then, uh, I had to look him up and and have a chat with him. So, so what, so there are inflammatory mechanisms involved in tendonopathy, however, it's not the classic inflammation where you perhaps roll your ankle and you get an ankle sprain and you get the swelling and the Yeah. And the cardinal signs of of that.
Neal Millar (26:35):
Yeah, I mean we were taught, I suppose the clinicians were always taught, you know, high CRP highs are hot, swollen and, and therefore it was difficult to convince a, a set of clinicians that actually when you take a biopsy from a tendon that is under early tendon off, there are hugely dysregulated inflammatory mechanism inflammatory molecules and mediators and mechanisms that are going on that tendon that are actually driving the, the predominant driver of that disease at that time. So it took a long time to cont help contextualize that for clinicians, which is understandable. And also the sci, you know, from, you know, the science radically changed from the sort of era in the, you know, it was no longer okay to just say, right, well we find a molecule was crack on and it must be important, you know, science now we take biopsies, we look interrogate it at a level, you know, we look at the, we look at single cell, uh, you know, RNA sequencing.
Neal Millar (27:34):
We look at sub clusters of cells, we look at what molecules, how they do, we backtrack into mice, we put into humans. It's really moved on significantly. You know, we are now doing, we've just finished a biolo you know, we finished the il, the IL 17 trial for a teter cuff tendonopathy. So that was taking stuff we found in my lab. And now we systemically injected, you know, into the stomach and anti cine treatment for cuff tendinopathy. It's crazy if you think about it, but you know, in a subset of 40 patients with real who had early tendon up for less than six months and whose war score was really, you know, high or they were really painful, they got significantly better than a CEL competitor. And it was, and this was out till, you know, week 16. So what all we're saying is, I'm not saying that everybody that's gonna walk into clinic room is gonna need an antiinflammatory.
Neal Millar (28:27):
Get that outta, that's just crazy. What I'm saying is that those mechanisms are driving a dysregulated matrix response and maybe in, in a subset of patients, which we'll figure out targeting them with load. Cause let's remember all those patients in the biological trials still get loaded. Um, got, will get better and therefore we should be as a field trying at the end of the day, why are we doing all this? The patient sits in front of us, you wanna make them better? Do you really care what happens in the mouse? No. So we need to get treatments to make them better. And I think we are doing that. Um, and I think the inflammatory, I think inflammation is more readily accept or inflammatory mechanism more readily acceptable. I think when we publish a few more, uh, trials with novel mediators, then it will filter to the field and maybe they'll be more acceptance. That takes time. Takes time,
Jared Powell (29:20):
Yeah. So inflammatory mechanisms being present or or the, or the causal mems underpinning the onset of tendinopathy does not mean we're harking back to rest. Ice anti,
Neal Millar (29:32):
Oh god, tendinopathy.
Jared Powell (29:33):
No, absolutely. I just wanna make that clear. Yep.
Neal Millar (29:35):
Beautiful. That is crystal clear. You will listen if you're load load the people are me. Oh, what's your treatment? I always say load the blood patient. Just do that. Start off with and get them back and listen to them. I would always say that we're not going to change the paradigm where somebody's gonna come in and get an antiinflammatory rest. Absolutely not.
Jared Powell (29:57):
I'm, I'm fascinated you talked about that interleukin study, uh, a moment ago. How much can you speak about that, Neil? Is it
Neal Millar (30:03):
All sort? Yeah, so we can, that's in, that's in revision for, uh, public hit. So I presented that so I can talk a bit, I can talk a bit about that. That was, I mean you, you look in the, in the tender world, we have to be a bit braver than what we've been and we have to take risks. And that trial was risky and it actually, it never met its primary outcome. So you could argue that we failed and I would argue that we're not failing. We're probably not doing it right anyway. But in a group, so that was 96, that was three and 33 patients screened, two, three US sites, Glasgows the main UK site, and then we three EU sites. We had 96 patients. So 49 in the aisle, L 17 arm and whatever in the, in the placebo arm. And the placebo was injection of sailing into the stomach.
Neal Millar (30:48):
And when you looked at all those patients, I can't show you the grass, but basically the grass showed no difference in all comers. And what I always love and I always show is the patients got significantly better when they were injected with seal into their stomach. Okay? So this is, you know, this is where the conundrum with tendon comes. You know, they were given a loading program, the moon protocol for cough, they'd failed physiotherapy, they'd failed nonsteroidals, they were allowed to have had two injections. So these were the patients who, you know, were going to have a, a pointless subro compression if they saw an orthopedic surgeon. But, but when we looked again at those, and the reason we probably did failed its primary outcome is it's the first time we'd ever done a trial like that. Huge investment. I mean Novartis the drug company, this is millions of dollars of investment and we learned a lot.
Neal Millar (31:41):
And when we re reanalyze the data, we took the tact that actually the, the patients that had high or dysregulated i l 17 in my patient cohort biopsies were always early patients. It wasn't late patients. So we then went back in and said, right, if the, if the patient's symptoms are less than six months and they're really bloody sore, how does that look in the analysis? And we, we did this at various time points and we find that there was clear separation in the early patients. So less than six months of symptoms and who are really probably a vast score of around six or seven, really pretty painful. And therefore that has led to that trial will now go to, there's a phase three starting in later this year, which I'll lead. And that's a four six patient worldwide trial in that subset of patients to use 17 for recalcitrant cough tend.
Neal Millar (32:38):
And at look, that's where the field needs to go to challenge and change. And it is a bit, I would say we had only two most, uh, musculoskeletal tra clinical trials, whether it be away or 10, you normally have a dropout rate of about 20, you know, 20%. Cause patients get annoyed with forms. I only two patients in that trial were, were dropouts. And if you spoke to all the patients, they loved the fact that it didn't disrupt their life. They came for their injection, they did their physio, they didn't have to take time off for surgery. So actually we, and when you looked at the graph, when you looked at this subset, you know why those patients got better. Uh, you, you know, it wasn't, they improved their pain, their psychosocial, their emotional skill improved, their workplace improved and their lifestyle improved. Which shows us that. And we know that drug works in those areas and inflammation does work, remember in the brain, et cetera. And um, so that's how it shows you the areas we probably need to treat moving forward with inflammatory mechanisms are around the patient, you know, as a whole, rather than just thinking we have to make their pain there.
Jared Powell (33:46):
Did the saline group get an improvement in the psychoemotional or psychosocial,
Neal Millar (33:51):
Uh, wells when you sub subgroup it? No they didn't. No. Okay. So that's an interest, you know, so there's a lot to, there's a lot to pick apart in that trial and we will, we, that is, that will be published over the next couple of months. Um, and that, uh, should be in nature communication. So I'll, um, that should come out later. And it's an, I find it fascinating. I find the placebo response fascinating, um, in, in tendon as well. But you know, one of the pre questions you'd ask and what we might talk about also is structure is that we never, that this paradigm that we never see sometimes in tries a structure improvement, but the patient gets better. And where are we going with that? I think we, we do need to probably demonstrate structural improvement with some of these newer therapies so that we can, um, show patients and demonstrate, right, here's a defect in your tendon, we are improving it and therefore you can, we can up your load or we can do this and, and physically be able to show them.
Neal Millar (34:49):
Cause I think a lot of it is psychosocial in that you're not gonna harm this tendon. It is getting better. Here's how we're going to do that. It's not more drug, the drug is done this now, but you are going to now with this improved structure, be able to load it back to, you know, get your 10 and health back to 80 90% and then, and the overall improve. So I'm a big, we had a, we had a discussion about this few key opinion leaders in, in Dallas and really we felt that we as a field probably need to start focus a bit more in structure moving forward in trials to, to figure, to help figure that out and help people. And, and so we're, we're going to try and do that a little bit more in in in future trials to sort of, so,
Jared Powell (35:33):
So so do you think that's, sorry mate, do you think that's important from a, from a patient confidence perspective or do you think improving the structure will improve clinical outcomes because the structure is better?
Neal Millar (35:44):
I think it's both. I think it's both. But you need to, we need to connect with a, we need to show the patient some benefits, some physical. If you, you know, if you look, if you take a, a rheumatoid patient who's having a flare of a joint and you give them, uh, e NF or one of the newer aisle, you know, 17 blockers and they come back to your clinic in six, six weeks, they'll have an all rheumatologists care about now is structure. So they have flipped completely. They want to see an MRI improvement in the structure of that joint of the, of the cartilage or the less synovitis so that they know they're getting the patient into remission so that their lifestyle will improve, they can function and they can get back to work. So rheumatologists treat Pat, you know, this, this paradigm, we don't treat the scan, we treat the patient.
Neal Millar (36:32):
Of course we always treat the patient but they are treating the scan because they know from all trials that are done in, in the concept is that if we improve the structure, the patient will ultimately get better after that. So I, I, I'm toing, I'm debating that in the field at the moment. And my personal opinion is what you said is that if the structure is better, we can actually load it and and give it, get it better. But also physically showing a patient that there's been some improvement in structure, I feel would have a huge influence on their outcome. Mm-hmm. , will we, and just to say to everybody, will we get there? I'm not so sure. I think there's a long way to go with this. So don't, I'm not saying this is imminent around the corner. I think this is, um, this is a long game, but I would hope that we could be like the way rheumatologists are now that we can give a patient and say here's an exercise program, you fail. Here's a drug with an exercise program, here's a scan. It's look how it's improved. Continue with your load management and you'll get there and we get them better and not work for everybody. But that's, that would be an ideal word.
Jared Powell (37:42):
I'll tell you what, it'll make our job a lot easier if I could say let's do this and then we'll verify with imaging down the track, look it's improved by 30%, 50%, there's less inflammatory, blah blah blah in the tendon, blah blah, whatever. We could take a biopsy. There's all these things we could do to quantify the change, right? And then that would feed into that patient beliefs and psychology so much and then incentivize continued exercise, so on
Neal Millar (38:11):
And so yeah, rather than when they come back and they've done their loading program, they're still as mourning as they were when they first presented the clinic. And, and you know, and I would argue, okay, so the comeback and the structures, if the structure's better and patients say, well I'm still painful, but then as you say, you've got a hook to say, well look, you are doing a good job. Your tissue is healing, keep going. And I would argue that those I would agree with you, that would drastically change. I feel patient outcome. Cause they would be incentivized and they would see that loading is in or with plus, minus whatever it's is working. So I'm completely in agreement with you.
Jared Powell (38:47):
Yeah. A anchoring these ethereal concepts of getting better or not to something objective and quantifiable. So important for patients. And I'm I, with recent evidence that's come out, I'm gonna go to the lubar spine for just a minute of like dis herniations that can heal. Sometimes I find someone who comes in with a large disc herniation, I rarely see anything but shoulders. But some, every now and then I'll see a lumbar spine, they'll come in with a, uh, a huge disc herniation. I'll show them some of evidence of healing and that immediately like de threatens that concept of a large dis herniation. Even though it may not happen to them and it may not happen quickly. It's possible, you know? So I think that's a really important point you raised. Cool mate,
Neal Millar (39:30):
Let's go. Yeah,
Jared Powell (39:32):
Let's, uh, let's, we're running outta time. I'm very conscious you've got four, uh, beautiful girls who are banging down the door. Any second to shine? Dad, where's breakfast? But, uh, let's, let's, can we linger for, I'm gonna, I'm gonna leave exercise cause I think exercise is, is kind of obvious it all, it all kinds of works. You can use isometrics, you can use eccentrics, you can use isotonics, you can use plyometrics hopefully in a, in a progressive manner, right? You don't have to do one or the other. Is that correct? Are we happy there?
Neal Millar (39:59):
That is correct. That is, yes, absolutely. We can kneel that one day. Absolutely.
Jared Powell (40:03):
. Love it. So I wanna just go for a little bit with, with imaging, with radiological imaging because that's, that's your wheelhouse. So if somebody comes to you, I'm gonna say with a, an acute obvious mid portion Achilles pain and I'm also gonna say a classic sort of rotated cuff tendonopathy type presentation. The, the cuff one's a bit harder because there's a lot more things you probably have to differentiate diagnose. But the mid portion Achilles will start there. What do you do for imaging?
Neal Millar (40:32):
I don't do anything for imaging at the start. I mean, you know, I work in a different healthcare system, you know, in the nhs patients don't come with a scan, so I would then have to request a scan at the moment that will take a number of weeks. So I I, if it's a button I don't see, I would argue my practice, I don't see many patients like that. Uh, and they're usually sent to me much further down the line. But I, I don't feel imaging is going to, unless there's, can I just remind listeners, unless there's a clinical suspicion that there's some other joint, there's, you know, they've got uveitis or you know, skin psoriasis, don't forget to use Paul and sort of screening eight questions to say am I, I'm I making sure I'm not missing some other important disease here. But if it's classic mid portion, I just, I just tend to get them loaded, see them back in six to eight weeks and then reevaluate.
Neal Millar (41:20):
If at that point they weren't improving them might get Chris to change their loading program. I wouldn't even imagine them at that point. It would need to be 12, 60 weeks down the line. If they were recal, I'd say look, let's get, and I usually get an mr cause that's quicker at the moment for me and I talk the patient through that then. Um, so I'm not a huge, although I like imaging, I'm not a huge fan of everybody getting an image. Now if you go to the states or Australia, patients walk in with it, you know, an MR and say look, you know, so, um, but we just don't have the capacity here and, and personally I don't see that it adds much to those early patients. Absolutely. In later more complex patients it's very important. But not in those early patients.
Jared Powell (42:03):
Agree. I think it'll be a waste of resources initially. So what about, let's go to the shoulder, let's go to the upper limb. What's your, and I'm, I know there's not prescriptive, I know there's not an algorithm, but like the classic patient who comes in, you're pretty sure there's no red flags based on their signs, symptoms and history and you're an expert. What would you do for imaging? Would you just shelve it or would you go for
Neal Millar (42:25):
It? I, I, again, I just, I mean I get standard x-rays of the shoulder every time because I think actually you can, you know, it's underappreciated what you can, you know, you can diagnose cuff tendinopathy on, on x-ray, you can, you know, it can give you a pointer sclerosis on the, but change the GT mag, the GT and you might see some actually time. So I get standard x-rays and cuff tend, there's no way I'm at that point they're getting an exercise program and they're back to see me in probably about eight to 12 weeks just the way I have to work. And then I would probably add in, if they came back, I'd probably add g I tend to add gtn quite early. Cause look, there is a, there is a placebo element to that, but it's a hook to say to the patient, you're not responding this. Let's change up the loading and let's add this adjunct in. Which may work the flip of a coin if you look at the stats. Ok, so it might work for you, it might not, right? Um, and then I would see that, so
Jared Powell (43:21):
JTN is Gly Trina,
Neal Millar (43:23):
Sorry, glycerol Trina, five mil, usually a five milligram patch cut into half that was pioneered by uh, George Morrell in Sydney. And I think is underutilized. I think it's underutilized to be frank. Cause nobody made any money in the tender words. So that's, that's to be brutally honest, but it's a great, it was the first real translational story and I use it quite a bit in my practice. And if, if it's a placebo effect, I don't really care because it's not harming the patient. One in 20 patients might get a headache. It's very safe and that's utilizing probably the placebo response. But we probably should use that a bit more. And then down the line I might, I, I would usually get, if it's uh, you know, usually an sometimes ultrasound, I'm not really, it just depends what's quicker at the time. And then I do the only area, I still sometimes use an injection, albeit I was part of the, I was the on the grass trial, it helps me figure out what's happening with the patient.
Neal Millar (44:21):
Um, but I use it sparingly. I do use shock wave again down the line. If they're, and that's normally six to nine months down the line. If they're not not improving, I may consider that. Although there's not a wealth of evidence and then you're into the crappy position when you get to be a surgeon. When people come and say, well, you know, I've tried all this, this and this and you know, there is, could you not just do chemo surgery? And then you're like, well, surgery doesn't really work and oh, but I still want, so I sort of make a deal with my patients at the start and say along the lines, look, I'm a surgeon, I like to operate every Monday, but I I ain't gonna operate on you for at least a year if you don't have a tear of the tear cuff here.
Neal Millar (45:03):
And when you're imaging coming, you know, eventually I say, there's no chance you're going to get me, you'll have to get second opinion because it's just not something I would, I think is, is correct. I then discuss with them after a year, if they're still coming back and want to kill me, then sometimes I will operate and you know, you can't again argue against the placebo effect of al decompression because the, you know, the seesaw tried, showed scope of somebody's shoulder and wiggle it around. There's a huge placebo effect in that. As long as you're truthful, honest, open with your patient and describe that placebo effect and the risks and complications of surgery. Is that, I would argue is that really a bad way to treat a patient? I don't think so because you're, you're, it's a journey with them and you're listening to them and you're informing them. I think doing an operation in the first three months is a little information cause you're gonna earn a couple thousand dollars. Yeah, I think that's wrong. Mm-hmm. So, um, that's my, no, but I agree with you. Cuff is, you know, cuff is the huge challenge of 10 because it is not the same as Achilles. It's not same as, you know, it, it's hard. It's mul more multifactorial and you know, partial fitness tears. How do we, you know, we could go on all day. Yeah. But that's my sort of, that's where I sit on that
Jared Powell (46:19):
And then you get to the subscap and the bicep, it all gets a bit, a bit tricky. Yeah. Super. Is it Alright, I can handle that. So I I I I agree with your stepped approach, basically exercise. If that doesn't work, gtn maybe an injection, maybe shock wave maybe here and then a full 12 months later you would entertain the idea of a subacromial decompression. I think that's totally fair because, you know, exercise doesn't help everybody. There's, it's like 40 to 50% of people fail to improve after six months with exercise, right? So what do we do with half of the population? There has to be some sort of backup on,
Neal Millar (46:55):
And you have to, you know, this is the other thing with pragmatic trialing. You know, people love at the moment to say that orthopedic surgery is crap. They love to show that. Having, you know, there's a few investigators in Australia who like to say that, you know, a knee scope is never gonna work for, you know, tear. But that isn't, that is a trialing reality in maybe five to 600 patients. The real world that we sit in the real world. I sit here in Glasgow and I see socioeconomic deprived patients who patients will, a subset of those patients with a surgery will get better. All we need to maybe appreciate is not be so dismissive. We've sort of gone the other way with orthopedic surgery at the moment. We're so dismissive that, but we shouldn't be as long as the patient has is getting a procedure at the right time. After, as you say, when everything else is failed rather than getting it maybe at the start. I completely agree, but it, it pains me a little bit at the moment that larger journals, for example, love to take studies that show a knee scope, a shoulder scope, something, you know, a decompression doesn't work and they roll with that and they get media and everybody goes, ah, orthopedic surgeon, they just a lot of cash. They do. But maybe it's just that the pathways that we get to surgery need to be better defined. I think so.
Jared Powell (48:16):
Neal Millar (48:17):
A I'm stop my run. I'll stop my run now I'm gonna stop. Right.
Jared Powell (48:20):
The, the, the orthopedic society of, of, uh, the UK is not gonna kick you out just yet. You've, you've made your defense like it. No, but there, there is a place for that because there has to be, we can't just sit on our, because mate, if we were gonna police exercise often exercise doesn't outperform placebo as well. So everything it has has its own sort of, um, shortcomings, right?
Neal Millar (48:42):
Yeah, yeah. Agreed. Agreed.
Jared Powell (48:44):
Oh mate, I'm gonna let you go. You've gotta go and make breakfast. I don't know what you, hopefully yes, I've got, I've got
Neal Millar (48:48):
Four. I've got four. Four for lunches and breakfasts to me. Listen, thank you. I hope, um, that's been helpful in some way. It's been great. This is very good fun.
Jared Powell (48:58):
I wish we had two hours. There's a lot more. I wanna,
Neal Millar (49:00):
I think we would need a half a day. Really
Jared Powell (49:04):
, where can people find you? And I'm certainly gonna direct people to a lot of you work. Where can people find you on the social?
Neal Millar (49:08):
So, um, Twitter is at tendon Glasgow. Um, I'm also the university, uh, website, but I mostly, you know, Twitter's quite good. Cause that's where I sort of, any papers that come along, anything we highlight, maybe I've have a rant a certain day I might do that, although I try to keep that to minimum. So, and I'm more than happy if anybody just wants to email me. It's, uh, Neil n e l Miller ar Glasgow uk. Look, I, I think the only way tendon research is going to get better, I'm gonna finish in this, is to say that from what I've learned in my career is collaboration is key. You need to speak to physios, you need to speak to sports physicians, and you need to get outta your siloed of, I only do this because if you do that and collaborate, your patient will get better, you'll learn more, you'll be more enthused and you'll, as I say, you're patient at the end of that, you're sitting in your room will get better treatment. So collaboration is key in my world.
Jared Powell (50:08):
A lovely way to finish. Naomi Miller, thank you very much.
Neal Millar (50:11):
No problem. Thanks Tara.
Jared Powell (50:15):
Thank you for listening to this episode of the Shoulder Physio podcast with Neil Miller. If you want more information about today's episode, check out our show [email protected]. If you liked what you heard today, don't forget to follow and subscribe on your podcast player of choice and leave a rating or review. It really helps the show reach more people. Thanks for listening. I'll chat to you soon. The Shoulder Physio Podcast would like to acknowledge that this episode was recorded from the lands of the LAN people. I also acknowledged the traditional custodians of the lands on which each of you are living, learning, and working from every day. I pay my respects to elders past, present, and emerging, and celebrate the diversity of Aboriginal and Torres Strait Islander peoples and their ongoing cultures and connections to the lands and waters of Australia.