3. Preserving the Hip with Orthopedic Surgeon, Joel Wells, M.D.

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00:00:00 

Jennifer Milner 

Welcome to bendy bodies with the hypermobility MD. This is Jennifer Milner, your guest cohost, Dr. Bluestein  and I are so thrilled to have Dr. Joel Wells as our guest today. Dr. Wells is an assistant professor in the  department of orthopedic surgery and a comprehensive hip surgeon at UT Southwestern. He sees patients at the  sports medicine clinic at Richardson Plano, and is also the medical director for miles for hips, an organization  that supports the international hip dysplasia Institute. Dr. Wells had two wishes growing up to play professional  baseball and attend Tulane university school of medicine. He was drafted by the New York Mets, his senior year  at Abilene Christian university, and also accepted to Tulane being more excited about being accepted to Tulane.  He made the decision to choose a medical school over baseball. Dr. Wells followed his passion and earned his  medical degree at Tulane university followed by an internship in surgery at the Brigham and women's hospital  and a residency in orthopedic surgery at Harvard orthopedics and Massachusetts general hospital. 

00:01:05 

Jennifer Milner 

He then received advanced training in joint preservation, resurfacing, and reconstructive surgery through a  fellowship at Washington university in St. Louis in recent years. Dr. Wells has received numerous honors and  awards most recently being selected as the young alumnus of the year for Abilene Christian university,  

00:01:36 

Joel Wells 

Dr. Wells.  

00:01:37 

Jennifer Milner 

Hello, and welcome to bendy bodies.  

00:01:40 

Joel Wells 

Hello, and thank you so much for this opportunity. Thank you very much.  

00:01:44 

Jennifer Milner 

We are so glad to have you here today because we know that hip issues are very common in dancers with hypermobility, but first I would love to know what got you to this point to being the specialist. What led you to  where you are today?  

00:01:57 

Joel Wells 

Well, thank you, Jan and Linda so much for this opportunity and, of course, and Jen, you kind of outlined it very  nicely and that, I specialize in hips and how did I come to, being a loving hips and wanting to help patients with  hip disorders? Well, you've outlined it nicely that I was an athlete. I grew up, being very athletic and, training to  

be the best at things. And, as I went through my training, I, I love the anatomy of the hip. I love the pathology,  and I also loved the patients that had hip pathology, and that's why I chose, hip surgery, but also the big, portion  of hip surgery is also a non-operative care for patients with hip disorders. I think that's very important, but I love  the cradle to grave hip issues from patients with, pediatric hips, as well as sports hips and dancer's hips.  

00:02:58 

Joel Wells 

That can go wrong with the hips and also the elderly. I like being able to focus one joint because it is so  complex and we are still learning about the hip.  

00:03:10 

Jennifer Milner 

Absolutely. Tell us about what you do specifically and how that's different than what a typical hip doctor might  do.  

00:03:20 

Joel Wells 

So, historically, most orthopedic surgeons are somewhat, a sports focus, pediatric focused or joint replacement  focused. I think, a newer, upcoming an orthopedics is, a joint specific focused, specialty in what I do in  orthopedics. I actually have clinic tomorrow at Texas gutters, right? I do, patients that are younger with hip  pathology before they need a hip replacement. I go to everything that's in between. Knowing what can go wrong  with a hip and trying to preserve it's very important. What's near and dear to my heart is trying to prevent hip  pathology before it presents with arthritis. Of course, arthritis, once we know that a patient has a in stage  arthritis, the treatment is a total hip, but my goal is trying to prevent that. I think it's very important to  understand that a lot of pathologies that lead to arthritis can be prevented because there's a mechanical reason  why hips wear out.  

00:04:30 

Jennifer Milner 

That makes a lot of sense. Now having been a dancer and having gone through my dance career in the nineties  and into the early two thousands, I think the first time that I heard the phrase a hip preservationist was meeting  you and talking to you about it. It seems like a relatively new approach in the field. Is that fair to say,  

00:04:52 

Joel Wells 

It's, it's extremely new and it's actually, it's very new to actually be so kind of not super specialized in medical  school. You, you kind of learn about everything. When you're learning about that, you feel like, a lot about  everything, but once you learn about something so specific, you understand how little you knew. I think that's  very important in the hip and that we know really so little about hip preservation. We know certain factors in  certain, deformities that will lead to arthritis, but can we really preserve a hip is still being investigated. As we  learn more about the anatomy of the hip and the blood supply of the hip, we can treat these deformities and  hopefully preserve them.  

00:05:49 

Jennifer Milner 

That's so interesting. Rather than trying to improve the hip replacements down the line, we're trying to get to the  point where we don't even need the hip,  

00:05:58 

Joel Wells 

But, well, yes, that's the ultimate goal and that's something I'm fighting every single day, especially with  industry because, with industry, hip replacements are very important, right? They're a big portion of industry, especially in orthopedics and joint replacements are a big part of basically revenue for certain companies and  preserving a hip kind of prevents that in a way you are going against mainstream advice, trying to preserve  something.  

00:06:28 

Jennifer Milner 

Yeah. I could see that I could see how that would be different or maybe not the first approach that some people  would want to take. I've also seen, with the hips and the trends with it. I mean, labral tears were not even an  issue that people would deal with 20 years ago. Even that in itself has come so far. It used to be from my point  of view, just as a dancer, it used to be a much bigger idea of, well, it's either this or it's this, and now there are so  many smaller things in between that can be done. That's not quite so drastic and not quite so big. Now moving  to what you're hoping for, which is not even needing to do anything because we're working preemptively on it.  

00:07:11 

Joel Wells 

I think that's the most important part having a, basically a focus team for these dancers or whomever, for their  hip pathology. I'm just one piece of the puzzle, but, I'm also, an important piece of the puzzle in order to guide  them in the right direction. Just like Yoojin we work together.  

00:07:30 

Jennifer Milner 

Yes, absolutely. Now you do see a fair number of dancers, and they do have a high rate of hip dysplasia. Can  you explain first to our listeners what hip dysplasia is and why there is a higher prevalence amongst dancers?  

00:07:45 

Joel Wells 

Yeah. So, hip dysplasia is something I love and I have, basically, one and two, my research and everything that I  do is basically, for hip dysplasia and hit impingement. Why is that? Well, number one, because those two  pathologies, whether it's femoroacetabular impingement or hip dysplasia are the number one reasons that we  have hip pain and lead to arthritis. Hip dysplasia in a nutshell is basically a shallower hip socket. I know some of  our listeners are somewhat will say, Hey, well, my German shepherd or golden retriever had hip dysplasia. It's  actually very similar because these breeds have a genetic predisposition to a shallower hip socket. What does  that do? It means it's something so simple having a shallower hip socket, but what does it do? It leads to a barren  path of mechanics to the hip, and it can lead to early degeneration. Why? Because the mechanics of the hip are  off and the hip is a pure ball and socket joint.  

00:08:57 

Joel Wells 

If it's not a ball or a socket, then the cartilage is at a disadvantage because of mechanics. And so it's a properly  formed socket. Hip dysplasia in a nutshell is a shallower hip socket. There are a lot of varieties that, that I study  and everything, but basically when you have a misshapen femoral socket, it can lead to earlier arthritis because  of the mechanics.  

00:09:27 

Jennifer Milner 

Okay. Why do you see that more in dancers.  

00:09:31 

Joel Wells 

We'll hit? So the hip range of motion, I like to use the term Goldilocks. It's kind of like the perfect scenario. If  you have too little coverage, then you have excessive motion because you have an excess motion before you  impinge. On the other side of the joint, think of a ball and socket joint, like a baseball and a glove. If you have a  very shallow buddies ball glove, such as a catcher's Mitt, you have more area to catch that ball. Whereas if you  have a, a outfielders glove, it's, there's a lot of room and that you can easily hit on that leather, the similar, aspect  to the hip. The hip joint, if you have a very shallow socket, you have much more range of motion before one  bone, the femur bone it's against the acetabulum bone, and this can lead to impingement, well, dancers need  excessive motion because it's an amazing sport that requires that.  

00:10:34

Joel Wells 

Patients with hip dysplasia often have excessive motion because that's what their anatomy will allow them to do.  

00:10:42 

Jennifer Milner 

I see. It sounds like you're saying that hip dysplasia in general can lend itself to a more aesthetically pleasing  dancer. Yes.  

00:10:54 

Joel Wells 

It, it can lead to more aesthetically pleasing dancer that is able to do things that other dancers can not, but at the  same time, is that a, a healthy hip or is that a hip that will stay pain-free that's another question.  

00:11:10 

Jennifer Milner 

Right. We see it more commonly in dancers because it contributes to the aesthetic of dance, but that doesn't  necessarily mean that they're going to be healthier or have a longer career because of that. Exactly. Yes. Perfect.  Do you see more hypermobility in your dance patients like hypermobility in general in your dance patients than  in the general population?  

00:11:33 

Joel Wells 

Well, so that's a great question, Jen. To be honest with you, I probably see more hypermobile patients in with hip pathology, not just dancers and all hip pathology. Oh, interesting. I definitely think that dancers have a sub group of hypermobility, which is somewhat helpful the one time, but it's kind of a balance. We talked about that  kind of Goldilocks, but, I definitely see, a lot of hypermobile patients. Every single patient I see, I am testing for  hypermobility.  

00:12:07 

Jennifer Milner 

Interesting. It seems that the percentage of hypermobile people you see is probably higher than the percentage of  hypermobile people in the general population.  

00:12:18 

Joel Wells 

I completely agree with that. That's something that needs to be studied, which I am, because I am truly  fascinated about it.  

00:12:26 

Jennifer Milner 

Oh, that's so interesting. I can't wait to see what you find out. How does hypermobility change, how you might  approach an issue?  

00:12:34 

Joel Wells 

Yeah. The thing is, all too often, we get to, especially as orthopedic surgeons or any provider, we get focused  one area, one pathology. So, I, I see a lot of patients that are sent to me that, have quote unquote, normal  radiographs, but their hips for the most part are unstable in my opinion, because of their hypermobility. No one  really took the time to check, how they are actually hyper mobile, their Beighton score and a patient, especially  a dancer that is having hip discomfort that has normal radiographs should always be screened for hypermobility.  

00:13:20 

Jennifer Milner 

Do you see a fair amount of people with hypermobility that goes more extreme, like to, connective tissue  disorders like EDS or Marfan or that thing.  

00:13:32 

Joel Wells 

I do. I do. I have a close relationship with, genetics here at UT Southwestern, as well as my mother-in-law is a  geneticist and we have, we both have a very keen, interest in hyper-local patients because what's unique about joints, whether it's a shoulder or the hip or the knee, is that excessive motion in a joint causes pain, despite  radiographic evidence of anything wrong with that. That's because of excessive motion and soft tissue and  ligamentous laxity is a very important part of joint health.  

00:14:16 

Jennifer Milner 

I know that you are a surgeon, but I also know from working with you that you do not always jump to surgery as  the first solution. What informs your cautious approach and what has brought you to that point?  

00:14:32 

Joel Wells 

Well, everything I do, I try to be very evidence-based right. My goal is my research is looking at outcomes,  right? And so, there are things that I know when I see a radiographically or an exam that I know will definitely  lead to some degeneration or some, significant pathology that I can correct. If I see one of those, then of course I  let the patient and their family know, but there are a lot of things that are somewhat in-between that we're not  fully sure, like these patients are symptomatic at an early age yet the long-term studies that we know do not  necessarily mean that they're going to end up with in-stage arthritis or significant pathology that at this stage I  can treat. In my heart, I have a very hard time putting through a patient, through a surgery that, may help, but  may not help. I definitely think that, understanding a patient's hip pathology, whether it be treating them  surgically or non-surgically is the most important.  

00:15:45 

Joel Wells 

I think the most important part of my job is educating patients about their hip mechanics, their pathology, their  kinematics, and what can go wrong if we don't correct these.  

00:15:59 

Jennifer Milner 

Yes. Well, and you said earlier, that there's so much about the hip that we still don't know. I have seen so many  hip surgeries that have complications further down the line with dancers, with hypermobility, we have scarring  issues the way we regrow can be different. There are so many complications that you don't necessarily anticipate  just from injections or doing surgeries, you try to fix one thing and then it ends up causing complications with  another. I would think that would also be part of the decision-making process of, do we want to start a chain  reaction here if we don't have to,  

00:16:39 

Joel Wells 

You couldn't have said it better. That that is phenomenal because, every action has a reaction. Whether it's a w  whether it's as simple intervention as an injection, which is not benign to a surgical intervention, which is  exceptionally not benign, they can have these downstream effects that these, especially in these patients that I  see that are very young, is that you don't want to start them on the kind of downward spiral to, having chronic  pain or other issues just because of this initial inciting events. That's why I think number one is starting with the  education with these patients, because every treatment that we do is important yet has some risk. At the same  time, we have to let patients and their families know what we're treating, and it should be a shared decision  making process.  

00:17:41 

Jennifer Milner 

Absolutely. Trying to look further than being well enough to do this Nutcracker, but trying to see what we can  do to the next seven.  

00:17:50 

Linda Bluestein 

Nutcrackers.  

00:17:51 

Joel Wells 

Exactly. Yes. So, it's dancing is such a phenomenal sport and I love it, and I love the patients because they are,  dancers, it, they are true athletes, my opinion, and, almost to a fault. So, helping these patients understand that, getting them through, not just the, like you said, the first Netcracker, but my goal is to have them having a long,  professional career is the most important, not just getting them to the next one.  

00:18:25 

Linda Bluestein 

Absolutely. That's fantastic. So it's post dance also, right. That we want to make sure that people can be as  functional as they possibly can be. And so, Dr. Wells, you are a hip specialist as opposed to a general orthopedic  surgeon and what things would be make a, a dancer seek out a specialist, that's doing, more specific things like  you are. Yeah.  

00:18:50 

Joel Wells 

So, basically, as we're becoming so advanced with medicine, we're becoming a nation of specialists, and I think  that is really important, but at the same time, we can't lose our generalists to be kind of the go-to for certain  things. For me, I, I, I honestly, I see the majority of my patients, of course, I'm happy to see anyone, but I see  almost all, any hip pathology. Then, 95% of the patients I see have hip pathology. I think that's really important  because, seeing a generalist, yes, they can triage things, but, no knowing the nuances is very difficult. And, and  as I teach residents and medical students, I, I don't expect them to know the nuances. This is something that you  need to learn and it takes time. Having a generalist, whether it's a hip preservation specialist or a hip specialist,  or a shoulder specialist is really important when it comes to our super specialized patients.  

00:19:59 

Linda Bluestein 

Are there ways that people can find some, hip preservation specialists like yourself, if they're not in your area or  are not able to travel to come see you, a lot of people have difficulty sitting when they have, I start developing  problems with their hips and that kind of thing. So, is there, do you have any suggestions for how somebody  could find someone that would have, a mindset at least on the same track as yours? Because I think that's a  fantastic approach to be not thinking surgery as a earlier step in is absolutely necessary.  

00:20:31 

Joel Wells 

That's phenomenal. That's the kind of, besides the dysplasia, that's my other very important things that I want to  help with is that, there are a few kind of go-to places that we have, whether it's, international hip Institute or, the  internet is really important and finding physicians. I think it's, it has a, a great wealth of knowledge at the same  time. You have to take it with a grain of salt. I think it's very important that as us as physicians, really my goal is  to show what outcomes and kind of what research is important that should be publicly noted. Something that's  near and dear to me is actually publishing, live, outcomes on whether it's social media or on your webpage on,  treatment options. That's caught with often some controversy and also some debate. I definitely think when we  look for a restaurant to eat at or a mechanic, there are a lot of options on the internet to find a ratings and things  like that, currently ratings of physicians or outcomes, and what they do is very oblivious and it's very difficult  for patients.  

00:21:54 

Joel Wells 

I think having a go-to website, whether it's an unpaid should be an unbiased, a website, because medical  knowledge is very different that patients can go to help find help wherever their provider may be. That's  something that's, that, I am working on. Correct.  

00:22:13 

Linda Bluestein 

That's really fabulous. I think you said that really well, that we can get so much information before we go to a  restaurant. Now, obviously we have to take any of these things with a grain of salt, but something is critically  important. I have patients that are young and have had already multiple hip surgeries and they're not doing well.  I mean, if they're coming to see me for pain management, they're probably not doing well, and maybe they did  need the surgeries, but it seems like in a number of cases that they perhaps could have maybe had a different  outcome, at least, so far. So.  

00:22:47 

Joel Wells 

If that was, not just, on social media or, opinion, but if that actual outcome, how that patient was, objectively doing was published in easily knowledgeable, then I definitely think patients would benefit. That is not currently  being done basically anywhere in my life.  

00:23:12 

Linda Bluestein 

Right. Right. Absolutely. I mean, if we had more of a value based medical system where you looked at the  outcomes relative to the cost, right. That would be, I know Dr. Michael Porter talks about this a lot, that whether  it's a center of excellence for headaches or hips or anything else that if you look at outcomes and what did it cost  to get that outcome, that would be such a great way to actually do our healthcare, but that's unfortunately not  how we're doing it right now. Okay.  

00:23:40 

Joel Wells 

Not even cost. Right. So, like, it's, I think more on outcome and so costs can be skewed because you can make  things cheaper and you can make a patient's popery possibly do better, short term. But, I hate to use the baseball  analogy. Of course I was a baseball player, but like, I did not get a scholarship or paid to strike out. Right. But  healthcare is very different. I get paid, honestly, I get paid and rewarded to operate no matter. Right. Absolutely.  I, I think that needs to change and that, no one gets paid to us about, a hundred, you get paid the bat over 300  and do well. We need to define what our outcomes are in order to provide patients a better service.  

00:24:33 

Linda Bluestein 

Definitely. I love that. And, and within the dance world, have you seen changes that make you concerned and  are there changes that you would like to see happen in the dance world?  

00:24:44 

Joel Wells 

Yeah. So, I, I think the biggest thing is that in the dance world, especially in hip pathology, is that we now can,  safely get to the hip. When I say safely, I mean, not the story, neurovascular structures, but it doesn't mean  patients do well. I see a lot more of patients getting scoped early on very quickly, whether their hip or other  joints are being operated on just because they have a possible pathology, but it may not be their underlying,  diagnosis. In the hip world, I see a lot of patients, basically going into surgery to quickly, in my opinion, without  really exhausting, without really that knowledge of their, joint pathology.  

00:25:35 

Linda Bluestein 

That makes sense. And, and what advice would you give to hypermobile dancers as they try to stay healthy in  their own career?  

00:25:45 

Joel Wells 

Yeah. I love that question. And, the advice I would give is one, I want every single one of my patients to  continue to dance if they can. Right. But, at the same time I would never tell them to one stop dancing, but to  understanding their hip in and understanding their joints and trying to, be a better, to strengthen their hips in  order to be a better dancer or the strength in their joints. So, dancing is so much more, a strength is it is a range  of motion. These patients often kind of lack the joint stabilizing, mechanics of their hip or their shoulders or  other joints. Focusing on strengthening, not so much of their range of motion is very important in a balance of  that.  

00:26:39 

Linda Bluestein 

Yeah, yeah. That I know Jen and I both definitely agree and it's so hard because they want the range. They S  they see things on social media and they, real quote unquote reality TV. Right. It's not really reality, but, they  see these things and they think, I want to be able to do that. Whether, I mean, they maybe were hyper mobile,  

they might be hypo mobile. Right. They might have actually less range, but they're going to cause some kind of  injury to themselves because they see other people doing things and they're going to, they try to do it. So it can  definitely be challenging.  

00:27:15 

Joel Wells

Yes, yes. At this time. But, I was an athlete and pushing yourself to the max is part of being an athlete. And  that's why I love dancers. At also the same time you have a coach, right. You have a team to help you get there  in a safe way. Yes.  

00:27:34 

Linda Bluestein 

And, and I would add also that one of the things I like about you and the way that you practice is that you will  consistently send the dancers with hip issues back to their coaches, back to their teachers, to do private work, to  fix their technique and to have them strip it down, step back and make sure that what they're doing right. That  they're strengthening correctly and working in a really safe range. Hearing it from me to tell them to slow down  is one thing, but hearing it from their doctor saying, Hey, let's step back and let's do this. And let's really work  on the basics. Then, two months from now, it's going to be so much better, is so important. That I value that a  doctor will do that and say that to them.  

00:28:20 

Joel Wells 

Yeah. And Jen, and that's so important. Right. I, I'm just one orthopedic surgeon right. In a, in a big  metropolitan city. I have patients that fly in to see me and from all over DFW or elsewhere, they, you don't, you  can't, you discuss with therapist right off there, but what I like to do, I like to give therapist, my email, my  cellphone, so we can at least talk because it is a team effort.  

00:28:49 

Linda Bluestein 

Absolutely. And I that's so important. I totally agree,  

00:28:54 

Joel Wells 

Because you can't just write a script saying hip dysplasia or hip impingement and expect really everyone to be  on the same page. It just doesn't work like that. Patients, specifics, this doesn't work like that. And so every  patient is different. I really feel like every patient, especially in these complex hip patients and this dancers need  focused care. The only way you can do that is really talking one-on-one,  

00:29:22 

Linda Bluestein 

That's fabulous. I love that you share your email address with them. That's, that's fantastic. You just mentioned  impingement again, and I thought if you could maybe, go over, we talked about dysplasia met, you've  mentioned impingement, If you could maybe just explain again about, impingement, labral, tears, arthritis, just.  People understand what some of these different things are, because maybe they've heard these things in their  doctor's office. The doctor has either said, let's do an injection, let's do surgery. If you could maybe explain what  some of those things are and, how people might be able to judge, in addition to what you said about looking at,  does their doctor produce information about outcomes either on social media or in their office, even that they  can ask, Hey, do you have any data that you can share? Can you just explain more about those things?  

00:30:15 

Joel Wells 

Definitely. Linda, thank you. So we'll start with hip impingement. So, to be honest as us orthopedic surgeons,  that we are very, we're very simple, minutes of men and women. So, hip impingement basically means that, the  hip joints, either the femur or the acetabulum is impinging or touching one another. I, I think that too term often  gets used too loosely because even hip dysplasia patients can impinge on certain ranges of motion. Right? So if  you're able to do certain motion activities, and splits, you can pit Nickley and pinch, right. It does not that you  have hip impingement. It, hip impingement is usually, used as femoroacetabular impingement, meaning the  femur in the tablet or the socket side is touching one another. The thing is that touching one another can cause  damage. And you mentioned labral tears. Well, the labor room is basically a, a circle around the acetabulum.  

00:31:30 

Joel Wells 

It's a, it's basically a ring that is lining the acetabulum. It's an extension of the established cartilage and it's it  serves as a bumper or a, a gasket, kind of a washer around the hip. What that does is if you have hinged over  time, repetitive impingement getting one bone against the other can cause, it can cause tears, or pain because of  that impingement. Just because you have a labral tear does not mean you have hip impingement. Just because you are impinging does not mean you have femoroacetabular impingement. It's much more complex, but that,  those are the kind of the simple ways to look at it is that one bone is hitting against the other and a labral tear.  That a portion of the cartilage that surrounds the socket side of the acetabulum, is that is torn or frayed or worn  out because of some process it's causing hip pain.  

00:32:33 

Linda Bluestein 

That makes a lot of sense. I guess one thing that I'm wondering is in your practice over.  

00:32:40 

Jennifer Milner 

This, whatever time period that you want to pick, do you feel like you're seeing more injuries in dancers and  maybe even other athletes as people are pushing themselves harder, their dancers are doing more overstretching  over splits. You know, things like this.  

00:32:58 

Joel Wells 

Well, without a doubt. And, and so, I I'll use, I, I had clinic today and I believe I had a, I, I saw 28 hips. I, I, I,  like I said, I, I purely exclusively say hips and stuff that 48 hips, almost half of them, they were not dancers  necessarily, but they were from either yoga or other, somewhat, highly kind of static stretching activities. And,  the thing is that, every hip is unique to that patient. That's one reason why I love the hip so much because hip  range of motion is inherent to each patient. It, it, there's a lot of factors that go into hip range of motion. It's not  just off tissue, it's just not stretching. It is bony morphology, it's rotation. It's a pelvic tilt and obliquity all that  factors into motion. If one person is trying to mimic another person that, they may not be able to reach, then  they can cause damage to the soft tissue structures in and around the hip.  

00:34:07 

Joel Wells 

To answer your question, people are taught that from the little age when they're in elementary school, that  stretching is the most important part. Well, the hip is very unique. It's very different than the knee or the elbow  where the risk, it's a constrained ball and socket joint.  

00:34:23 

Jennifer Milner 

What my dancers would say to you, and they're 10 and 12 and 14 year old wisdom is, if they maybe not my  dancers because they know better now, but what a lot of dancers would say, if they want to sit in the hyper splits  or the over splits and put their bottom on the floor and put their feet up on a chair, one foot in front and one foot  behind up on chairs, and really sit in that over split, why is that bothering the hip when they're stretching their  hamstrings? What does that stretch have to do with their hips is what they would like to know.  

00:35:00 

Joel Wells 

Exactly. That's why, I, I think, I can talk to patients till I'm blue in the face, but if I show them a model, if I show  them their x-rays, then I, I think they really understand. That's why, the majority of what I do daily is educating  patients. And that's what I love. Right. And it never gets old. I love it so much. It's really showing these patients  that do that, what their hip is doing. And, you can tell them that, but if, unless you show them, they don't  understand. So, I really think that, showing them a model. A lot of these patients that have really complex hips, I  always get advanced imaging. We have a great protocol at UT Southwestern that we've developed a, a low dose  CT scan because all of these patients are actually very young and, radiographs can be, it can be harmful and  throughout their life, well, low dose CT scan, that's just equivalent to a few x-rays can show them a perfect  model of their hip and also help them understand what is going wrong.  

00:36:14 

Linda Bluestein 

Interesting. So, are you saying that you're doing these CT scans when they are actually, doing various different  positionings rather than just, for most of us when we've had a CT or an MRI where we're laying, supine, we're  like laying on our back and we're in a fairly neutral position.  

00:36:31 

Joel Wells

Page 9 of 14 

Episodes have been transcribed to improve accessibility of this information. Our best attempts have been made to ensure accuracy,  however, if you discover a possible error please notify us as soon as possible. 

Transcript for Bendy Bodies Podcast, Episode 3: Preserving the Hip with Orthopedic Surgeon Joel Wells, MD 

Oh man, Leno, you just brought up a huge, awkward topic that I love. CT scans, we're working on that, but so w  we actually, I have a grant research money and everything that we're, I'm actually working closely with the  engineers and they Gates, labs at UT Dallas. We are actually studying these hips with hip impingement and  dysplasia and getting their actually joint mechanics, because problem, what you just brought up is that his CT  scan you're laying down in a CT scanner, right. It doesn't show a functional motion, but right. If you can take a  patient with their actual, physical range of motion, their clinical range of motion, their actual gate data, and then  also their advanced imaging, and you can mesh that all together. You could have a four-dimensional imaging to  actually show them how their hip is working and what's wrong with it. Yes.  

00:37:32 

Joel Wells 

That is a, that is currently underway. It is being done as we speak at UT Southwestern. Wow.  

00:37:41 

Linda Bluestein 

Really fabulous. I mean, whether people are hypermobile or not, it's so much better, if you can get a much more  complete picture like that.  

00:37:49 

Joel Wells 

Yeah. It's so much better to get a complete picture, but also it's so much better to understand one sip pathology,  because these patients are not just a labral tears. They're not just dysplastic patients. They're much more than  that and understanding their four dimensional aspects of their hip is the best way to fully treat them.  

00:38:11 

Linda Bluestein 

Definitely. And, and in addition to that, getting the education and, explaining, showing them this four  dimensional, I mean, that all sounds fantastic. What else can we do as individuals to improve joint health and  help to preserve our own hips?  

00:38:28 

Joel Wells 

So that is joint preservation. It doesn't have to be the shoulder doesn't to be the hip or the knee, but joint  preservation. Honestly, the number one thing you can do for a joint is move it. Okay. Understanding the certain  motions of the hip is important, but a joint in motion stays in motion. It's a fine balance, right? And so patients  often, once they stop an activity or they graduate from high school to college, they may actually become less  active and then their joints actually end up hurting more because it's not moving. So, number one for a healthy  joint, I joined in motion, stays in motion. Number two, understanding the proper motions and mechanics of that  joint is number two. I think, I, I never, I, I, I try to never limit any of my patients into doing things that they love  to do. And so that's my goal.  

00:39:32 

Joel Wells 

Every single day is showing up to work, trying to help patients achieve what they consider their goal in life or  their quality of life. That answer means something different to everyone. It starts with number one joint motion.  There are some supplements and things that we're studying that there are some okay randomized trials that are  okay, for joint health. But the thing is with the hip. I know this is a big one that the hip is that the thing, whether  it's STEM cells or supplements the problem with the hip. What's what I love about the hip is that it's usually  mechanical, right? It's not necessarily biologic. There are some things that I see that are biologic that cause  pathology, but majority of the things are not it's mechanical. It's understanding the mechanics of your hip. And,  if there's significantly, if they're significantly different from the normal population, correcting those mechanics,  then that can provide the better joint health.  

00:40:39 

Jennifer Milner 

Absolutely. I will say also, I was speaking to Lisa Howell about hips. She's a physiotherapist from Australia and  a large, she plays a large role in the dance medicine world as well. She and I were talking about hip specifically  and dancers struggling with turnout and rotation and extension and all these things. She said, she had seen so  many teen dancers who have had x-rays or whatever kind of imaging they've done. They've been told, we'll look  at your pictures. You're never going to get more turnout. You're never going to do this. You're never going to do that. She said, nine times out of, well, 90 times out of 10 95 times out of a hundred, let's say she would look at  them and say, that's just not true. What we're looking at is not biological. We're looking at mechanical, just like  what you just said. There are very few x-rays or images that she would look at and categorically.  

00:41:34 

Linda Bluestein 

Say, Hey, we need to move in a different direction. It's so important to know what they want and to be able to  give them the tools, to try to achieve that and to say, Hey, let's see what the mechanical issues might be that are  going on. So I love that. I love that answer.  

00:41:51 

Joel Wells 

And so that's so true. Jen, and so, honestly, you can't, you can never tell a patient or a dancer what they can and  can't do by a static x-ray so many people do, but an x-ray is a two dimensional representation of a four  dimensional object. You can't, stomp on someone's dreams. You can't tell them that they can't do something just  from a two dimensional representation of a four-dimensional object.  

00:42:24 

Linda Bluestein 

Amen. Are there any guidelines that you can give our listeners in terms of, I'm thinking about labral tears  specifically? is there anything in terms of like, obviously we have the caveat that this is medical information, not  advice, obviously we're speaking to, whoever's listening and cannot provide individual information, but are  there any, in terms of like location of the labral tear, how much of the labor might be torn or, cause I feel like  that's an area of a lot of confusion and when they get a recommendation that yeah, we should go in and clean up  this torn labor, if you can provide any information about that would be fabulous.  

00:43:07 

Joel Wells 

Yeah. Linda, and so number one, I think if anyone is diagnosed with a quote-unquote labral tear that is young in  a dancer, and that wants to continue to dance, I would recommend number one and this is in my practice and I  don't think anyone would actually argue this is that they should see a hip specific physician, whether it's a  physical medicine and rehab orthopedic surgeon, or someone that specializes in hips. That's number one, I think  they should get to someone that understands hips and, can honestly triage them as necessary because, patients  that are young, normal patients, in our age groups that we're talking about should not have labral tears in my  opinion. Just because they may be have radiographic evidence or a radiologist written a labral tear made mean  they may not even have a label here, to be honest with you, they may not have the proper imaging to diagnose  that.  

00:44:16 

Joel Wells 

Two, if they do, it is best to see a specialist. I don't think anyone would argue with that, with regards to, what  should be done with the labral tear, or, w after that, it is much more complex than that. That's why I really think  that, if someone recommends, Hey, you need to have a surgery for this labral tear. It is, it is never bad to have a  second opinion and not, I share even as a surgeon, I often think it is good for patients because that's part of the  educational process, right. Having patients understand their pathology and see, providers that can kind of  helpfully, help educate them. I would also recommend they seek a second opinion if someone recommends  surgery. Lastly, so what are some guidelines for labral tears and things like that. There are some guidelines  currently for femoroacetabular impingement, but I'll tell you that these are, I don't know if you've read many  guideline, studies and things like that.  

00:45:32 

Joel Wells 

These are very basic. Why are they basic? Because I don't know if you've ever sat on a panel trying to create  guidelines for guidelines are very difficult because we always stratify things according to the current literature  and what in space we have. So that's the beginning of this talk. We talked about, this is all fairly new. We do not  have, level one evidence to support a lot of the things we do. That's why I think seeing multiple opinions is  important, but also seeing a specialist that only deals with their hip pathology is very important. So, to answer  your question and not to kind of sidestep it, I think number one, you should see a hip specialist, number two,  you should seek a second opinion or even a third opinion. Lastly, the current, guidelines, although they're great for standard femoroacetabular impingement, they may not pertain to dancers and other kinds of subspecialty  populations.  

00:46:41 

Linda Bluestein 

Okay. That's great. What are some practical steps that, hypermobile dancers can take to increase the longevity of  their career?  

00:46:52 

Joel Wells 

So, I think number one is listening to your hip and listening to your, and so, when things start, you start feeling  something that, I think it's best to be seen sooner than later. Okay. So, I think that's very important in that, you  don't want to be seeing someone after they'd been having pain for four years and now they can't dance and then  

they want to get back to dancing. I think seeing those patients that, four years previously, it's the most important,  because I think that's where the management that's where the changes can.  

00:47:30 

Linda Bluestein 

Occur. Okay. That makes sense. And, and for just people in general, who are interested in more information  about hip preservation, maybe they've had surgery, maybe they haven't had surgery. Are there, do you have any  other advice that you would give those people?  

00:47:48 

Joel Wells 

Yes. I'm actually, we're working on a, I'm a medical director for miles for hips right now, and I've been blessed  with this opportunity. My goal for that is actually to provide unbiased educational area for hip pathology. So,  there are a lot of resources out there. Number one, I think seeing a hip specialist is very important if you're  having a hip pain and then also, working on, international hip dysplasia Institute, as well as miles for hips,  having a safe place for patients to go that is unbiased. Social media is phenomenal, for some news and things,  but, sometimes it comes with a bias. So, my goal with miles for hips, online is to help provide an unbiased, safe  opinion, for patients that they can seek out, whether it's a, a surgeon, whether it's a provider or information,  about their hip.  

00:48:56 

Linda Bluestein 

Fabulous, and anybody can go to the miles for hips. And, we'll have a link on the bendy bodies website, but  anybody can join or participate in those conversations.  

00:49:08 

Joel Wells 

Anyone. Yes, anyone's welcome to join and, w it is building, and it's definitely going to be a great thing, but, the  mission in my opinion is providing good education for patients with hip pains period. And so, an unbiased, safe,  evidence-based, opinion.  

00:49:31 

Linda Bluestein 

Fantastic. You have anything, do you have anything else that you would like to add and can you also let people  know where they can find you?  

00:49:38 

Joel Wells 

Yes. So, I, I just want to one thing that I thank you, Jen and Linda for this amazing opportunity and that, this is,  near and dear to my heart and what I wake up every morning wanting to help. And, and I love, patients with hip  pathology, especially dancers because it is a true sport and I want to help, but to, you can find me, of course you  can Google, Mitchell, Wells MD. I'm very reachable, anytime, and you can find me on social media or my web  

page at UT Southwestern, and then also miles for hips is a great resource. It's a collaboration of, phenomenal  people that, just have a goal of helping patients with hip pathology and that's just miles for hips. Then, lastly,  thank you guys so much again for this opportunity.  

00:50:44

Linda Bluestein 

Oh, so grateful for you being here in the work that you are doing and, being willing to speak with us. It's, it's  absolutely fabulous. Just so everybody knows miles for hips is the number four. It's miles, M I L E S and then  the number four hips. We will have links in the show notes. Everyone will be able to, find you too, to get more  information, because this is such a critically important topic, especially because it affects so many young people.  

00:51:12 

Joel Wells 

Yes. I want to say that all this for miles for hips and everything is completely voluntary, right. I I'm the medical  director, and everyone that's on the board, just only doesn't because, cause they want to help. Right. And we  have no financial incentive. I think that's really important, w when you come to an unbiased opinion.  

00:51:34 

Linda Bluestein 

Absolutely, absolutely. That, that makes perfect sense. We'll thank you so much for coming on today, Dr. Wells,  and, you all have been listening to bendy bodies with the hypermobility MD and today our guest has been Joel  Wells MD orthopedic surgeon, specializing in joint preservation, resurfacing and reconstruction as medical  director of miles for hips. Dr. Wells focuses on prevention, early diagnosis and innovative treatment options to  minimize the longterm impacts of hip dysplasia, check out their website for more information. Please go to  bendy bodies.org for links to some of the research that Dr. Wells has done miles for hips and where he can be  found at UT Southwestern. This podcast is for informational purposes only, and is not a substitute for medical  advice. Please see your own medical team prior to making any changes to your health care. The bendy body  original music is by Andrew Sevino and sound editing was by Rhett Gill.  

00:52:34 

Linda Bluestein 

Thank you for tuning in, and we will see you next time on bendy bodies with the hypermobility and deeds.  Thank you so much, Dr. Wells and our guest co-host today. Jennifer Milner.  

00:52:45 

Joel Wells 

Thank you. Thank you so much.