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

[00:11] Jennifer Milner: Welcome to Bendy Bodies with the Hypermobility MD. This is Jennifer Milner, your guest co-host. 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 medical school over baseball.
[01:01] 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. 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. Dr. Wells, hello and welcome to Bendy Bodies.

[01:48] Joel Wells, M.D: Hello, and thank you so much for this opportunity. Thank you very much.

[01:55] 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?

[02:09] Joel Wells, M.D: Thank you, Jen and Linda, so much for this opportunity. And Jen, you outlined it very nicely in that I specialize in hips. How did I come to loving hips and wanting to help patients with hip disorders? Well, you 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 loved the anatomy of the hip. I love the pathology. And I also love the patients that had hip pathology, and that's why I chose hip surgery.
But also, a big portion of hip surgery is non-operative care for patients with hip disorders, and I think that's very important. I love the cradle-to-grave hip issues — from patients with pediatric hips to sports hips and dancers' hips, everything that can go wrong with the hips, and the elderly as well. I like being able to focus on one joint because it is so complex, and we are still learning about the hip.

[03:22] Jennifer Milner: Absolutely. So tell us a little bit about what you do specifically and how that's different from what a typical hip doctor might do.

[03:32] Joel Wells, M.D: Historically, most orthopedic surgeons are somewhat sports-focused, pediatric-focused, or joint replacement-focused. I think a newer development in orthopedics is a joint-specific focused specialty. What I do in orthopedics — I actually have clinic tomorrow at Texas Scottish Rite — I see patients who are younger with hip pathologies before they need a hip replacement. And then I cover everything in between.
[04:07] Knowing what can go wrong with the hip and trying to preserve it is very important. What's near and dear to my heart is trying to prevent hip pathology before it presents with arthritis. Once we know that a patient has end-stage arthritis, the treatment is a total hip. But my goal is 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.

[04:34] Jennifer Milner: That makes a lot of sense. Now, having been a dancer and having gone through my dance career in the '90s and into the early 2000s, I think the first time I heard the phrase "hip preservationist" was meeting you and talking to you about it. So it seems like a relatively new approach in the field. Is that fair to say?

[05:04] Joel Wells, M.D: It's extremely new. And it's very new to be so super specialized. In medical school, you learn a little bit about everything, and when you're learning about that, you feel like you know 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 — we know really so little about hip preservation.
[05:29] We know certain factors and certain deformities that will lead to arthritis, but whether we can really preserve a hip is still being investigated. All of this began with Dr. Ganz and his PAO, and also his surgical hip dislocation. 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.

[06:01] Jennifer Milner: That's so interesting. So rather than trying to improve hip replacements down the line, we're trying to get to the point where we don't even need them.

[06:09] Joel Wells, M.D: Yes, that's the ultimate goal. And that's something I'm fighting every single day, especially with industry. Hip replacements are very important to industry — they're a big portion of orthopedics revenue for certain companies. Preserving a hip kind of prevents that. In a way, you are going against mainstream advice trying to preserve something.

[06:40] Jennifer Milner: Yeah, I could see how that would be a different or maybe not the first approach some people would want to take. And I've also seen, with the hips and the trends around them — labral tears were not even an issue people would deal with 20 years ago. So even that in itself has come so far. It used to be, from my point of view just as a dancer, a much bigger idea of, well, it's either this or it's that. And now there are so many smaller things in between that can be done that aren't quite so drastic. And now moving to what you're hoping for, which is not even needing to do anything because we're working preemptively on it — I love that idea.

[07:22] Joel Wells, M.D: Exactly. And I think that's the most important part — having a focused 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 you, Jen, we work together.

[07:41] 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?

[07:57] Joel Wells, M.D: Hip dysplasia is something I love, and basically all my research and everything I do is focused on hip dysplasia and hip impingement. Why? Because those two pathologies — whether it's femoroacetabular impingement or hip dysplasia — are the number one reasons we have hip pain and the leading causes of arthritis.
[08:22] Hip dysplasia, in a nutshell, is a shallower hip socket. Some of our listeners may say, "Hey, 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. And what does that do? Something so simple — having a shallower hip socket — leads to aberrant pathomechanics of the hip. It can lead to early degeneration because the mechanics of the hip are off.
[09:03] The hip joint is a pure ball-and-socket joint. If it's not a proper ball or a proper socket, then the cartilage is at a disadvantage because of mechanics. So hip dysplasia, in a nutshell, is a shallower hip socket. There are a lot of varieties, but basically when you have a misshapen socket, it can lead to earlier arthritis because of the mechanics.

Jennifer Milner: Okay. And so why do you see that more in dancers?

[09:37] Joel Wells, M.D: The hip range of motion — I like to use the term Goldilocks. It's the perfect scenario. If you have too little coverage, then you have excessive motion because there's more range 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 baseball glove, such as a catcher's mitt, you have more area to catch that ball. Whereas with an outfielder's glove, there's a lot of room and you can easily hit on that leather.
The hip works similarly. If you have a very shallow socket, you have much more range of motion before the femur hits against the acetabulum. Dancers need that excessive motion because it's an amazing sport that requires it. And patients with hip dysplasia often have excessive motion because that's what their anatomy allows them to do.

[10:53] Jennifer Milner: I see. So it sounds like you're saying that hip dysplasia in general can lend itself to a more aesthetically pleasing dancer?

[11:05] Joel Wells, M.D: It can. It can lead to a more aesthetically pleasing dancer who is able to do things that other dancers cannot. But at the same time, is that a healthy hip? Is that a hip that will stay pain-free? That's another question.

[11:21] Jennifer Milner: Right. So 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.

[11:35] Joel Wells, M.D: Exactly, yes.

[11:37] Jennifer Milner: Do you see more hypermobility in your dance patients than in the general population?

[11:45] Joel Wells, M.D: That's a great question, Jen. To be honest, I probably see more hypermobile patients with hip pathology — not just dancers — across all hip pathology.

[11:55] Jennifer Milner: Oh, interesting.

[11:57] Joel Wells, M.D: I definitely think that dancers have a subgroup of hypermobility, which is somewhat helpful at times, but it's a balance — we talked about that Goldilocks idea. I definitely see a lot of hypermobile patients. Every single patient I see, I am testing for hypermobility.

[12:19] Jennifer Milner: Interesting. So it seems that the percentage of hypermobile people you see is probably higher than the percentage of hypermobile people in the general population.

[12:29] Joel Wells, M.D: I would completely agree with that, and that's something that needs to be studied, which I am doing, because I'm truly fascinated by it.

[12:38] Jennifer Milner: Oh, that's so interesting. I can't wait to see what you find out. So how does hypermobility change how you might approach an issue?

[12:48] Joel Wells, M.D: All too often — especially as orthopedic surgeons or any provider — we get focused on one area, one pathology. I see a lot of patients sent to me who have what are, 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 hypermobile they actually are, their Beighton score. A patient, especially a dancer, who is having hip discomfort and has normal radiographs should always be screened for hypermobility.

[13:31] Jennifer Milner: And do you see a fair amount of people with hypermobility that goes more extreme, like to connective tissue disorders like EDS or Marfan syndrome or that sort of thing?

[13:43] Joel Wells, M.D: I do. I have a close relationship with genetics here at UT Southwestern, and my mother-in-law is also a geneticist. We both have a very keen interest in hypermobile patients because what's unique about joints — whether it's the shoulder, the hip, or the knee — is that excessive motion in a joint causes pain despite a lack of radiographic evidence of anything wrong. And that's because of excessive motion. Soft tissue and ligamentous laxity is a very, very important part of joint health.

[14:21] Jennifer Milner: And 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. So what informs your cautious approach and what has brought you to that point?

[14:45] Joel Wells, M.D: Everything I do, I try to be very evidence-based. My goal is that my research looks at outcomes. There are things that I know when I see radiographically or on exam that will definitely lead to some degeneration or significant pathology that I can correct. If I see one of those, then of course I let the patient and their family know.
[15:17] But there are a lot of things that are somewhat in between that we are not fully sure about. These patients are symptomatic at an early age, yet the long-term studies we have do not necessarily mean they're going to end up with end-stage arthritis or significant pathology that I can treat at this stage. In my heart, I have a very hard time putting a patient through a surgery that may or may not help. I definitely think that understanding a patient's hip pathology — whether treating them surgically or non-surgically — is the most important thing. And so I think the most important part of my job is educating patients about their hip, their hip mechanics, their pathology, their kinematics, and what can go wrong if we don't correct these.

[16:10] 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 — scarring issues, the way tissue regrows can be different. There are so many complications you don't necessarily anticipate, just from injections or from surgeries. You try to fix one thing and it ends up causing complications with another. And I would think that would also be part of the decision-making process — do we want to start a chain reaction here if we don't have to?

[16:50] Joel Wells, M.D: You couldn't have said it better. Every action has a reaction. And whether it's a simple intervention like an injection, which is not benign, or a surgical intervention, which is exceptionally not benign —

[17:10] Jennifer Milner: Right.

[17:10] Joel Wells, M.D: — they can have these downstream effects. Especially with these patients I see who are very young, you don't want to start them on a downward spiral toward chronic pain or other issues just because of this initial inciting event. That's why I think number one is starting with education with these patients, because every treatment we do is important yet carries some risk. We have to let patients and their families know what we're treating, and it should be a shared decision-making process.

[17:53] Jennifer Milner: Absolutely. And trying to look further than being well enough to do this Nutcracker, but trying to see what we can do to do the next seven Nutcrackers.

[18:02] Joel Wells, M.D: Exactly. Dancing is such a phenomenal sport, and I love it, and I love these patients because dancers are true athletes in my opinion — almost to a fault. Helping these patients understand that — getting them through not just the first Nutcracker, like you said, but having a long professional career — that is the most important thing, not just getting them to the next one.

[18:37] Jennifer Milner: Absolutely. That's fantastic.

[18:39] Dr. Linda Bluestein: It's post-dance also, right, that we want to make sure that people can be as functional as they possibly can be. Dr. Wells, you are a hip specialist as opposed to a general orthopedic surgeon. What sort of things would make a dancer seek out a specialist doing more specific work like you are?

[19:04] Joel Wells, M.D: As we're becoming so advanced with medicine, we're becoming a nation of specialists. I think that is really important, but at the same time, we can't lose our generalists as the go-to for certain things. For me, I see almost exclusively hip pathology — about 95% of the patients I see have hip pathology. Seeing a generalist, yes, they can triage things, but knowing the nuances is very difficult. As I teach residents and medical students, I don't expect them to know the nuances — this is something you need to learn and it takes time. Having a specialist, whether it's a hip preservation specialist, a hip specialist, or a shoulder specialist, is really important when it comes to our super-specialized patients.

[20:11] Dr. Linda Bluestein: Are there ways that people can find a hip preservation specialist 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 start developing problems with their hips. Do you have any suggestions for how somebody could find someone who has at least a similar mindset to yours? I think it's a fantastic approach to not thinking of surgery as an earlier step than is absolutely necessary.

[20:43] Joel Wells, M.D: Linda, that's — besides hip dysplasia — my other very important area where I want to help. There are a few go-to places, whether it's the International Hip Dysplasia Institute or the internet, which is really important for finding physicians. It has a great wealth of knowledge, though you have to take it with a grain of salt.
[21:15] I think it's very important that as physicians, my goal is to show what outcomes and what research are important that should be publicly noted. Something near and dear to me is actually publishing live outcomes — whether on social media or on your webpage — on treatment options. That often comes with some controversy and debate. When we look for a restaurant or a mechanic, there are a lot of options on the internet to find ratings. Currently, ratings of physicians or their outcomes are very difficult for patients to find. Having a go-to, unbiased website where patients can find help wherever their provider may be — that is something I am working on currently.

[22:21] Dr. Linda Bluestein: That's really fabulous. I think you said that really well — we can get so much information before we go to a restaurant. Obviously we have to take any of these things with a grain of salt, but with something as critically important as this — I have patients who are young and have already had multiple hip surgeries and are not doing well. 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 they might have had a different outcome. So I'm —

[23:05] Joel Wells, M.D: If that actual outcome — how that patient was doing, what the patient was objectively doing — was published and easily accessible, then I definitely think patients would benefit. And that is not currently being done basically anywhere, in my opinion.

[23:23] Dr. Linda Bluestein: Right, absolutely. If we had more of a value-based medical system where you looked at the outcomes relative to the cost — I know that Dr. Michael Porter talks about this a lot — whether it's a center of excellence for headaches or hips or anything else, looking at outcomes and what it cost to achieve them would be such a great way to deliver healthcare. But that's unfortunately not how we're doing it right now.

Joel Wells, M.D: And not even just cost, right? I think more about outcome. Cost can be skewed because you can make things cheaper and have patients possibly do better short term. I hate to use the baseball analogy, but I was a baseball player — I did not get paid to strike out. But healthcare is very different. I get paid and rewarded to operate no matter what.

[23:50] Dr. Linda Bluestein: Right, right.

[23:52] Jennifer Milner: Absolutely.

[24:22] Joel Wells, M.D: And so that needs to change. No one gets paid to bat a .100. You get paid to bat over .300 and do well. We need to define what our outcomes are in order to provide patients better service.

[24:45] Dr. Linda Bluestein: Definitely. I love that. And within the dance world, have you seen changes that concern you? And are there changes you would like to see happen in the dance world?

[24:56] Jennifer Milner: Yeah.

[24:58] Joel Wells, M.D: I think the biggest thing in the dance world, especially in hip pathology, is that we now can safely get to the hip — and when I say safely, I mean without destroying neurovascular structures. But that doesn't mean patients do well. I see a lot more patients getting scoped early on very quickly, whether their hip or other joints are being operated on, just because they have a possible pathology that may not even be their underlying diagnosis. In the hip world, I see a lot of patients going into surgery too quickly in my opinion, without really exhausting all options and without a thorough knowledge of their joint pathology.

[25:43] Dr. Linda Bluestein: That makes sense. And what advice would you give to hypermobile dancers as they try to stay healthy in their career?

[25:57] Joel Wells, M.D: I love that question. The advice I would give is, one, I want every single one of my patients to continue to dance if they can. But at the same time, I would never tell them to stop dancing without first helping them understand their hip, understand their joints, and try to strengthen their hips in order to be a better dancer. Dancing is so much more about strength than it is about range of motion. These patients often lack the joint-stabilizing mechanics of their hip, shoulders, or other joints. Focusing on strengthening — not so much on range of motion — is very important in maintaining that balance.

[26:51] Dr. Linda Bluestein: Yeah. I know Jen and I both definitely agree. And it's so hard because they want the range. They see things on social media and on quote-unquote reality TV — it's not really reality — and they think, I want to be able to do that. They may be hypermobile, or they may actually be hypomobile and have less range, but they're going to cause some kind of injury to themselves because they see other people doing things and try to copy it. It can definitely be challenging.

[27:26] Jennifer Milner: Yes.

[27:27] Joel Wells, M.D: Yes, but at the same time, I was an athlete, and pushing yourself to the max is part of being an athlete. That's why I love dancers. But you also have a coach and a team to help you get there in a safe way.

[28:46] Jennifer Milner: Yes. And I would add 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 — to have them strip it down, step back, and make sure that what they're doing, they're doing right, so that they're strengthening correctly and working in a really safe range. And 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, let's really work on the basics, and then two months from now it's going to be so much better" — that's so important. I value that a doctor will do that and say that to them.

[29:33] Joel Wells, M.D: Jen, that's so important. I'm just one orthopedic surgeon in a big metropolitan city. When I have patients who fly in from all over DFW or elsewhere, you can't always get to talk directly with their therapist right away. But you know what I like to do? I like to give the therapist my email and my cell phone so we can at least talk, because it is a team effort.

[30:02] Jennifer Milner: Absolutely. And that's so important. I totally agree.

[30:06] Joel Wells, M.D: You can't just write a script saying hip dysplasia or hip impingement and expect everyone to be on the same page. It just doesn't work like that.

[30:15] Jennifer Milner: Right.

[30:16] Joel Wells, M.D: Patient specifics just don't work like that. Every patient is different. I really feel like every patient — especially these complex hip patients and these dancers — needs focused care. And the only way you can do that is really talking one-on-one.

[30:35] Dr. Linda Bluestein: That's fabulous. I love that you share your email address with them. That's fantastic. And you just mentioned impingement again. If you could maybe go over — we talked about dysplasia, you've mentioned impingement — can you explain impingement, labral tears, and arthritis a little bit so people understand what some of these things are? Maybe they've heard these terms in their doctor's office and the doctor has said, let's do an injection, or let's do surgery. If you could explain what some of those things are and how people might be able to judge, in addition to what you said about looking at whether their doctor produces outcome data — can you explain a little bit about those conditions?

[31:28] Joel Wells, M.D: Definitely, Linda, thank you. We'll start with hip impingement. As orthopedic surgeons, we are very simple men and women. Hip impingement basically means that the hip joint — either the femur or the acetabulum — is impinging or touching one another. That term often gets used too loosely, because even hip dysplasia patients can impinge on certain ranges of motion. If you're able to do a full split, you can technically impinge, right? But that does not mean you have hip impingement as a diagnosis.
[32:17] Hip impingement is usually used in the context of femoroacetabular impingement — meaning the femur and the acetabulum, or socket side, are touching one another in a way that causes damage. You mentioned labral tears. The labrum is basically a ring that lines the acetabulum — it's an extension of the acetabular cartilage, and it serves as a bumper or gasket, a washer around the hip. If you impinge over time, repetitive impingement — one bone hitting against the other — can cause tears or pain.
[33:13] Just because you have a labral tear does not mean you have hip impingement. And just because you are impinging does not mean you have femoroacetabular impingement. It's much more complex than that. But the simple way to look at it is that one bone is hitting against the other, and a labral tear means that a portion of the cartilage that surrounds the socket side — the acetabulum — is torn or frayed or worn out because of some process that's causing hip pain.

[33:46] Dr. Linda Bluestein: That makes a lot of sense. And I guess one thing I'm wondering is, over whatever time period you want to pick, do you feel like you're seeing more injuries in dancers and maybe even other athletes as people push themselves harder — more overstretching, oversplits, things like this?

[34:11] Joel Wells, M.D: Without a doubt. I had clinic today and I saw 28 hips. I purely and exclusively see hips, and of those 28, almost half were not necessarily dancers, but they came from yoga or other somewhat highly static stretching activities. And the thing is, every hip is unique to that patient. That's one reason I love the hip so much — hip range of motion is inherent to each patient. There are a lot of factors that go into hip range of motion. It's not just soft tissue. It's not just stretching. It is bony morphology, rotation, pelvic tilt and obliquity — all of that factors into motion.
[35:08] So if one person is trying to mimic another person, they may not be able to reach the same range, and they can cause damage to the soft tissue structures in and around the hip. To answer your question — people are taught from a young age in elementary school that stretching is the most important thing. But the hip is very unique. It's very different from the knee or the elbow or the wrist. It's a constrained ball-and-socket joint.

[35:36] Jennifer Milner: So what my dancers would say to you, in all their 10 and 12 and 14-year-old wisdom — 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 oversplits, put their bottom on the floor with their feet up on chairs one foot in front and one foot behind, and really sit in that oversplit: why is that bothering the hip when they're just stretching their hamstrings? What does that stretch have to do with their hips?

[36:14] Joel Wells, M.D: Exactly. And that's why 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 they really understand. The majority of what I do daily is educating patients about their hip. It never gets old — I love it so much.
[36:40] Showing these patients what their hip is doing in those positions is what makes it real. You can tell them, but unless you show them, they don't understand. I really think that showing them a model is key. For a lot of these patients with complex hips, I always get advanced imaging. We have a great protocol at UT Southwestern — a low-dose CT scan, because all these patients are very young and repeated radiographs can be harmful throughout their life. A low-dose CT scan, equivalent to just a few X-rays, can show them a perfect model of their hip and help them understand what is going wrong.

[37:27] Dr. Linda Bluestein: Interesting. So are you saying that you're doing these CT scans with patients in various different positions, rather than just supine in a fairly neutral position as is typical?

[37:44] Joel Wells, M.D: Oh, Linda, you just brought up a huge topic that I love. Four-dimensional CT scans — we're working on that. I have grant research money and I'm working closely with engineers and the Gait Labs at UT Dallas. We are actually studying hips with impingement and dysplasia and capturing their actual joint mechanics. The problem with a standard CT scan is that you're laying in a scanner — it doesn't show functional motion. But if you can take a patient's actual physical range of motion, their clinical range of motion, their actual gait data, and their advanced imaging, and mesh that all together, you could have a four-dimensional image that actually shows how their hip is working and what's wrong with it. Yes, that is currently underway at UT Southwestern.

[38:53] Dr. Linda Bluestein: Wow, that's really fabulous. Whether people are hypermobile or not, it's so much better if you can get a much more complete picture like that.

[38:57] Joel Wells, M.D: It's so much better to get a complete picture, but also so much better to understand one's hip pathology, because these patients are not just labral tears or just dysplastic patients — they're much more than that. Understanding the four-dimensional aspects of their hip is the best way to fully treat them.

[39:24] Dr. Linda Bluestein: Definitely. And in addition to the education and the four-dimensional imaging — that all sounds fantastic — what else can we do as individuals to improve joint health and help preserve our own hips?

[39:41] Joel Wells, M.D: Hip preservation — that is joint preservation. It doesn't have to be the shoulder, the hip, or the knee. Joint preservation. And honestly, the number one thing you can do for a joint is move it. Understanding certain motions of the hip is important, but a joint in motion stays in motion. It's a fine balance. Patients often, once they stop an activity or they graduate from high school to college, become less active, and then their joints actually end up hurting more because they're not moving. So number one for a healthy joint: a joint in motion stays in motion. Number two is understanding the proper motions and mechanics of that joint.
[40:34] I try to never limit any of my patients from doing things they love to do. My goal every single day is helping patients achieve what they consider their goal in life or their quality of life — and that answer means something different to everyone.
[41:00] There are some supplements and things that we're studying, and there are some reasonably solid randomized trials for joint health. But with the hip specifically, whether it's stem cells or supplements, the problem is that the hip is usually a mechanical issue — not necessarily biologic. There are some things I see that are biologic, but the majority are mechanical. Understanding the mechanics of your hip, and if they're significantly different from the normal population, correcting those mechanics — that's what provides better joint health.

[41:53] Jennifer Milner: Absolutely. I will say also — I was speaking to Lisa Howell about hips. She's a physiotherapist from Australia who plays a large role in the dance medicine world. She and I were talking about hips specifically and dancers struggling with turnout, rotation, extension, and all these things. She said she had seen so many teen dancers who had had X-rays or imaging done and been told, "Look at your pictures — you're never going to get more turnout. You're never going to do this or that." And she said 95 times out of 100, 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 images she would look at and categorically say, "We need to move in a different direction." So it's so important to know what a patient wants and to give them the tools to try to achieve that — to say, "Let's see what the mechanical issues might be." I love that answer.

[43:04] Joel Wells, M.D: That's so true, Jen. 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 they can't do something just from a two-dimensional representation of a four-dimensional object.

[43:37] Jennifer Milner: Amen.

[43:40] Dr. Linda Bluestein: Are there any guidelines you can give our listeners in terms of labral tears specifically? Obviously we have the caveat that this is medical information, not advice, and we cannot provide individual recommendations. But are there any guidelines in terms of, say, the location of a labral tear, or how much of the labrum might be torn? I feel like that's an area of a lot of confusion, especially when someone gets a recommendation to go in and "clean up" a torn labrum.

[44:20] Joel Wells, M.D: Linda, number one, I think if anyone — especially a young dancer — is diagnosed with a labral tear and wants to continue to dance, they should see a hip-specific physician, whether that's a physical medicine and rehab doctor, an orthopedic surgeon, or someone who specializes in hips. That's number one. They should get to someone who understands hips and can honestly triage them as necessary.

[45:02] Jennifer Milner: Yes.

[45:04] Joel Wells, M.D: Patients that are young — in our age groups that we are talking about — should not, in my opinion, have labral tears. And just because they have radiographic evidence or a radiologist's read of a labral tear doesn't necessarily mean they actually have one. They may not have had the proper imaging to diagnose that. If they do, it is best to see a specialist — and I don't think anyone would argue that.
[45:36] With regards to what should be done with a labral tear after that, it is much more complex. That's why I really think that if someone recommends surgery for a labral tear, it is never bad to get a second opinion. Even as a surgeon, I often think it is good for patients — it's part of the educational process, having patients understand their pathology and see providers who can helpfully educate them. I would recommend seeking a second opinion if someone recommends surgery.
As for current guidelines on labral tears — there are some guidelines for femoroacetabular impingement, but they are very basic. Why? Because we don't have level 1 evidence to support a lot of what we do. As we talked about at the beginning, this is all fairly new. Seeing multiple opinions is important, but also seeing a specialist who only deals with hip pathology is essential. To directly answer your question: number one, see a hip specialist. Number two, seek a second or even third opinion. And lastly, the current guidelines, although great for standard femoroacetabular impingement, may not pertain to dancers and other subspecialty populations.

[47:54] Dr. Linda Bluestein: Okay, that's great. And what are some practical steps that hypermobile dancers can take to increase the longevity of their career?

[48:06] Joel Wells, M.D: Number one is listening to your hip and listening to your body. When you start feeling something, it's best to be seen sooner rather than later. You don't want to see someone after they've been having pain for four years and now they can't dance and want to get back to dancing. Seeing those patients four years previously is the most important thing — that's where the management and the changes can occur.

[48:44] Dr. Linda Bluestein: That makes sense. And for people in general who are interested in more information about hip preservation — maybe they've had surgery, maybe they haven't — do you have any other advice you would give them?

[49:00] Joel Wells, M.D: Yes. I'm actually working on this right now as medical director for Miles for Hips. My goal with that organization is to provide an unbiased educational resource for hip pathology. There are a lot of resources out there, but number one, seeing a hip specialist is very important if you're having hip pain. And through the International Hip Dysplasia Institute as well as Miles for Hips, the goal is to have a safe place for patients that is unbiased. Social media is phenomenal for some information, but sometimes it comes with bias. My goal with Miles for Hips online is to provide an unbiased, safe resource for patients — whether they're seeking a surgeon, a provider, or just information about their hip.

[50:09] Dr. Linda Bluestein: Fabulous. And anybody can go to Miles for Hips, and we'll have a link on the Bendy Bodies website, but anybody can join or participate in those conversations?

[50:21] Joel Wells, M.D: Yes. Anyone is welcome to join. It is growing and it's definitely going to be a great thing. The mission, in my opinion, is providing good education for patients with hip pain, period — an unbiased, safe, evidence-based resource.

[50:43] Dr. Linda Bluestein: Fantastic. Do you have anything else you would like to add? And can you let people know where they can find you?

[50:51] Joel Wells, M.D: Yes. I just want to thank you, Jen and Linda, for this amazing opportunity. This is near and dear to my heart and what I wake up every morning wanting to help with. I love patients with hip pathology, especially dancers, because it is a true sport and I want to help.
[51:18] You can find me — Google me, Joel Wells MD. I'm very reachable, and you can find me on social media or my webpage at UT Southwestern. And then Miles for Hips is a great resource — a collaboration of phenomenal people who just have the goal of helping patients with hip pathology. Thank you both so much again for this opportunity.

[51:57] Jennifer Milner: We are so grateful for you being here and for the work that you are doing and being willing to speak with us.

[52:03] Dr. Linda Bluestein: It's absolutely fabulous. Just so everybody knows, Miles for Hips uses the number 4 — so it's Miles, M-I-L-E-S, and then the number 4, hips. We will have links in the show notes so everyone will be able to find you and get more information, because this is such a critically important topic, especially because it affects so many young people.

[52:24] Joel Wells, M.D: Yes. And I want to say that everything with Miles for Hips is completely voluntary. I am the medical director and everyone on the board does it purely because they want to help — there is no financial incentive. I think that's really important when it comes to an unbiased resource.

Jennifer Milner: Absolutely.

[52:46] Dr. Linda Bluestein: Absolutely. That makes perfect sense. Well, thank you so much for coming on today, Dr. Wells. You all have been listening to Bendy Bodies with the Hypermobility MD. 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 long-term impacts of hip dysplasia. Check out their website for more information, and please go to bendybodiespodcast.com for links to some of the research that Dr. Wells has done, Miles for Hips, and where he can be found at UT Southwestern.
[53:32] 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 healthcare. The Bendy Bodies original music is by Andrew Savino, and sound editing is by Rhett Gill. Thank you for tuning in, and we will see you next time on Bendy Bodies with the Hypermobility MD. Thank you so much, Dr. Wells, and our guest co-host today, Jennifer Milner.

[53:47] Jennifer Milner: Thank you.

[53:52] Joel Wells, M.D: Thank you so much.