Hypermobility: Here's What Providers Should Know About Their Patients | Conversations in Regen Ep. 9

When it comes to hypermobility, here's what providers should know about their patients to improve outcomes.

Movement Before Needles—Always. → Visit My Website https://pxl.to/AD/tq8nuql

Why do some hypermobile patients keep coming back with the same injuries? Are we overlooking deeper connective tissue issues? And can regenerative treatments really make a long-term difference in stability and pain? In this conversation, we dive into hypermobility and here's what providers should know about their patients—from understanding the spectrum of hypermobility syndrome to tailoring hypermobility treatment strategies that address both physical and neurological factors. Drawing on years of experience treating complex connective tissue disorder cases, including ehlers-danlos syndromes, we explore realistic ehlers danlos syndrome treatment options, treatment for hypermobility, and practical insights for how to help hypermobility patients thrive.

I walk you through not just what is hypermobility, but also when movement therapy should take priority over injections, and where orthobiologics fit into the bigger picture. You’ll hear nuanced perspectives on regenerative medicine, regenerative medicine orthopedics, and how to match orthobiologic treatments—like regenerative injection therapy, regenerative joint therapy, and regenerative orthopedic medicine—to the right pathology. From identifying early warning signs in patient histories, to deciding between prolotherapy and PRP, to using supportive tools like orthotics and bracing, this episode is packed with practical takeaways that you can apply right away.

We also tackle the ethical side of treating hypermobility and EDS with limited research. You’ll learn why transparency in expectations is essential, how to differentiate between injury and pain, and the importance of integrating psychological support for patients with central sensitization. Whether you’re considering orthobiologics for shoulder instability in athletes, managing recurring joint subluxations, or simply trying to understand how to better evaluate and track hypermobile patients, this discussion gives you a deeper framework to guide decision-making.

By the end, you’ll have actionable strategies to improve diagnostic precision, select the right regenerative therapies, and create multi-disciplinary care plans that address both joint mechanics and nervous system sensitivity. This is not about promising miracles—it’s about making informed, ethical choices that can reasonably improve patient function and quality of life.

Building a successful cash-based orthobiologic practice is not a single decision. It is a series of the right decisions made in the right order. The Business of Orthobiologics offers three distinct programs designed to meet physicians at different stages of readiness — whether you are just beginning to explore PRP, ready to build a full practice system, or committed to going all-in on a comprehensive transformation.

Learn More here: https://thebusinessoforthobiologics.com/programs-explanation 

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Transcript

SPEAKER_00 0:00

I think that it's important to recognize when hypermobility is good versus bad. Hypermobility is not a curse and it's not something that is necessarily a scare tactic into doing expensive procedures for no reason.

SPEAKER_01 0:12

Ultimately, I think it's just identifying and realizing that there are things that we can offer these patients that aren't surgery, that aren't cortisone, that can really massively positively impact their life. And so without further ado, I would like to welcome Dr. Sean Patel. He is double board certified both in sports medicine and physical medicine and rehab, fellowship trained in interventional pain management, and honestly a rock star and a prince of a guy. Wonderful to work with side by side, but I think even better as a patient and doctor. I've seen him work his magic in his clinic. And not only is he an amazing doctor, but a fantastic teacher and instructor for interventional or the biologics foundation. And he has some very cool talents, including maybe a little bit of breakdancing. So you're gonna have to give us the information on that. Dr. Patel, can you give us a little bit more background on your passion and what you're up to? And maybe where you're located.

SPEAKER_00 1:59

Sounds good. Well, thank thank you so much for such a nice introduction. Yeah, so my name is Seanik Patel. I've been practicing in Southern California for over 10 years now. But honestly, it's been a pleasure over the course of the last several years now working with yourself. And you've been an amazing force in the regenerative medicine space. And I honestly I have to commend you on this podcast because this is a wealth of information, both on the science side, but particularly on the business side of bringing orthobiologics to the forefront. So really honored, honestly, to be on this podcast. So thanks so much for inviting me.

SPEAKER_01 2:39

Absolutely. Absolutely. Do you want to share anything else about maybe your practice, your passion, a little bit about that, and then we'll get started.

SPEAKER_00 2:49

Absolutely. Yeah. So, you know, my first exposure to regenerative medicine was like 16, 17 years ago when I had the opportunity to follow some prolo therapists, old school prolo therapists treating the New York City ballet, and seeing how there were some treatments that could expedite the healing process, for lack of better words, and treat a patient population that was otherwise a very challenging patient population to treat. It really sparked my interest, and I kind of sought out mentors since then to build my practice. So I've been practicing, like I said, over 10 years in Southern California. I'm in Newport Beach now. And with the nature of my practice, I see more complex cases. So I see a lot of everything from postoperative cases to patients that are not candidates for surgery, all the way through to a growing hypermobile and EDS patient population, which is a challenging population to manage, but it has been really fruitful and it's really a fun population to treat. And the experience has been very multifaceted, let's put it that way.

SPEAKER_01 3:57

Awesome. Awesome. We'll get into that a little bit later. Again, welcome everybody. Thanks, all of you, who have taken time out of your day to join us for this amazing conversation. So for those of you who don't know me, I'm Dr. Ariana Demers. I'm a board certified fellowship trained sports medicine orthopedic surgeon and regenerative medicine enthusiast. I do a lot of training and educating both in orthobiologics and ultrasound, which I'm obsessed with. And I am also obsessed and passionate with helping doctors to incorporate orthobiologics seamlessly in their practices and be successful at it. So we deserve success as physicians to help our patients and really affect positive change. And so that's one of the things that I'm just so passionate about is really allowing doctors to make massive positive impact for their patients. Without further ado, I do believe that orthobiologic treatments will be first line treatment for musculoskeletal care in the next five years. I think the way of cortisone is going away. And I do believe that we now have a better option in orthobiologics. And so ultimately, that is my passion. This is what I do. And I'm just so happy to be able to bring this to you. So here's the deal successful integration for a lot of us is hard. And, you know, we know orthobiologics is the best treatment, but how do we be successful, right? Maybe you've tried some things and you've had like, man, I don't know the design as well. And I was guilty of that when I started. I thought PRP was this magic thing, the blood went in a black box, magic happened and popped out on the other side, magic pixie does. Turns out that's not true. But, you know, there was a lot of learning on my part with technique, with cash-based business, with marketing, with sales. And maybe you thought I'm just not good at this, but it's not our fault because we did not learn this in school. And maybe some of you are awesome on the doctoring side and maybe struggling on how to be successful and capitalize on what is going to be a $4 billion orthobiologics market. So don't get lost in the things that we didn't learn. We deserve more, right? And so if you so desire, go ahead and just put in the chat what you are struggling with most, especially on the business side, just because we didn't learn this and things that maybe you want to learn more about. So the question is, how do we win, right? And while we are talking about science here today, we also need to talk about how we talk about this with our patients. And so, Dr. Patel, we'll go into this a little bit about the conversations that you have with your patients. How do you breach this subject with your patients so we all win? Obviously, you need a system, right? You need the orthobiologic knowledge. We're not gonna go over all this today, but we are gonna get you a little bit further down your journey to be wildly successful in your orthobiologic practice. And so we are gonna start with that knowledge base with Dr. Patel. So why don't we just get down to business and get going? So we have questions, right? We're talking about the science, um, but we have questions on this issue with hypermobility. And I have so many questions for you. And this is your growing niche in your practice, and we've talked about this offline. But are we over-relying on orthobiologics or even prolotherapy to stabilize hypermobile joints? Or do you think that there is more of a systemic or connective tissue? Do you think you can actually change the natural history of this tissue and connective pro tissue problem?

SPEAKER_00 8:14

That's a great question. First and foremost, we have to ask the question what is hypermobility? I think this has become a very big catchphrase. It's the new fibromyalgia. Well, there's two new fibromyalgia, hypermobility, three. Hypermobility, long COVID, and neurodivergence. So all three of those have become catchphrases over the course of the last few years. And quite frankly, all three of those have a lot of overlapping things that are associated, a lot of correlation that we see with hypermobility, neurodivergence, long COVID, and a lot of the old school things we used to think of as fibromyalgia, chronic fatigue, all of those kind of catch-alls. But the first question we got to ask is what is hypermobility? Does it actually exist? I mean, the short answer to that is yes. And I think, like a lot of other things in medicine and in science, as we learn more about how to appropriately diagnose, we're learning that yes, we can actually diagnose hypermobility in patients. Now, does that mean that all hypermobile patients are EDS? Or do we have a genetic predisposition to hypermobility? And the short answer to that is I don't know. The truth is, hypermobility is a spectrum, and if we look at a variety of different organizations that have put research into this now, we kind of lump people into that hypermobility spectrum disorders umbrella. At one end of that is your genetic conditions, are your genetic conditions like EDS, Marfans, etc. But is it necessary that we have a genetic condition or is it just a genetic predisposition? Or is hypermobile or can hypermobile mobility be even ietrogenic, or can it be just brought on by the variety of activities that we do, etc. So, you know, if we accept the fact that the concept of hypermobility exists, then it's like what do we do about it? Not all hypermobile patients have symptoms. Plenty of hypermobile people have zero symptoms whatsoever. So just because we have hypermobility does not necessarily equal anything to be concerned about. When I talk to my patients, and this kind of crosses over a little bit into the business side of things and how to talk with patients, I think it's important to discuss that fact. And it's important to recognize that hypermobility is not a curse and it's not something that is necessarily a scare tactic into doing expensive procedures for no reason. Hypermobility refers to laxity of our ligaments.

SPEAKER_01 10:53

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SPEAKER_00 11:08

And what I tell all my patients straight up is that all kids are hypermobile, and that's by nature. We're all extra flexible when we're kids, so we don't tear things when we're bouncing off of walls. But as we get older, our ligaments should tighten. And for a subset of patients, whether it's introduced by activity or whether it's genetic, those ligaments stay a little bit looser. Now, that in and of itself is not an issue, but if you have loose ligaments and if we're not strengthening our muscles appropriately, if we're not moving correctly, or if we introduce extrinsic factors like injury or excessive manual manipulation or a variety of other things, well then that hypermobile patient can become injured, so to speak. Some people, yeah, 100%. Um, and I actually think that this is Ariana, this is where I kind of disagree with you a little bit. I don't think orthobiologics are or should be the first line of treatment for musculoskeletal care. I think movement should be, you know, and I think that it's easy for us to fall into the next best sexy treatment thing that we can use, but it's fundamental to get our patients moving correctly. And I think that strengthening our muscles and getting the body moving in an appropriate manner is the primary single most beneficial treatment for our hypermobile patient population. Now, we can strengthen muscles, but we can't strengthen ligaments. So if we are strengthening the muscles appropriately, but we're still having issues associated with excess laxity of a joint or a tissue, then that's the circumstance where an orthobiologic may be of benefit. But if we use an orthobiologic without getting the body moving correctly in the first place, then we're gonna be spinning our wheel.

SPEAKER_01 13:21

Yeah. Thank you for calling me out on that one. Thanks a lot. No, but ultimately you're right. I mean, just like we know diet and exercise is foundational for health, I think proper movement, proper muscle patterns are appropriate. Now, I do have a follow-up question to that, though. Is that possible if we're overstressed, if you're having injury? Can you actually introduce muscle pattern movement during injury?

SPEAKER_00 13:58

Yeah, so yeah, yes and no. And I think it depends on your level of injury, so to speak. I start so circling back to our passions right now. I started breakdancing again because my son is in breakdancing, but I also started jujitsu because my son's in jiu-jitsu too. And I'm desperately trying not to get injured, so I'm not going hardcore. But our jujitsu professor quoted somebody that he saw online saying that he was training a kid and the kid got a boo-boo. And the the question that was asked were are you hurt or are you injured? Because if you're injured, you gotta go to the doctor, you gotta go to the hospital, you gotta go X, Y, and Z treatment. If you're hurt, well, then walk it off, right? So there's a difference between hurt and injured, and I think that it's important for us to take a second to sit back and actually diagnose before we advise on the appropriate treatment plan. And this is particularly true for the hypermobile patient. So if you see a hypermobile patient and we see that they have pain, is it pain or is it an injury? And that's the first and most prominent thing that we need to explore. So an appropriate history, right? Did this come on from an actual injury, or did this some was it something that gradually came on over time? Was there a dislocation that was associated with it? Was there a car accident? Was there excessive chiropractic manipulation? Was there something that caused an injury? That's number one. Number two is your physical exam. And not just having your physical exam as myopic at looking at the joint and hand, but looking at the whole kinetic chain to see, because sometimes a hurt knee could be coming from the abnormal mechanics of the ankle, foot, hip, or low back. Right? So paying attention to all of those things, and then your imaging. Now, with imaging, it's interesting because we all know that imaging does not necessarily equal pain, but the opposite is true. The lack of findings on imaging, or rather, the lack of findings on an imaging report does not necessarily equal symptoms or lack of symptoms. You get what I'm saying? It's important to look at our imaging and look for the subtle findings that may be suggestive of an actual injury taking place, looking at multifidae atrophy and a lumbar MRI, or looking at ultrasound and seeing if there's abnormal fibers or tendinopathy or cortical irregularity or osteophytes that may be suggestive of abnormal biomechanics in that area. Really digging deep and seeing, all right, is this patient hurt or injured? Then we can dictate, all right, is movement the appropriate thing for that type of situation?

SPEAKER_01 16:48

Yeah, that's that I think that's the subtlety is absolutely correct. I'm so glad you clarified that because I do think it's important. So we still have questions for you. So the next question is can regenerative therapies like PRP or even your prolotherapy experience truly offer that long-term relief for hypermobile patients? Or are we just chasing symptoms and are they gonna be like coming back? How do you educate and how do you talk to your patients about expectations for this?

SPEAKER_00 17:23

Yeah, this is an important thing for us to think about, right? Because as we all know, orthobiologics are not currently covered by insurance and can become expensive, particularly if they're repeated over time, right? So is this something that's first of all necessary in the first place and then necessary over time? So I have seen patients that have had significant benefit with orthobiologics in the hypermobile patient population. I think some of this has to do with matching the right treatment to the right condition. So if we have somebody that has true injury, tear, dislocation, tendinopathy, chronic sprain type pictures that we can visualize on imaging, then an orthobiologic like PRP or even cell therapy for those circumstances can actually be a game changer. And a lot of us have seen substantial improvement on before and after imaging of soft tissue injuries having some pronounced healing take place. Now, with a hypermobile patient, you may see somebody that doesn't necessarily have a torn ligament, but you could see on exam that they're grossly lax. So that might be a circumstance, depending on the laxity or the situation, that something as strong as a PRP or cell therapy may be beneficial. But if there's not something that's robust, then prolotherapy could actually be a really good treatment that's relatively inexpensive. Injecting a concentration of dextrose is going to be substantially less expensive than PRP or cell therapy and can be used for multiple body regions, can be used repetitively over time in a manner that is affordable to patients and can be beneficial long term for patients as well. It's something interesting to consider as far as matching the right biologic to the right pathology, but also we have to recognize that the hypermobile patient typically, not always, but typically also we have to look at the whole picture. So again, movement, the exercise. If we're just doing prolotherapy or stem cells or whatever, and they're not strengthening their muscles, they're not moving correctly. Again, we're just gonna be spinning our wheels. But also, going back to my mention of neurodivergence and having a correlation there, I think that there is a strong component of this hypersensitivity of the nervous system in these hypermobile patients as well. So, one thing that I implore you all to do is have that discussion with your patients about how sensitive they feel to their pain. They feel their joints going out. Why do they feel their joints going out? Well, they've trained their system to become very, very in tune with the excess mobility that they've had for X amount of time. Getting someone like a talk therapist involved as a part of the treatment plan can be really beneficial. And I found the most benefit from talk therapists that are actually specialized in trauma therapy. Trauma therapists deal with the hypersensitivity of the nervous system quite a bit. So that's something that might be a part of your game plan when you're trying to optimize your outcomes out of orthobiologic treatments.

SPEAKER_01 21:00

That's so helpful, I think, because we've all seen these patients that were like, I just touched you. Like, honestly, does that hurt? And I think the answer is for them, yes, they're sensitized. And the the mind is a powerful thing used for good or for bad, or just sensitized, traumatized, and overly in tune and can be reversed. But a talk therapist who said is an expert at that piece, I think is brilliant. Do you use that for a minority of your patients, for most of your patients? Is that something that you're regularly integrating into your treatment protocols?

SPEAKER_00 21:46

It is something that I'm more regularly integrating now. Going to the business of medicine for a quick second. If you're integrating orthobiologics in, this should not be a consult that takes 15 minutes. My consults take a While and in the consults, I'm examining the chief complaint, but I'm also taking a step back to look at nutrition, exercise, sleep patterns, and how they are psychologically. If I get any sense that there's this central sensitization or sympathetic overtone or type A type personality, right? If I'm getting any of those senses, then I'm gonna delve a little bit deeper and ask them about do they consider themselves anxious? Do they consider themselves having had traumas in childhood? I just just asking a couple questions, and I don't expect to open up the floodgates here, but getting a sense of if that's a part of the picture at all, and that's a part of my discussion. I've now linked up with I have a patient of mine who's has EDS, who is a trauma therapist, and I've linked up with a few other therapists that have experience with this. Getting those resources together in your locale could be hugely beneficial, also because it is time prohibitive for us to manage it ourselves. Now, there's some people that may want to. I like sticking needles in people, so I think that's what I want to focus my skill set on, but we can't ignore the other pieces of the puzzle. So if we have the appropriate team to manage that, it's a small thing that could make a huge difference.

SPEAKER_01 23:30

Yeah, awesome, awesome recommendations. I'm gonna be putting that in my files as to maybe a little bit more on the history, on that social history piece. I think it's important. So awesome. For when we talk about pain and pain relief and painful things, pain is this thing that is not well defined and is subjective. There are some objective measurements, but for the most part, this is a subjective measurement, right? And so we have this conversation with our patients all the time about this. So what a great way to kind of categorize that. Well, ultimately, we're not done. We still have more questions for the expert. The question is, is it ethical to offer orthobiologic treatments to EDS when research is maybe not a hundred percent there just based on volume? We have much more research on knee arthritis and PRP. The amount of literature for orthobiologics and EDS is not as robust. And so, what how do you kind of couch this and have that discussion when it comes to research-backed care?

SPEAKER_00 24:47

Yeah, so the truth is that it's not ethical for you to do that and you shouldn't. And if you have hypermobile patients, you should send them my way. No, but no, it's a delicate, delicate balance. Here's the thing: there are a lot of people that promise crazy things, and particularly it seems like in the regenerative medicine space, there seems to be more and more and more, despite the amount of people out there that are trying to advocate for appropriate care. There seems to be more and more people that are making crazy promises about crazy things. Like, I'm gonna stick some IV stem cells and cure everything that's under the sun that's going on with you. The truth is, with any orthobiologic treatment, even when it comes to neostearthritis, we have to be very honest with ourselves and with our patients in regards to what the literature does and does not show. Making false claims is the kiss of death for our specialty, period. And as much as it's exciting to bring these treatments on board for our patients' care, and as much as this can be very beneficial, it's a slippery slope to start saying, Oh, shoot, I heard about this thing, let me try that and make these false claims. So that's where the ethics really comes into play. So is it ethical to treat EDS patients, hypermobile patients with orthobiologic? Yes, absolutely. However, what you say and how you say it to the patient matters. So if you say something like, hey, I'm going to inject a prolotherapy or PRP solution to your ligaments, and it's going to strengthen all of your ligaments, and you're not going to have any instability. And if you're saying this to a hypermobile type EDS patient, we don't have any evidence to suggest that. We have evidence that suggests that it can help with improving some of the pain, some of the stability, but not reverse their genetic condition. I mean, it sounds stupid, but it's it's very, very clear, and we have to be very clear with that. It also goes back to saying that we have to hit these patients with a multifactorial approach. And if we're not using that approach, then that's where I think the ethics is an important factor for us to consider. Now, as far as the science is concerned, there is a plethora of science in support of PRP for kneostearthritis. Right? There is level one evidence for lateral epochondylosis and gluteal tendinopathy, and there's great evidence for plantar fascia, and there's growing evidence for ligament sprains and various different things. Spine has some growing research in support. However, we have to also recognize that it's still technically early on, with the exception of knee arthritis, which has by and far a ton of research at this juncture. What we also have to recognize is there's crappy research for everything else in this patient population. There's no research for corticosteroid injections, and arguably steroid injections based off of the basic science could make their situation worse. Right? There's not enough research, period, in this patient population. So we have to take a step back and first recognize that, and second, look at first do no harm. So with the alternatives being essentially corticosteroid injections, because these aren't gonna be surgical patients unless there's a severe amount of instability, with the alternative being a corticosteroid injection, which will arguably make their situation worse, then we have to think about is it ethical to not offer orthobiologic management?

SPEAKER_01 28:43

Absolutely. We've had that this conversation that withholding care that may be beneficial may be the unethical option. Absolutely.

SPEAKER_00 28:57

Well, yeah the problem though is that since it's not covered by insurance, people are like, all right, shit, we're gonna be spending all this money. Sorry, Chris. We're gonna be spending all this money to do a treatment that may or may not work. Be honest. And the same patient that may not pay for a PRP treatment may still get Botox and filler for aesthetic reasons. Be honest with what your outcomes may or may not be. It's up to them on how they want to spend their money, but you have to be honest.

SPEAKER_01 29:28

Yeah, absolutely. Absolutely. Well, obviously, we still have more questions. Now, do we do you think we're doing enough to differentiate between evidence-based care and compassionate experimentation, right? Like let them make their judgment on what they want to spend their money on. How do we get this research with it because this population is small in the whole grand scheme of things? So, how do you get really good evidence-based information to then inform our care options? I have like a couple of patients, and I think we all have a couple of patients, unless you're you, and you have like a billion of them, the center for, but how do you kind of continue to get this collection of data?

SPEAKER_00 30:16

So, first of all, collecting data in the first place is something that's important. A lot of us are proponents, advocates, and that's that in and of itself is something that is absolutely important. But if we're collecting our data and we don't recognize that that patients may have hypermobility, then that's another factor for us to consider too. So it's really important to integrate some simple physical exam tests into your normal repertoire. Baiton score is something that's simple, that's been validated to show some level of hypermobility as a part of the picture. Asking simple questions like do you bleed easily, bruise easily, did you ever do party tricks with your fingers when you were a kid? Looking at skin elasticity, asking more thorough review of systems. And it doesn't have to be something that you're asking, it could be something that could be done by your EHR, your paperwork, or your staff before you even walk into the room. But having that information leading into it is very important. Because if you now identify the hypermobility, which by the way, I think EDS is rare. I don't think hypermobility is rare. At this juncture, and again, I'm completely biased, however, I think that there's more people that are hypermobile than we recognize. Because as I mentioned, hypermobility does not necessarily equal symptoms. In fact, up until this advent of hypermobility as a new fibromyalgia lately, we always said that stretching and being extra flexible was a good thing. Right? So football players going into Pilates and yoga is a good thing. Absolutely, because we need to be more flexible. However, I think that this is something that is underdiagnosed, and if we recognize it first, then all of a sudden we can collect our data more effectively in seeing, all right, this is what's working and not working for this patient population. So I think that's something really important, not only collecting our data, but being able to identify hypermobile patients in general.

SPEAKER_01 32:24

Don't miss out. Please subscribe to our newsletter now to stay ahead of the world of orthobiologics. You can find the link below. Additionally, if you're ready to start this journey with me in my orthobiologics masterclass, come join us. Now, I'm gonna fess up that I didn't learn. I learned about it in school, but in my orthopedic training, this was not a discussion. And I'm sure it saw me way more than I saw it early on, until I had a number of patients that continued to educate me by continuing to show up with these complaints and these weird things. And I'm like, oh my gosh, this continues to be a recurring theme. Can you give our audience maybe the top five things, either answers to questions or experiences or like things that should make them pause and go, hmm, maybe I'm dealing with hypermobility.

SPEAKER_02 33:25

What where do you get that?

SPEAKER_01 33:26

Where do you think that those top five things that kind of peak your like, wait, wait a second, maybe this is something else?

SPEAKER_00 33:34

So, yeah. So if you see a patient, just on history first, let's start, right? If you see a patient that has tried X amount of things already, and that things have had temporary benefit but not held, or if you see the patient that is chronically going to a chiropractor two times a week in order to get adjusted because they feel out of position. Or if you see the patient that has complains of weakness, and not just necessarily of the joint in question, but globally, or if you see the patient that's complaining of muscle tightness more globally. Again, five, ten years ago, the default was fibromyalgia if we couldn't figure out what was going on. But if you smell that coming in your door, then at least start asking some additional questions. So, what are those questions that we ask? As a part of my history with everyone at this juncture, even if I'm not smelling anything, I say, Are you now or have you ever considered yourself very flexible? It's a simple question. And some people will be like, No, absolutely not. Right? Now, if I still get the smell test, I may still dig a little bit deeper because somebody that is a lifelong yogi may still say that she or he is not very flexible because in comparison to their friends that they roll with, they're not. But they could still touch their elbows on the ground. Alright, maybe you're still a little bit flexible. Right? But asking that question is number one. Number two, asking about if they've ever dislocated things, if they've ever felt things go out of position, then that's something important as well. And then asking some of the more subtle things like do you bleed or bruise easily? Have you had any vision issues, any heart issues? Oh, yeah, I have some valve issues in my heart, and I bruise easily. And oh, do you keloid or do you scar easily? Right? These are the questions that are do you have GI issues, right? And these are the questions that start getting us more than just a little bit of hypermobility, but do we have a hypermobility spectrum disorder?

SPEAKER_01 35:48

Awesome. Yeah, I mean, honestly, I I was a couple or a good number of years into practice before I ever even used the Baiton score for my patients. And I mean, I now I'm like, oh my gosh. Like I have it on my clipboard. I'm like, are you bendy or are you not bendy? Because it does seem to show up more often than I would have expected, especially if you're categorizing it in just EDS terms. But I do appreciate that it probably is more of a spectrum where you're maybe more mobile than the majority, but not genetically predisposed. So awesome.

SPEAKER_00 36:26

And just because we find somebody that's hypermobile doesn't mean we necessarily have to do anything about it. Meaning that just because they're extra flexible doesn't necessarily mean they have EDS.

SPEAKER_01 36:35

Right.

SPEAKER_00 36:35

You know, we don't have to biopsying them. Right, exactly. If we're treating a mild knee arthritis in somebody that has hypermobility, maybe we shouldn't just be injecting our PRP intra-articular. Maybe we should put some into the extra-articular ligament structures, and maybe we should take a step back and think about the physical therapy component of things. And maybe we should look at the whole kinetic chain as a part of that, right? So that's the only thing. It doesn't necessarily mean we have to set them up for a billion prolotherapy injections for the rest of their lives, but just having that thinking hat on changes the dynamic of the care.

SPEAKER_01 37:14

Yeah, awesome. So the question is what is the next step? Like, how do you implement this, right? We now have to kind of take all of this awesome knowledge drop that you gave us and figure out how to get those right patients, how to determine who's gonna do well with prolotherapy, who's gonna do well with PRP versus cell-based therapies, and really be able to talk to those patients and attract those patients and say, hey, listen, do you have these issues? Do your joints feel out of place? And be able to identify those people that you can probably help. They need your help, right? They've tried X, Y, Z, P DQ, and they're still seeking answers. And I still remember this patient. She's been my patient for a really long time, and she gave me the majority of my education because I treated her without knowing to start. And then once I had more education and more tools, including prolotherapy, including orthobiologics, I was able to change her life drastically. She had hip instability and she had daily subluxation. She wasn't able to exercise days, wasn't able to walk, she just was really struggling with activities of daily living. We used some prolotherapy to start because honestly, I was like, well, I don't know. Well, like this is reasonable, this is inexpensive. We can try this, see how you do. And she said, came back and she said, Oh my gosh, what did you do? Because this is massively different. And so we treated her initially with just prolotherapy. She then subsequently came back and said, you know what, I need something longer lasting. And we said, I can't guarantee it, but we can try PRP and see if it'll give you a longer lasting result. And indeed it did. And she still has some hyperlaxity, but nothing comparatively. She said, Oh my gosh, the difference is I used to have daily subluxations. I haven't had a subluxation of my hip in nine months. And so for that experience, like that is night and day difference. And I'm sure you've had a number, a thousand like that, where they're just like, oh my gosh, what did you do? And can I tell my friends? Right.

SPEAKER_00 39:30

Yeah, absolutely.

SPEAKER_01 39:31

Yeah. So ultimately, I think it's just identifying and realizing that there are things that we can offer these patients that aren't surgery, that aren't cortisol, that can really massively positively impact their life. So if you want that fast track to figuring out how to get your right patients, we've gotten the knowledge drop from Dr. Patel. I'm just gonna invite you to the next step, which is my Bob Live or Business of Orthobiologics event at Toby. For those of you who are gonna be at Toby, come a day early, come hang out with me, learn how to integrate PRP seamlessly into your workflow, get a step-by-step roadmap to get the right patients in the door that you know you can treat and what the right pricing strategies are for those patients, and then proven strategies to run a profitable cash-based PRP practice. So please come join me. It's gonna be so much fun, and I'd love to see you all. Just a little bit of housekeeping, and then we'll get to QA. This is the regular price for the full day of business of orthobiologics, how to get that successful cash-based practice up and running so you have freedom to treat patients well. And there's also an option for a VIP day with VIP strategy lunch with me. So this is that QR code, get your ticket. And if you need more information, you can get that at businessoverthebiologics.com. But I want to thank you and turn this over to questions. You can come off mute, you can pop them into chat. Um, and then Dr. Patel, is there any? Oh my gosh, yeah, we got a lot of questions here. Let's see here. Yes, lots and lots of questions. So let's see. I have, yeah, there's a pandage here, and he wanted to just put this in our thought process that controlling that stability of the heel with orthotics can be a really helpful mobility control mechanism. Have you found that to be helpful in your practice as well?

SPEAKER_00 41:58

Yeah, absolutely. I think orthotics and bracing in general can be a game changer for hypermobile patients, particularly when we get into that EDS population where there's overt collagen synthesis deficit and overt instability, because we're not going to be able to stabilize everything. Some things may require surgery, some things may benefit from orthobiologics. But if a simple fix like an orthotic can provide some measurable stability to a joint, then that could be a game changer for patients. Absolute game changer. Same thing with various different bracing for the fingers and wrists, same thing with bracing for the knee, even things like taping can be really helpful. So anything and everything, we gotta kind of think back to some of the basics of providing stability to areas. But we also have to think about one thing is not only the stability from a ligament standpoint, but we also have to think about muscle control from a neurological standpoint as well. And this is something that we oftentimes neglect because we see patients that have in the hypermobile camp that have these ridicular symptoms, but then you get an MRI and it looks completely normal. But if you look a little bit deeper at that MRI, maybe there's some subtle annular tears, maybe there's some multifidiatrophy of one side or the other, and you examine them, they have dural tension, they have proximal distal weakness. So for your podiatrist and you see this ankle instability, checking gluteus media strength, checking butt strength and hip external rotators can actually play a big factor into seeing what other things are a part of the picture. So, yeah, I don't know if you notice, but I'm verbose at times. So that's for that.

SPEAKER_01 43:39

No, no, I didn't notice at all. Now I have a couple of questions from a more technical or practical standpoint. From a pro-therapy standpoint, is there a preferred strength of dextrose? Are you using more of a high concentration, low concentration? Do you differ? Your prolo therapy for your hypermobility patients versus your standard flexibility patients?

SPEAKER_00 44:07

Good good question. I typically start my prolo therapy at a 12.5% dextrose mix or at bare minimum 10% dextrose. I don't go to a higher dextrose concentration unless I know the patient and have treated them before because this kind of goes back a little bit to the hypersensitivity of some of these patients, and some of them could be a little bit sensitive if we're causing too much inflammation, which is also why I taper expectations and have this discussion with patients when we're discussing even things like PRP. I had a recent EDS patient with repetitive rib subluxations, and it was multiple rib levels that she was having subluxations. And I had this open, honest conversation about look, I think we should start with prolotherapy and start very, very, very gentle. And her having some experience with prolotherapy in other joints, she really wanted to do PRP. So I was like, yo, let's just start with a couple ribs and let's not go overboard and treating everything. Even then, she had a substantial flare of her pain and her sensitivity. So we have to be very careful about dosing and starting kind of low and slow with these patients, unless they have experience previously.

SPEAKER_01 45:19

Yeah, I was that I was gonna ask you that. Now, is it part of your protocol to start with prolotherapy and kind of work up and see how their body responds? That's been my experience, is like they are very expressive, you know, they're very easy to have kind of a massive flair if you're not kind of gentle and kind of step tiptoe into this. Has that been your experience as well?

SPEAKER_00 45:48

So yeah, I think it depends on the pathology. So if somebody had an overt patellophemoral dislocation or has had more overt issues than that has visible damage on imaging, then perhaps a bigger gun to start with may be appropriate. However, if there's not that overt findings on imaging, then starting with prolotherapy would be very reasonable. In my rib patient, I started with six months of talk therapy and stellate ganglion blocks first to calm down the system leading up to her treatment. Because I think we have to recognize the hypersensitivity of the nervous system as a part of their picture.

SPEAKER_01 46:33

Gotcha. Dr. Don Buford is asking: Have you seen any difference between high dose PRP and cellular treatments for ligamentous laxity? Not so much the cervical, but any other large joints. And then there's a second part of that question, but go ahead and answer that one first.

SPEAKER_00 46:50

Yeah, so I think the place that I've seen the most benefit from using something like BMAC has been for unstable shoulders, multidirectional shoulder instability or recurrent dislocations that are not a candidate for, or the patient's trying to actively avoid surgery. If they're a candidate for surgery, I'm begging them to do surgery at times. And sometimes it's a matter of combining orthobiologics with surgery in those circumstances. However, if they're not a candidate or uh adamantly opposed to it, those are the situations where I would consider BMAC. I have had one occurrence of post-BMAC immobility causing adhesive capsulitis. I kind of like that in this type of patient population. Now I don't like it, but I like it. Right? And the fact that could be caused tells me that there's a robust inflammatory component that can cause some cinching of the saran wrap, so to speak, with BMAC more so than PRP. So that's the type of circumstance that I would consider going straight to cell therapy. But you better believe I'm doing nerve blocks and having the appropriate pain management afterwards for those circumstances.

SPEAKER_01 47:59

Yeah, and then uh follow-up question number one is do you do more capsular or intraligamentous injection? And then do you include the ligament insertion, even Io insertion of these ligaments or tendons?

SPEAKER_00 48:17

Yeah, so uh I'll go in reverse order. Io insertion of tendons I do fairly frequently, particularly when you have that traction, cuff, footprint, cortical irregularity, and underlying edema. That's an area where you can squirrel a small 25 gauge or even a 22 gauge into that footprint and get some infiltration there. I think that's really important. Hernague showed that there's a change in your parasites in the regions of full thickness rotator cuff tears, and that's something for us to conceptualize as we think about the whole functional unit. So I think treating the bone is an important part of management. When it comes to laxity, I have not hit the bone at a ligament insertion. I don't also think that I've seen much in terms of edema in the bone as ligament insertions in these patients, particularly. I've seen it in some other circumstances, ACL, for example, but not necessarily as much in the hypermobile patient. I will go to the footprint of the ligament and I'll bathe the ligament itself. I don't know though, what the right answer is for that circumstance. I just do that because I feel like that's right. But we have no double-blinded randomized controlled trials, ligament attached to the channel.

SPEAKER_01 49:38

I'm honestly, this is a me asking for my own edification and you know, also to kind of bolster my n of five to ten of these hypermobile patients and say, okay, if I've got 10 and you've got a hundred and Dr. Beaver's got a 10, a 20 to 30. Like if we can, as a collective, say, okay. As a group, we tend to consider this as a treatment thought process. It's not set in stone, but I do think it's important. There is another question.

SPEAKER_00 50:17

Just to mention that we gotta think about our brain trust and what the treatment of hypermobile patients has its roots in more traditional hackett Hamill Patterson prolotherapy type scenarios where things were done without image guidance for a significant amount, but it worked. So my first exposure to prolo therapy was in the New York City ballet with an old school prolo therapist poking and shooting at multiple different areas. What were they shooting? Oftentimes it was where ligament attachments were, but a lot of times, like, what were they shooting? Right? So, but it worked. So I think that now with image guidance with ultrasound, we can visually see that we can hit ligament attachments, we can hit along the ligaments, and what harm is there in doing that with when we have appropriate image guidance? Right, as long as we know our appropriate anatomy, as long as we are taking courses like ortho sono next week in Vegas, then we are able to visualize things and not just necessarily hit ligament attachment points, but actually bathe the ligament itself with appropriate safety, then why not?

SPEAKER_01 51:31

Yeah, absolutely. Now we have one more question and a thank you. Great talk, Dr. Patel. Can you comment on treatments for rotational athletes like baseball, golf, who deal with shoulder instability as a part of their change in mobility is why they're good at the sport and want to return back to this activity ASAP?

SPEAKER_00 51:53

I think it's fascinating. I'm fascinated by the overhead athletes and underhead athletes like golfers that are challenging their physiologic range of motion, for lack of better terms. I think that it's important to recognize when hypermobility is good versus bad. If it's causing bony changes, it's probably bad. If there's dislocations that are recurring, it's probably bad. If it's an induced hypermobility due to repetitive external rotation in a glenohumeral internal rotation deficit type athlete, then is it necessarily bad that they have that end range? Well, it depends. Are they impinging posteriorly? Is it because their anterior capsule has issues? Are they just overusing their shoulder because they have weakness elsewhere? One of the most valuable lessons that I had from the late Jerry Melanga's clinic when I was training under him was actually one of his colleagues. A patient came in with GERD and throwing athlete, and I worked up that shoulder like crazy. I was like, all right, this is what we're gonna be doing. And the first question that Agison asked me was, How's his butt strength? And I said, I'm sorry, what? So we went in and spent a half an hour evaluating his butt, and it was because his glute mead was weak and he was pushing off inappropriately that he was putting too much torque in that arm, and that's what was causing the issue. So we have to take a step back and look at the whole picture in these patients before we start just injecting the shoulder.

SPEAKER_01 53:27

Brilliant, brilliant. Well, we are over time. There is a little comment from a physical therapist that joined us. The using microcurrent has been a game changer to be able to target the central sensitization and hypermobility. So that might be something that you can reach out to your PT colleagues. And she's in the Northeast, so thank you so much. This is so good. Definitely, I think these MDI and subluxation patterns include butt strength and that you have to look at that entire kinetic chain. So great job. Thanks so much for sharing your wealth of knowledge. I really appreciate it. This is where the fun happens, and we get to actually have this cool conversation. If there's anything else that you want to talk about, put a shout out, things that your center does, by all means let us know. Otherwise, we'll just thank you for your time.

SPEAKER_00 54:23

No, thank thank you very much. This is a pleasure, so much fun. And like I said, I'm honored to be a part of this. Follow me on social at regen Dr. Patel.

SPEAKER_02 54:34

Yeah.

SPEAKER_00 54:35

Otherwise, I looking forward to seeing you all at upcoming conferences. And thank you so much again.

SPEAKER_01 54:41

Yeah, absolutely. If anyone's looking for more training on Ultrasound Guidance, Orthasono, the best, still the best training program after all these years, put on by Dr. John Buford. It is coming up very shortly in Vegas. So www.orthosono.com. I don't get paid to do that. It's just a great course and we'll be there teaching. So look forward to seeing you. Yes, region drattel at region dr patel. Thank you so much, everybody. We'll check you guys out next time and see you then. Have a great rest of your day.