Knee Arthritis Treatment Dallas: Are We Treating the Wrong Part of the Knee?
- cassis101
- 3 hours ago
- 4 min read
Treating Knee Arthritis in Dallas
For decades, the conventional explanation for knee osteoarthritis was simple: the cartilage wears away, the bones rub together, and eventually you need a knee replacement.
I believe that explanation is incomplete.
In many patients, the cartilage is not the primary problem—it is the victim.
Modern research increasingly recognizes osteoarthritis as a disease of the entire osteochondral unit, including the cartilage, synovium, ligaments, menisci, and the subchondral bone that lies directly beneath the cartilage.
If the foundation is failing, should we be focusing only on the joint space?
Why Knee Arthritis Treatment Dallas Should Include the Subchondral Bone
When people search for knee arthritis treatment Dallas, they usually want relief from pain.
But many of my patients have a different objective.
They want to preserve the knee they were born with, stay active, continue traveling, playing golf, hiking, exercising, or enjoying time with their families, and postpone irreversible surgery whenever clinically appropriate.
The subchondral bone is not simply structural scaffolding. It provides mechanical support for cartilage and participates in the biology of the osteochondral unit. MRI findings such as bone marrow lesions have been associated with pain and with progression of knee osteoarthritis.
If abnormalities exist beneath the cartilage, it is reasonable to ask whether treating only the joint space addresses the full problem.
What Randomized Research Has Shown
One of the most compelling investigations in this field was performed by orthopedic surgeon and researcher and colleagues.
In a randomized study of patients with osteoarthritis affecting both knees, one knee received image-guided subchondral (intraosseous) bone marrow concentrate, while the other received intra-articular bone marrow concentrate. Because each patient served as their own control, the comparison was particularly informative.
The investigators reported superior clinical outcomes and imaging findings in the subchondral-treated knees. During extended long-term follow-up, substantially fewer of those knees progressed to total knee replacement compared with knees treated using intra-articular injection alone.
In another long-term study from the same research group, approximately 82% of carefully selected patients with advanced knee osteoarthritis who underwent subchondral bone marrow concentrate treatment avoided total knee replacement over roughly 15 years of follow-up. Patients demonstrating improvement in bone marrow lesions tended to experience better outcomes than those with persistent lesions.
Although additional independent research is desirable, these studies have significantly influenced the discussion surrounding bone-targeted regenerative therapies.
Does This Mean Intra-Articular PRP or BMC Has No Role?
Absolutely not.
Numerous randomized controlled trials and meta-analyses have demonstrated that intra-articular platelet-rich plasma (PRP) can improve pain and function in appropriately selected patients with knee osteoarthritis. Intra-articular bone marrow concentrate also remains an important treatment option in many clinical settings.
However, these procedures primarily focus on the environment inside the joint.
For patients with moderate to advanced knee osteoarthritis—particularly when MRI demonstrates subchondral bone abnormalities or bone marrow lesions—the available evidence suggests that precision image-guided intraosseous bone marrow concentrate may provide greater potential for long-term joint preservation than intra-articular injection alone.
That distinction is important.
Improving symptoms is valuable.
Potentially influencing the underlying biology of disease progression may be even more valuable.
My Philosophy on Knee Arthritis Treatment Dallas
Every patient deserves an individualized evaluation.
Some patients may benefit from intra-articular PRP.
Others may be candidates for intra-articular bone marrow concentrate.
Still others may warrant a discussion about targeting the bone beneath the cartilage with precision image-guided regenerative techniques, particularly when MRI findings suggest subchondral pathology.
In selected cases, a combined approach may also be appropriate.
Rather than asking, “What should we inject into the knee joint?” I believe we should ask, “Which structures are driving this patient's symptoms, and how can we target them most precisely?”
Frequently Asked Questions
Is cartilage the only cause of knee arthritis?
No. Current understanding recognizes osteoarthritis as a disease involving cartilage, subchondral bone, synovium, ligaments, menisci, and surrounding tissues.
What are bone marrow lesions?
Bone marrow lesions are MRI findings within the subchondral bone that are associated with pain and may be linked with progression of osteoarthritis in many patients.
Does everyone with knee arthritis need intraosseous treatment?
No. Treatment should be individualized based on MRI findings, physical examination, symptoms, goals, and clinical judgment.
Can regenerative procedures guarantee that I will avoid knee replacement?
No. No orthobiologic procedure can guarantee avoidance of surgery. The goal is to improve pain, function, and potentially support joint preservation in appropriately selected patients.
Is intra-articular PRP still worthwhile?
Yes. High-quality studies support intra-articular PRP for improving pain and function in many patients with knee osteoarthritis. The decision between intra-articular, intraosseous, or combined approaches should be personalized.
My Takeaway
As our understanding of osteoarthritis evolves, I believe patients deserve more than a discussion about cartilage.
They deserve a conversation about the health of the bone beneath the cartilage.
For motivated individuals seeking to preserve mobility and maintain an active lifestyle, understanding the role of the subchondral bone may open the door to treatment strategies that extend beyond symptom relief and focus on long-term joint preservation.
Subchondral vs. Intra-Articular BMC in Bilateral Knee OA (15-Year Follow-Up):
PubMed: 32617651
Hernigou P, et al. Int Orthop. 2021. (Direct head-to-head RCT showing 20% vs. 70% TKA rates.)
Subchondral BMC vs. Contralateral TKA in Bilateral OA (15-Year Follow-Up):
PubMed: 32322943
Hernigou P, et al. Int Orthop. 2021. (82% TKA avoidance, BML regression as predictor.)
Combined IA + Subchondral Approaches
Subchondral and Intra-Articular BMAC for Knee OA (Pilot Study):
Kon et al. (PDF) or PubMed-related context. Positive 12-month clinical + MRI (BML reduction) results.
IA PRP/BMC Reviews & Meta-Analyses
PRP for Knee OA (Systematic Reviews/Metas): Search PubMed for recent ones (e.g., 2023–2025 metas showing superior short-medium term pain/function vs. HA/steroids/placebo). Example overview: PMC article on PRP.
Centeno/Regenexx Context on IO/BMLs: Pain Physician 2021 on BML treatment (mixed PROs) and related Regenexx blog discussions on bone targeting.
Additional Supporting Resources
BMLs & Subchondral Bone Pathogenesis Reviews:
PMC: Bone Marrow Lesions in OA
Nature Reviews: Subchondral Bone in OA
Dr. Deborah Westergaard is a double board-certified physician with more than 30 years of experience performing advanced image-guided musculoskeletal procedures. Her practice emphasizes precision orthobiologics, individualized care, and helping active adults make evidence-informed decisions about preserving mobility and joint function.
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