If I had a dollar for every time someone told me they were “bone on bone,” I’d fund my own orthopedic wing. It’s the phrase you hear at races, in the coffee line, at book club—everywhere knees gather. But what does “bone on bone” actually mean? And does it automatically mean you need a knee replacement? Short answer: Not always. Long answer: Let’s dig in.
I wrote this with Dr. Sabrina Strickland in mind—my knee doctor and a top orthopedic surgeon at Hospital for Special Surgery—because if anyone knows knees, it’s her. We’ll cover what “bone on bone” is, when knee replacement makes sense, and what other options are worth exploring, from implants like Misha to injections, PT, and yes, the much-hyped stem cells.
What “Bone on Bone” Really Means
When people say “bone on bone,” they’re talking about severe osteoarthritis (OA). In a healthy knee, cartilage cushions the ends of your bones so they glide without friction. With OA, that cushion wears down. On X-ray, it can look like the space between the bones—your joint space—has shrunk or vanished. That’s where the phrase comes from.
But here’s the twist: imaging doesn’t always match pain. Some folks with scary X-rays feel fine. Others with mild imaging changes hurt like crazy. Pain comes from a mix of cartilage wear, inflammation, alignment, muscle strength, meniscus damage, and even the way you move.
As Dr. Sabrina Strickland puts it, “Imaging is one piece of the puzzle. We treat people, not pictures. The decision isn’t just about what the X-ray shows—it’s about your function, your goals, and what you’ve already tried.”
Translation: your life, your pain, and your goals matter as much as your films.
When A Knee Replacement Makes Sense
Total knee replacement (TKR) or partial knee replacement (PKR) can be a miracle for the right person. The hardware today is excellent. Many people walk the same day and return to activities in a few months. But knee replacement is a major surgery. It comes with risks and recovery. So how do you know if it’s the right call?
You may be a good candidate if:
- Pain disrupts daily life despite conservative care (PT, meds, injections).
- Your knee buckles, locks, or limits function (stairs, sleep, standing).
- You have advanced arthritis in most or all compartments of the knee.
- You’re healthy enough for surgery and ready to commit to rehab.
Who might benefit from a partial knee replacement?
- People with arthritis limited to one compartment (often the medial side).
- Good alignment, stable ligaments(MCL/LCL, ACL, and PCL), and good range of motion.
- Desire to keep as much of the native knee as possible.
Pros:
- High success rates
- Reliable pain relief
- Predictable outcomes
Cons:
- Surgical risks (infection, clots, stiffness)
- Recovery and rehab commitment
- Artificial joint lifespan (often 15–20+ years, but varies)
If your knee has severe, multi-compartment damage and your pain is relentless, a knee replacement may restore your life. If not, you might have some great options to try first.
The Ladder: Start Conservative, Then Climb
Think of knee care as a ladder. You start on the lower rungs and climb only if you need to.
Lifestyle and Physical Therapy
- Strength training. Strong quads, glutes, and hips offload your knee. Even a 10% strength gain can reduce pain.
- Weight management. Every pound lost can take about four to five pounds of pressure off the knee. That’s not a guilt trip; it’s physics—and it helps.
- Movement hygiene. Swap deep lunges for shallow ranges. Shorten your run. Add cycling, swimming, or the elliptical.
- Bracing and taping. Offloader braces can reduce pressure on the painful side.
- Footwear and orthotics. Support matters. Your shoes can change knee load.
Evidence note: High-quality PT consistently reduces pain and improves function in knee OA. It’s unglamorous and incredibly effective.
Medications and Injections
- NSAIDs. Over-the-counter options like ibuprofen or naproxen can help; prescription options may last longer. Not a long-term solution for everyone—watch your stomach, kidneys, and blood pressure.
- Topicals. Diclofenac gel can be a safer way to get anti-inflammatory relief.
- Corticosteroid injections. They are Effective for managing short-term pain flares. Relief can last weeks to a few months. Not ideal to repeat often.
- Hyaluronic acid (viscosupplementation). Think “joint lube.” Results vary—some feel great, others feel nothing. Works best for mild to moderate OA.
- Platelet-rich plasma (PRP). Uses your own platelets to calm inflammation. Growing evidence supports PRP for certain patients, especially earlier in the disease process. Not usually covered by insurance.
These options won’t rebuild cartilage, but they can buy time and improve life while you plan next steps.
The Misha Knee System: A Middle-Ground Option
If you’ve heard whispers about the Misha Knee System, here’s the gist: it’s an implant that sits outside the joint and helps offload the medial (inside) compartment of the knee. Think of it as a shock absorber that takes pressure off the worn area when you walk. It doesn’t remove bone. It doesn’t replace the joint. And it’s designed for people with medial compartment osteoarthritis who aren’t ready for a partial or total knee replacement.
Who might be a candidate?
- Medial compartment OA with pain that limits activity
- Prior conservative treatments were tried without enough relief
- Decent range of motion and alignment
- Desire to preserve bone and delay replacement
Potential benefits:
- Pain relief by offloading the sore side
- Bone-sparing—future options stay open
- Faster recovery than joint replacement for many patients
Considerations:
- Not for everyone (tricompartmental OA or severe deformity may rule it out)
- As with any implant, there are risks (infection, device-related issues)
- You still need strength and movement training for the best results
For me, the MISHA took almost 10+ months before I started feeling like I could run again. Now, I’m at the point where I’m slowly getting back.
Stem Cells and Regenerative Hype: What’s Real?
If you’ve been on social media for five minutes, you’ve seen knee “miracle” stories. Let’s cut the noise.
- Stem cell therapy. Most clinics use bone marrow concentrate or adipose (fat)-derived cells. The term “stem cells” gets used loosely. There is currently no strong evidence that these treatments regrow cartilage in advanced OA. Some people report pain relief, especially in the early stages of the disease. Results vary widely, and treatments are often expensive and not covered by insurance.
- PRP. Better evidence than stem cells for symptom relief in mild to moderate OA. Not a cure, but can improve pain and function.
- Exosomes and amniotic products. Interesting science, not enough high-quality evidence for OA yet.
Dr. Strickland’s perspective aligns with many academic centers: try PRP when appropriate, be cautious with “stem cell” marketing, and weigh cost versus likely benefit. If you’re paying out-of-pocket, make sure you understand the odds.
Meniscus, Alignment, and Cartilage Procedures
Your knee is a team sport: cartilage, meniscus, ligaments, muscles, and alignment all play together. If one piece is off, you feel it.
- Meniscus repair or root repair: If you’ve had an acute tear (especially a root tear) and your joint isn’t too arthritic, repairing it can restore load sharing and reduce pain.
- Osteotomy (HTO): If your leg alignment shifts load to the painful side (varus “bow-legged” or valgus “knock-kneed”), a realignment surgery can offload the damaged area and delay arthritis progression. Great for active patients with unicompartmental disease.
- Cartilage restoration: Procedures like MACI (autologous grafting), osteochondral grafts, or synthetic implants are for focal cartilage defects rather than widespread arthritis. Ideal in younger, active patients with isolated lesions.
These are not one-size-fits-all, but in the right hands for the right knee, they can be game-changers.
How to Decide: A Simple Framework
When your brain is spinning, use this checklist to get grounded.
1) Symptom snapshot
- How bad is the pain on a 0–10 scale?
- What can’t you do today that you want back?
- Does the knee swell, lock, or give way?
2) What have you tried?
- PT (at least 6–12 weeks with progressive strength work)
- Meds/topicals
- Injections (steroid, HA, PRP)
- Bracing, footwear, activity changes, weight loss
3) Imaging and exam
- X-ray for joint space and alignment
- MRI if a meniscus or cartilage lesion is suspected
- Functional tests (single-leg sit-to-stand, step-down)
4) Match the treatment to your goals
- Want to keep running 5Ks? Ask about alignment, bracing, PRP, or Misha if you’re a candidate.
- Need predictable pain relief for daily life? Partial or total knee replacement may be the best bet.
- Early disease? Go heavy on PT, weight loss, PRP, and smart training.
5) Consider timing
- Big trip or race coming up? Plan injections and PT first.
- Ready to be done with constant pain? Replacement might be worth it.
And through all of this, keep your eyes on quality-of-life metrics: sleep, stairs, standing at events, playing with kids or grandkids. Those matter more than any radiology report.
What About Recovery and Expectations?
- PT is non-negotiable. Whether you get injections, Misha, an osteotomy, or a replacement, strength and motion work are your insurance policy.
- Pain isn’t linear. You’ll have good days and “why did I do this?” days. Stick with the plan.
- Function first. Measure wins by what you can do: walk farther, climb stairs, stand without throbbing.
A Word From the Expert
Dr. Sabrina Strickland, orthopedic surgeon at Hospital for Special Surgery, shared this: “The best outcomes come when treatment matches the person’s goals. Some patients do beautifully with nonoperative care or joint-preserving options. Others are ready for knee replacement and get their life back fast. We look at pain, function, alignment, and activity level—then choose the path that fits you.”
My Two Cents (And a Pep Talk)
If your knee hurts, you’re not weak—you’re human. You don’t have to jump to surgery, and you don’t have to suffer needlessly either. Start low, build strong, and keep an open mind. Use data, not fear. Ask hard questions. Bring your goals to the table.
And yes, if someone tells you you’re “bone on bone,” smile and ask: “Okay, but what can we try first?”
Action Steps You Can Take This Week
- Book a consult with an orthopedic knee specialist who treats across the spectrum, not just surgery.
- Start a targeted PT program focused on quads, glutes, hips, and balance.
- Try a top-tier shoe with cushioning and stability; consider an offloader brace if pain is medial.
- Discuss injections — steroid for a flare, HA, or PRP for ongoing symptoms.
- Ask if you’re a candidate for Misha, osteotomy, or partial replacement before jumping to total.
- Track your function: stairs, sleep, walking time. Decisions get clearer when you see trends.
You deserve a plan as individual as your stride. With a smart approach—and a great doctor in your corner—you can move from “bone on bone” dread to daily wins.
