Intraosseous Injections
Most clinics treat arthritis from inside the joint space. We also treat the bone beneath it — delivering marrow concentrate into the subchondral bone, where advanced arthritis actually lives.
Why the bone beneath the cartilage matters
Arthritis isn't only a cartilage problem. As a joint degenerates, the subchondral bone under the cartilage remodels, stiffens and develops the bone marrow lesions that light up on MRI — changes tightly linked to pain and to how fast the joint deteriorates.
An injection into the joint space never reaches that layer. Intraosseous delivery does: under imaging guidance, bone marrow concentrate is placed directly into the subchondral bone, putting regenerative cells and growth factors inside the compartment driving the disease.
Dr. DeWald is among the few physicians offering intraosseous delivery for the knee, hip, shoulder and other joints — typically paired with intra-articular treatment in the same visit, so both sides of the joint surface are addressed at once. The technique sits on top of IOF certification in Advanced Hip & Knee — the Interventional Orthobiologics Foundation's procedural credential for exactly this class of work.
The Hernigou data
The strongest long-term signal in orthobiologics comes from subchondral work. In a prospective randomized study by Philippe Hernigou and colleagues, patients with bilateral knee osteoarthritis received a knee replacement on one side and subchondral bone marrow cell injections on the other — and were followed for a mean of fifteen years. Most of the injected knees never required an implant. Read the study on PubMed.
No single study settles a field, and candidacy still decides everything — but for the right joint, this is fifteen-year randomized evidence that treating the bone changes the trajectory. The full literature, negative trials included, lives on our research page.
Your intraosseous visit, step by step
Candidacy & imaging
Exam plus review of your MRI — bone marrow lesions and subchondral change tell us whether the bone itself needs treating.
Marrow harvest
A small aspirate from the back of the pelvis under local anesthetic, concentrated on-site during your visit.
Subchondral delivery
The concentrate is placed into the subchondral bone under imaging guidance — usually alongside an intra-articular injection.
Structured recovery
Protected loading early, staged activity after — mapped to how subchondral bone actually heals.
Who intraosseous treatment is for
- Moderate-to-advanced knee osteoarthritis with bone marrow lesions on MRI
- Hip joint degeneration, including select early osteonecrosis cases
- Shoulder joint degeneration
- Bone marrow edema driving joint pain
- Joints where intra-articular injections alone fell short
- Patients weighing joint replacement who want the bone-level alternative first
Who it’s for
The MRI usually makes this call: subchondral change and bone marrow lesions argue for treating the bone, not just the space above it. An evaluation with imaging review settles whether your joint qualifies.
Common questions about intraosseous treatment
How is this different from a regular joint injection?
A standard injection floats treatment in the joint space. Intraosseous delivery places it inside the subchondral bone beneath the cartilage — a compartment ordinary injections cannot reach, and one deeply involved in advanced arthritis.
Does injecting into bone hurt?
It's more involved than a joint injection, but performed under generous local anesthetic with imaging guidance; comfort options are tailored to the patient. Expect a deep ache for a few days afterward — bone is simply slower to quiet down than soft tissue.
What's the evidence for this?
The centerpiece is Hernigou's randomized 15-year follow-up comparing subchondral bone marrow cell injection against knee replacement in the same patients — most injected knees never needed the implant. The full citation, alongside the rest of the literature, is on our research page.
Is it covered by insurance?
No — like most orthobiologics, this is cash-pay. Pricing is quoted before anything is scheduled, with documentation provided for any reimbursement you pursue.
Ask whether your joint needs bone-level treatment.
Bring your MRI. The evaluation reads the subchondral bone and tells you whether intraosseous delivery belongs in your plan.