Bone on Bone = Eventual Knee Surgery? Not necessarily…

Misconceptions about one’s health are everywhere, the internet is filled with them!  Is it anyone’s fault for such? Not necessarily. For a long time, Western Medicine has relied on a Biomechanical model or Cause and Effect in regards to tissue damage and pain.

To use an analogy, because I love them, society has often tried to associate someone’s body to a car.  If there is something wrong with your car you take it into your mechanic, he or she fixes it, and boom your car is good again.  Makes sense right? Well guess what, we are not cars! (shocking I know).  A car does not have one of the most perplexing groupings of matter we have ever found in the universe: the human brain.  The brain has a say in nearly every process which goes on in our bodies and is why we are not as straight forward to fix as a car [sometimes].  Such perplexity ties in nicely with the topic of this post: “Bone on Bone”.  “Bone on Bone” is a phrase I often hear from those coming in with knee pain and sometimes hip pain.

First off, what does “Bone on Bone” mean? “Bone on Bone” is  reference to the increased severity of OA (osteoarthritis) in a joint. Osteoartritis is the presence of inflammation of bones in a joint due to a reduction of cartilage.  In a healthy joint cartilage aids in the congruency of movement of the joint between the two bones.  Thus if someone has a joint which is “Bone on Bone” it suggests the amount of cartilage on the bones in the joint is reduced and inflammation present.  Some research has found a correlation between knee pain and OA. Gorial et al found a statistical positive correlation between increased knee OA and functional limitations in 150 individuals in 20181. Why does osteoarthritis happen? The answer remains up for debate but scientists are findings extended periods inactivity2, genetics3, previous surgeries in the affected joint4, and past medical history3, may play a roll in the development of OA.  As I had mentioned earlier we are not car (I would probably be a mini-van thanks to young children) and knee pain does not always correlate to more tissue damage in our bodies.

While some research has shown a positive correlation of increased knee pain with increased OA, some has not. Muraki et al did a large study in Japan with the idea to find what has a strong positive correlation with OA related knee pain.  They used 2,152 subjects who suffered from knee pain and observed quadriceps strength, lower extremity muscle mass, grip strength, knee radiographs and the degree of knee OA, and pain levels.  They found an independent positive correlation of quadriceps muscle strength (the muscle located in the front of your thigh) and knee pain5.  With such being found it suggests improved quadriceps strength will decrease knee pain and prevent it from happening in the future.  With a decrease in strength of the muscles around your knee and hip, the body is increasingly forced to rely on the passive structures of your ligaments, bones, and cartilage.  With age your ligaments and cartilage show signs of use and are not as strong as they were in youth.  An instability [problem] is perceived by the brain and a pain signal is created to bring it to the attention of the individual to either solve the problem or take caution.  By strengthening the muscles we can help to solve such an instability.  Improving the strength of muscles in your legs provides a lasting stability to aid your ligaments and cartilage.  From the Muraki et al study we know strengthening can help to decreased knee pain but it does not always solve the issue completely. I have worked with numerous individuals in which strengthening, while beneficial (you usually cannot go wrong with being as strong as an Olympian), did not provide the best results.  Thankfully we have other options.

Therapeutic exercise is not the only treatment physical therapy has to offer those with osteoarthritic knee pain.  Courtney et al posed the question “Does manual therapy (joint mobilizations) help to decreased knee pain”6.  They studied 40 individuals with moderate to severe knee OA and found most of whom (73% of them) had an abnormal conditioned pain modulation.  In other words, the system for perceiving pain by the brain was sensitized.  For these individuals it took less of a “nociceptive input” for his or her brain to register the pain signal. In the study Courtney et al performed joint mobilizations on all 40 individuals and found manual therapy aided in reduction of knee pain.  By providing the sensory system with the feedback of manually moving the painful joint the brain was able to retrain its abnormal pain system.

The research tells us strengthening the muscles of the hips and knee and performing joint mobilizations help to decreased osteoarthritic related knee pain.  We as individuals are not as straightforward as machines.  We are much more.  Plus everyone is a little different, obviously.  Thus what may work for one person may not work for another.  My job as a physical therapist is to find what works best for you!  I love it.  It provides variability to my day and many unique challenges.  In conclusion, “bone on bone” is not game over. GAME ON!

Written by Thomas Hunt, PT, DPT



1. Gorial FI, Anwer Sabah SA, Kadhim MB, Jamal NB. Functional Status in Knee Osteoarthritis and its Relation to Demographic and Clinical Features. Mediterr J Rheumatol. 2018;29(4):207–210. Published 2018 Dec 18. doi:10.31138/mjr.29.4.207

2. Musumeci G, Aiello FC, Szychlinska MA, Di Rosa M, Castrogiovanni P, Mobasheri A. Osteoarthritis in the XXIst century: risk factors and behaviours that influence disease onset and progression. Int J Mol Sci. 2015;16(3):6093–6112. Published 2015 Mar 16. doi:10.3390/ijms16036093

3. Smith MV, Nepple JJ, Wright RW, Matava MJ, Brophy RH. Knee Osteoarthritis Is Associated With Previous Meniscus and Anterior Cruciate Ligament Surgery Among Elite College American Football Athletes. Sports Health. 2017;9(3):247–251. doi:10.1177/1941738116683146

4. Fernández-Moreno M, Rego I, Carreira-Garcia V, Blanco FJ. Genetics in osteoarthritis. Curr Genomics. 2008;9(8):542–547. doi:10.2174/138920208786847953

5. Muraki S, Akune T, Teraguchi M, et al. Quadriceps muscle strength, radiographic knee osteoarthritis and knee pain: the ROAD study. BMC Musculoskelet Disord. 2015;16:305.

6. Courtney CA, Steffen AD, Fernández-de-las-peñas C, Kim J, Chmell SJ. Joint Mobilization Enhances Mechanisms of Conditioned Pain Modulation in Individuals With Osteoarthritis of the Knee. J Orthop Sports Phys Ther. 2016;46(3):168-76.

You may also like

Get Better and Stay Better

If you’ve been dealing with a nagging injury or persistent pain, don’t wait any longer. Schedule an appointment with one of our caring physical therapists today.