Bone marrow lesions (BMLs) are commonly identified on knee MRI and are increasingly recognized as an important contributor to knee pain, particularly in patients with osteoarthritis or prior joint injury. These lesions reflect changes within the bone beneath the joint surface and may be associated with pain, inflammation, and altered joint mechanics.
At our Miami clinic, we provide a comprehensive, non-surgical approach to the evaluation and treatment of bone marrow lesions focused on accurate diagnosis, symptom management, joint preservation, and individualized care planning.
Bone marrow lesions are areas within the bone that appear as signal changes on MRI, typically beneath the cartilage surface of the knee joint. They are sometimes referred to as bone marrow edema–like lesions, though they represent a variety of underlying bone changes rather than simple fluid accumulation.
Bone marrow lesions are most commonly seen in:
They are not visible on standard X-rays and are best identified using MRI.
Research has shown that bone marrow lesions are often associated with:
In many patients, bone marrow lesions correlate more closely with pain than cartilage loss alone. However, not all bone marrow lesions cause symptoms, which is why clinical correlation is essential.
Diagnosis involves correlating MRI findings with symptoms and physical examination. Evaluation typically includes:
Detailed history and symptom assessment
Physical examination focusing on knee mechanics and joint loading
Review of prior imaging
MRI of the knee to identify bone marrow lesions and associated joint changes
Imaging findings are interpreted in the context of symptoms, as not all lesions require intervention.
Bone marrow lesions develop when the subchondral bone — the dense layer of bone just beneath the articular cartilage — is subjected to abnormal mechanical stress, injury, or degenerative change. Common causes include:
Unlike cartilage loss — which is largely irreversible once established — bone marrow lesions can potentially regress with appropriate treatment, particularly when mechanical loading is reduced and biological support is provided. This is one reason why early identification and targeted treatment of BMLs is clinically important.
Symptoms may vary depending on lesion size, location, and underlying joint health. Common symptoms include:
Symptoms often overlap with those of osteoarthritis.
Treatment is individualized and focuses on reducing pain, improving function, and addressing contributing factors. If the bone marrow lesions is asymptomatic, it is unlikely that any treatment needs to be undertaken.
Physical therapy may focus on:
Activity modification is often an important part of treatment.
Appropriate medication strategies may include:
Medications can help manage symptoms while other therapies promote healing.
Targeted injections can reduce inflammation and pain:
These are performed under imaging guidance when appropriate to ensure accuracy and safety.
Knee braces, orthotics, and supportive devices may reduce strain and improve stability during activities.
In cases where conservative care alone is insufficient, regenerative medicine offers a biologically targeted approach to treating bone marrow lesions — one that specifically addresses the subchondral bone pathology rather than simply managing symptoms around it.
PRP concentrates growth factors from your own blood — including TGF-β, BMP-2, and PDGF — and delivers them into the joint under ultrasound guidance. While PRP is primarily an intraarticular treatment targeting the joint environment, it can reduce the synovial inflammation and mechanical stress that drive ongoing bone marrow lesion development and progression.
BMAC is the most biologically targeted treatment available for bone marrow lesions. Because BMAC is derived from bone marrow itself, it is biologically native to the tissue where BMLs occur. When delivered intraosseously — directly into the bone marrow lesion through the cortical bone under fluoroscopic guidance — BMAC delivers mesenchymal stem cells, anti-inflammatory cytokines, and bone-remodeling growth factors precisely to the site of pathology.
This is a fundamentally different approach from intraarticular injection. Standard joint injections deliver medication into the joint space. Intraosseous BMAC penetrates the bone itself to reach the lesion directly — the only way to address the subchondral bone pathology at its source.
Dr. Bonner performs intraosseous BMAC as part of the Regenexx network — one of the few practices in Miami offering this advanced technique. Research by Dr. Philippe Hernigou has demonstrated that bone marrow lesion regression after intraosseous BMAC is one of the strongest predictors of long-term joint preservation, with persistent BMLs larger than 3 cm³ carrying a hazard ratio of 4.42 for subsequent knee replacement (PMID 32322943).
Both PRP and BMAC are performed under image guidance — ultrasound or fluoroscopic guidance for intraarticular delivery, fluoroscopic guidance for intraosseous access — to ensure precise, safe delivery to the target tissue.
| Treatment Type | Purpose | Duration of Impact | Invasiveness |
|---|---|---|---|
| Physical Therapy | Improve movement and function | Long-term with adherence | Non-invasive |
| Medications | Pain and inflammation control | Short-term | Non-invasive |
| Bracing/Support | Reduce joint stress | Activity-dependent | Non-invasive |
| Injections (steroid, hyaluronic acid) | Reduce inflammation | Weeks to months | Minimally invasive |
| Regenerative Treatments (PRP/BMAC Stem Cell Therapy) | Support tissue healing and BML regression | Months to years | Minimally invasive |
| Surgery (if necessary) | Structural repair | Permanent | Invasive |
Many patients benefit from a coordinated, non-surgical plan before considering surgical intervention.
You may be a good candidate if you:
Treatment plans are individualized based on imaging findings, symptoms, and functional goals.
Active adults and professionals often place significant stress on the knees through sports and repetitive movements which can sometimes lead to the development of painful bone marrow lesions. Treatment focuses on:
The goal is to help patients remain active and productive while managing symptoms safely and effectively.
Rarely. Most cases of painful bone marrow lesions can be treated successfully with non-surgical care including therapy, patience, injections, and regenerative procedures.
When performed by trained specialists using your own biologic materials, regenerative procedures are generally considered safe and may support healing processes. These procedures should always be performed with imaging guidance like ultrasound and fluoroscopy to target very specific structures in or around the knee joint.
Recovery times vary by condition and treatment. Rehabilitation and regenerative care may take weeks to months for optimal improvement.
Imaging is used when it will meaningfully influence diagnosis or treatment planning. An MRI is the study that can detect a bone marrow lesion that may be associated with pain.
Bone marrow lesions are only visible on MRI. If your MRI report mentions “bone marrow edema,” “subchondral signal change,” or “bone marrow lesion” and you have significant knee pain, there is a strong likelihood the BMLs are contributing to your symptoms — they are the strongest MRI predictor of pain intensity in knee osteoarthritis. Dr. Bonner reviews MRI findings carefully at consultation to correlate the imaging with your symptoms and determine whether targeted treatment is appropriate.
A standard intraarticular injection delivers medication into the joint space. Intraosseous BMAC uses a specialized needle advanced through the cortical bone into the subchondral marrow lesion itself under fluoroscopic guidance — delivering stem cells directly to the bone pathology. This is a technically demanding procedure that most practices do not offer. It requires specific training, fluoroscopic guidance, and experience in intraosseous access techniques. Dr. Bonner performs this procedure as part of the Regenexx network’s advanced protocols.
Yes. BMLs can occur in the hip, shoulder, ankle, and spine — where they are called Modic changes at the vertebral endplates. The same principles of subchondral bone pathology apply across joints. Dr. Bonner evaluates and treats bone marrow lesions at multiple sites using targeted injection protocols appropriate to each joint’s anatomy.
If you are experiencing knee pain, or other painful condition, and want a comprehensive evaluation and non-surgical treatment plan, we are here to help. Contact our Miami clinic to schedule an appointment.
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