In a conversation with Dr. Borgmann, the editorial team of the Leading Medicine Guide learned more about conservative regenerative therapy for knee osteoarthritis (gonarthrosis).
Knee osteoarthritis — that is, degenerative wear and tear of the knee joint — is among the most common joint diseases and can significantly impact patients’ quality of life. While surgery is often viewed as a last resort, conservative regenerative therapy is becoming increasingly important.
The goal of these modern treatment approaches is to preserve joint function, relieve pain, and slow progressive cartilage loss – without surgery. Innovative methods such as extracorporeal shockwave therapy, PRP injections, or the use of biological healing stimuli open up new perspectives in the treatment of knee osteoarthritis and enable individualized, gentle care.
Patients with knee osteoarthritis typically seek medical help when pain and mobility limitations in everyday life increase. Individualized diagnostics play a central role in selecting the appropriate conservative treatment for gonarthrosis – especially in the context of regenerative approaches.
„When it comes to knee osteoarthritis, we first look at what brings the patient to us in the first place. Often it’s load-dependent pain that significantly reduces quality of life. Patients report that they can no longer be as active in sports as they used to be. Tennis, training, or jogging may still be possible, but issues arise on uneven ground, on trails, or in hilly terrain.
Especially in older people who enjoy hiking, we often notice they can no longer keep up on steeper climbs or longer ascents because their knees hurt. This can involve any type of load that triggers pain. In addition, with existing gonarthrosis, symptoms are sometimes only activated by overuse. This means the knee reacts to overload even if there were no prior complaints, showing up as pain, swelling, or sometimes even warmth.
Nocturnal pain or joint overuse can also occur, often without the patient being aware of it. The primary cause of all this is wear and tear – but we now know it is usually a so-called ‘silent inflammation.’ This leads to cartilage breakdown outweighing cartilage-preserving processes, so degeneration progresses. In terms of age, we generally talk about patients from 50 years onward.
In younger individuals who show signs before the age of 40, this is rather unusual and should be clarified more thoroughly; other causes such as rheumatic diseases or injuries, for example after an ACL tear in youth, may play a role. In such cases, biomechanical instability or malalignment can cause the symptoms. However, it is mainly patients over 50 in whom this degenerative condition occurs within the usual range“, explains Dr. Borgmann at the start of our conversation.
Osteoarthritis is not a uniform disease but a complex interplay of structural, functional, and inflammatory processes that can vary greatly from patient to patient. Imaging techniques such as X-ray, MRI, or 4D spinal and leg axis measurement provide precise information about the structural condition of the knee joint, such as cartilage wear, joint space changes, malalignment, or accompanying pathologies like Baker’s cysts or subchondral bone changes.
This information is essential to accurately assess the osteoarthritis stage and to decide whether a regenerative measure – such as PRP, shockwave, or laser therapy – is appropriate and promising.
„When a patient comes to us, diagnostics fundamentally begin with a detailed medical history, as this is truly the be-all and end-all for making a diagnosis. I place particular emphasis on finding out with which movements or activities the pain occurs, what aggravates it, and what relieves it. This is enormously helpful for identifying the exact cause of the symptoms and refining the diagnosis. A manual examination follows, during which we always consider the overall body statics.
The patient is usually examined in underwear so we can properly assess spinal posture, pelvic alignment, and foot position to identify malalignment or improper loading. The knee joint is then examined palpatorily. Ultrasound is usually sufficient for us to make the diagnosis, and we generally do not need X-ray or MRI.
MRI can be added to assess bony structures more precisely, for example if pronounced bone irritation or bone marrow edema is suspected, which would indicate a stronger activation of cartilage-degrading processes. For typical degenerative changes, an ultrasound exam is usually enough, but in cases where possible osteonecrosis or more significant bony involvement is in question, MRI is useful“, says Dr. Borgmann of the diagnostic workup, and continues:
„When deciding whether to continue conservatively or consider surgery, the examination results are decisive. As a rule, conservative therapy is the first choice, in about 95 to 98 percent of cases. I am consistently impressed that even with advanced degenerative changes, you can achieve good outcomes and make patients pain-free or significantly more comfortable through consistent, targeted inflammation management, rest, and reduction of irritation.
That allows them to manage daily life well. I only see a surgical indication when specific secondary problems arise that sustainably impair function. For example, with severe gonarthrosis and a substantial extension deficit, if the pelvis is markedly tilted and the spine is consequently affected. In such cases, it is necessary to treat these secondary problems, because the real issue is not only the knee but the malalignment that burdens other structures. Surgery is then sensible to break this vicious cycle“.
Regenerative therapies for knee osteoarthritis aim to activate the body’s natural healing mechanisms and halt or slow degenerative processes in the knee joint. Unlike purely symptomatic treatment, they leverage biological repair and regeneration within the damaged joint.
A central biological process is stimulating cellular regeneration – particularly of chondrocytes, the cartilage-forming cells. Treatments such as PRP therapy (platelet-rich plasma) or stem cell-based approaches promote the release of growth factors that can reduce inflammation and stimulate the formation of cartilage and connective tissue. This modulates the local immune milieu, thereby attenuating inflammatory processes and suppressing catabolic (degradative) mechanisms in the cartilage.
Another effect concerns the synovial fluid in the knee: regenerative therapies can improve its composition, enhancing the gliding ability of joint surfaces and reducing mechanical friction – an important prerequisite for pain relief and better mobility. In addition, methods such as shockwave therapy or electromagnetic transduction therapy promote microcirculation and cellular metabolic processes in the surrounding tissue.
This improves the supply to cartilage, capsule, and musculature and can lead to increased tissue vitality. Overall, regenerative therapies can positively influence the course of knee osteoarthritis by reducing inflammation, relieving pain, normalizing joint metabolism, and, in early to mid stages, even initiating structural regeneration processes. As a result, patients gain not only quality of life but often valuable time before surgery becomes necessary.
Dr. Borgmann explains further: „When it comes to conservative therapies, our approach follows a standardized protocol that broadly relies on proven combinations yet is tailored individually. The aim is to achieve synergistic effects through a range of regenerative methods and to target various tissues involved in the problem.
At the initial visit, we often start with focused shockwave therapy to treat different structures, including soft tissues such as the joint capsule and ligament apparatus that contribute to pain. This approach supports regeneration of the synovial lining and stimulates the formation of certain receptors, particularly the CD44 receptor, which plays an important role in healing. About a week later, we administer an injection of platelet-rich plasma (PRP) and hyaluronic acid to specifically improve the intra-articular environment, joint metabolism, and inflammatory activity.
This five- to seven-day interval is optimal because CD44 receptor expression is at its peak during this phase. Another building block is high-energy magnetic field therapy, which treats both soft tissues and bone. The interventional treatment of bone is especially important because irritation, such as bone marrow edema, can be addressed directly.
This edema lies beneath the cartilage and varies in severity depending on the case. As part of conservative therapy, we naturally also treat the musculature, especially the thigh muscles, using osteopathic techniques, pressure massage, and vibration treatments to reduce load on the knee. We also perform posture and movement analysis to balance muscular imbalances and improve leg stability. The goal is to achieve a lasting improvement“, and adds regarding the duration of therapy:
„The entire treatment process typically extends over about eight weeks. Initially, in the first two to four weeks, treatment is more intensive, usually twice a week, to target all tissues specifically and bring the body out of the inflammatory phase. The frequency is then reduced to about once weekly, and as patients do home exercises or train independently in the gym, intervals become longer.
Injections that we administer around the second week are usually repeated after four weeks and, depending on the case, again after three to six months. Finally, we regularly recommend a booster session, about once a year, to secure long-term treatment success. Regarding the period after treatment, the goal is to halt the progression of osteoarthritis as much as possible. A complete cure or reversal of osteoarthritis is not yet possible, although there are studies showing an increase in cartilage volume with PAP injections.
This change is probably more attributable to revitalization of the cartilage – better water absorption – rather than actual cartilage growth. We therefore do not currently view a cure for osteoarthritis as realistic. It is important to remain active long term, through exercise, weight reduction, a healthy diet, and adequate vitamin D and omega-3. We therefore recommend regular check-ups and, if necessary, booster treatments to maintain the condition as well as possible.
However, if pain, swelling, and movement restrictions increase significantly despite these measures to the point that everyday activities are barely possible, the limits of conservative treatment must be discussed and further options considered. Otherwise, treatment can be helpful for several years“.
PRP therapy, shockwave therapy, and other regenerative procedures differ in their mechanisms of action, target structures, and indications in knee osteoarthritis (gonarthrosis) – even though they all share the goal of slowing degeneration, relieving pain, and improving joint function.
„When a patient begins therapy, the timing of the first noticeable improvement can vary. Ideally, some relief should be felt after the first treatment, but that depends heavily on which tissue structure is primarily generating pain and how pronounced the overall findings are.
Some patients notice improvement immediately after the injection, while in others the first benefit may only occur after the second injection. This means the effect may only become apparent after about five or six weeks, although most patients should notice a tangible improvement within the first two to three weeks. It is a process in which the healing trajectory varies individually, but a positive trend should usually become apparent fairly soon.
As for application variants, there are certainly differences between providers. Devices differ in handling, but we believe the decisive factor is proper application and a solid treatment concept. Our therapeutic concept has been developed over the past ten years and is based on an intensive two-year advanced training program comparable to a specialization.
What is distinctive is the targeted interplay of various conservative methods, because only the combination of shockwave therapy, PRP injections, hyaluronic acid, high-energy magnetic field therapy, and muscular and postural activation yields the best possible results. That requires time, intensive training, and appropriate practice equipment, because the synergy of these methods makes the crucial difference – like a recipe in which only the right mix produces a delicious cake“, says Dr. Borgmann.
These therapies are usually private services. This means patients with statutory insurance must cover the costs themselves. Private health insurers cover the costs in roughly 90 percent of cases.
„For those with statutory insurance, treatment is not covered by the health insurers and must therefore be paid out of pocket. Nevertheless, it is a worthwhile investment, because these preventive measures help avert more serious problems and potential follow-up costs that could be much higher. Unfortunately, our healthcare system is more disease-oriented than prevention-oriented. It is therefore crucial that only a combination of proven therapeutic procedures and proper application can achieve optimal results“, emphasizes Dr. Borgmann.
PRP therapy (platelet-rich plasma) is based on injecting processed, platelet-rich autologous blood into the affected joint. The growth factors and inflammation-modulating substances in PRP stimulate cellular regeneration, particularly of cartilage and tendon cells. It is especially suitable for early to mid-stage osteoarthritis, especially in patients with inflammation-related pain phases and emerging functional loss. Studies show good results in terms of pain relief and functional improvement, particularly compared with hyaluronic acid.
In contrast, extracorporeal shockwave therapy (ESWT) acts mechanobiologically by using acoustic pressure impulses to promote increased microcirculation, metabolic activation, and tissue regeneration. Shockwaves are usually applied not intra-articularly but periarticularly – e.g., to treat accompanying tendinopathies, muscular imbalances, enthesiopathies, or trigger points. It is particularly effective for myofascially induced pain or painful accompanying structures that frequently occur secondary to osteoarthritis.
There are universally valid tips anyone can implement to optimally support the knee and at least slow osteoarthritis. The most important by far is sufficient exercise to strengthen the muscles around the knee and unload the joints.
„In addition to adequate physical activity, you should aim for an anti-inflammatory lifestyle characterized by a regular sleep rhythm, as sufficient, restorative sleep supports regeneration. It is also advisable to avoid acid-forming habits: do not smoke and reduce consumption of coffee, alcohol, and especially sugar or refined white flour products as much as possible.
From a nutritional standpoint, a low-carbohydrate, Mediterranean-style diet is recommended because it has anti-inflammatory effects and supports overall well-being. Taking dietary supplements, especially vitamin D and omega-3 fatty acids, can also be useful. It is worth having these levels checked to reach the optimal range. When acute pain flares up, home remedies such as quark (curd) compresses can also provide quick and simple relief.
Above all, the combination of exercise, healthy nutrition, sleep, and targeted supplements is an effective approach to slowing joint wear and alleviating symptoms“, recommends Dr. Borgmann, and with that we conclude our conversation.
Dr. Borgmann, thank you very much for the helpful insights into your work and the treatment options for knee osteoarthritis!
- Specialist in orthopedics and trauma surgery, Diplom-Osteopath (DGOM), and founder of the private practice Orthopassion in Freiburg – Center for Orthopedics, Osteopathy, and Movement Medicine
- Treatment focus: regenerative orthopedics and osteopathic medicine – a combination of modern high-tech medicine and manual therapy
- Therapeutic methods: extracorporeal shockwave therapy (ESWT), PRP therapy (autologous blood treatment), Tenex procedure (minimally invasive tendon treatment)
- Modern diagnostics: 4D spinal measurement, High Performance MotionLab with running and movement analysis
- Treatment approach: holistic and interdisciplinary, e.g., in CMD (craniomandibular dysfunction)
- Distinctive feature: integration of conventional medicine, osteopathy, and innovative diagnostics
