Therapeutic Strategy for Knee Osteoarthritis with Subchondral Bone Lesions: Combination Therapy of Extracorporeal Shockwave Therapy and Regenerative Medicine

Knee osteoarthritis (OA), once considered a cartilage disorder, is now recognized as a whole-joint disease involving the cartilage, subchondral bone, synovium, ligaments, and muscles implicated by biomechanical stress, inflammation, and immune responses. Bone marrow lesions (BMLs), closely linked to pain and disease progression, represent an important therapeutic target. Recent regenerative strategies include extracorporeal shockwave therapy (ESWT), platelet-rich plasma, autologous protein solution (APS), and mesenchymal stromal cells (MSCs), yet the optimal approach remains uncertain. This study compared ESWT alone, APS + ESWT, and intra-articular MSC + ESWT (MSC-A + ESWT) and retrospectively evaluated a newly developed combined intra-articular and intra-osseous MSC + ESWT (MSC-B + ESWT) in patients with OA and BMLs (2020–2024). Knee injury and Osteoarthritis Outcome Scores (KOOSs) at baseline, 3, and 6 months were analyzed. ESWT improved KOOS by 6 months, although with less improvement in cases with surface collapse. APS + ESWT accelerated improvement by 3 months, especially in cases without subchondral bone plate (SBP) tear. MSC-A + ESWT yielded the highest early gains but plateaued thereafter. MSC-B + ESWT showed marked improvement in SBP tear-type BMLs without collapse. Overall, ESWT was effective, APS enhanced early outcomes, and MSC-B + ESWT was promising for advanced cases.