Knee Arthritis: Injections, Bone-on-Bone, and When a Replacement Earns Its Place

Knee arthritis rarely announces itself. It shows up as stiffness on the first steps of the morning, an ache on the stairs at work, a knee that swells after yard work you used to do without thinking. And somewhere along the way, someone points at an X-ray and says the two words that scare people more than any others in orthopedics: bone-on-bone. This page is the conversation Dr. Kelly has in clinic every week — what is actually happening inside the joint, everything that can be done short of surgery, the honest truth about cortisone shots, and how to know when a knee replacement genuinely earns its place.

What knee arthritis actually is

Cartilage is the smooth, slick surface that caps the ends of your bones and lets the knee glide through millions of steps. Arthritis — osteoarthritis, in most knees — is that surface wearing thin over years and decades. Around here that often means a lifetime of farm work, Hanford shifts, ladders, concrete floors, and the sports that made all of it worth it. Once cartilage wears, no injection or supplement has been shown to grow it back. The goal of treatment is different: calm the joint down, strengthen everything that supports it, and keep you doing what you love for as long as possible.

Common signs of an arthritic knee include:

• Morning stiffness that loosens up as you get moving
• Aching with stairs, kneeling, or long days on your feet
• Swelling after activity that took no effort a few years ago
• Grinding or crunching (surgeons call it crepitus)
• A knee that feels less trustworthy on uneven ground

What does “bone-on-bone” actually mean?

“Bone-on-bone” means the cartilage in one part of the knee has worn all the way through, so on your X-ray the two bones appear to touch with no space between them. That space you see on a healthy knee X-ray isn’t empty — it’s cartilage, which doesn’t show up on X-ray. When the space is gone, the cartilage is gone in that spot. It describes your X-ray. It does not describe your pain, and it does not schedule your surgery.

Here’s the part that surprises people: published studies have repeatedly found that X-ray severity and pain don’t line up neatly. Dr. Kelly has patients with bone-on-bone X-rays who still hike Badger Mountain, and patients with milder-looking X-rays who can barely manage stairs. If you see him in clinic, expect to go through your X-ray together, side by side, until it makes sense to you. The questions he cares about more than the image: Can you sleep? Can you do stairs? What have you stopped doing?

Can you live with a bone-on-bone knee without surgery?

Yes — many people live full, active lives with a bone-on-bone knee, and the X-ray finding by itself is never the reason to operate. What usually makes it work: strong muscles around the joint doing part of the cartilage’s old job, smart adjustments to how you load the knee, and, when flares come, treatments that calm it back down. The X-ray doesn’t decide surgery — your life does.

If the non-surgical ladder below is keeping you sleeping, working, and doing most of what matters to you, the plan is simple: keep climbing it. When it stops holding your weight, that’s not failure — that’s information.

The non-surgical ladder for knee arthritis

Treatment for knee arthritis is a ladder, not a fork in the road. Most patients spend years on the lower rungs — and plenty never need the top one.

Physical therapy and activity changes. The single most durable rung. Stronger quadriceps and hip muscles take real load off the joint, and low-impact conditioning — cycling, swimming, walking on forgiving surfaces — keeps the knee moving without punishing it. A physical therapist builds this around your knee, your work, and your goals rather than a generic sheet of exercises.

Load management. Published studies estimate that each pound of body weight sends roughly four extra pounds of force through the knee with every step — which is why even modest weight loss often pays off out of proportion to the number on the scale. For arthritis limited to one side of the knee, an unloader brace helps some patients shift force away from the worn compartment.

Anti-inflammatories. Over-the-counter anti-inflammatories can take the edge off a flare for many people. They aren’t risk-free — it’s worth confirming with your primary care doctor that they’re safe alongside your health conditions and other medications.

Viscosupplementation (“gel shots”). These are injections of hyaluronic acid — a lubricant your joint fluid naturally contains, and worn knees run low on. The honest read: published studies are mixed. Some patients get months of meaningful relief; others notice little. Results vary — and Dr. Kelly will help you understand whether this is a good option for your knee, or not, before you commit.

PRP and biologics. Dr. Kelly offers platelet-rich plasma (PRP) injections — a concentrate of the healing factors in your own blood, prepared and injected the same visit. It’s one of the more promising developments in non-surgical arthritis care: in published studies, many patients report meaningful, months-long improvement in pain and function. It isn’t a cure, it won’t regrow cartilage, results vary from knee to knee, and it’s typically not covered by insurance — but for the right knee it can be a genuinely useful rung on the ladder. Dr. Kelly will give you an honest read on whether yours is a good candidate.

Cortisone. The most familiar rung — and the one that deserves its own honest conversation, below.

What are the side effects of a cortisone shot?

The most common side effects of a cortisone shot are a temporary pain flare for the first day or two, a short-term rise in blood sugar — something people with diabetes should watch closely — and, less often, thinning or lightening of the skin near the injection site. Some people notice facial flushing for a day or so. The rarest but most serious risk is infection in the joint.

Now the part fewer people explain before the needle goes in. Cortisone is a strong anti-inflammatory: it calms an angry joint down, usually for anywhere from a few weeks to a few months. What it does not do is regrow cartilage or fix the reason the joint got angry. That’s why second and third shots often don’t last as long as the first — the arthritis underneath is progressing. And there’s a reason injections are spaced out rather than given monthly: in published studies, frequent repeated injections may weaken the tissue around the joint over time.

So a cortisone shot is a great tool for calming a flare, buying time, or getting through a harvest, a season, or a family wedding. When the shots stop buying you much time, that’s not a failed shot — that’s the joint telling us it’s time to talk about the next rung.

Can a cortisone shot delay my knee replacement?

It can — and this is the part almost nobody mentions before the needle goes in. Published studies have associated cortisone injections given within roughly three months of a knee replacement with a higher risk of infection after surgery. For that reason, Dr. Kelly’s practice is to wait at least three months — sometimes longer, depending on the situation — between a cortisone injection in a knee and replacing that same knee.

What that means practically: if a replacement is realistically on the table in the next year, the timing of “one more shot” becomes a real scheduling decision to make together — not an afterthought. Sometimes the shot is still the right call. The point is deciding with your eyes open, so a shot in March doesn’t quietly move a surgery you wanted in May.

How long can you delay a knee replacement?

Usually as long as the non-surgical ladder keeps you living your life — for many people that’s years, and some never need surgery at all. Knee arthritis is almost never an emergency, and in most knees the cost of waiting is measured in quality of life, not danger. There’s no prize for suffering through five more years you didn’t have to — and no trophy for rushing into an operating room, either.

A few honest caveats. In some knees, worsening stiffness or deformity over time can make an eventual operation more involved, and muscles that stop being used lose strength you’ll want for recovery — one more reason staying active is part of the treatment, not a bonus. That’s why “wait and see” works best as a plan with check-ins, not a door you close. Track the trend line together: if each year costs you more of your life than the last, that trend is the answer forming.

When a knee replacement earns its place

The signals are rarely on the X-ray. They’re in your week: pain that wakes you at night despite everything you’re doing, stairs you plan your day around, a world that keeps shrinking, and shots or therapy that no longer hold. When several of those are true at once, a replacement stops being something to avoid and starts being the tool that can give you your life back.

When it’s time, Dr. Kelly performs Mako robotic-arm assisted total knee replacement at Tri-City Orthopedics — you can read how a robotic knee replacement is planned and an honest look at whether the robot is actually worth it. And before deciding anything, it helps to know what you’d be signing up for: the knee replacement recovery guide and the unvarnished first two weeks after knee surgery lay it out phase by phase.

And if you’re not there yet? Good. That’s what the rest of this page is for. More on how Dr. Kelly treats the knee — arthroscopy to replacement — lives on the knee page.

Straight answers, fast

Dr. Kelly’s approach to knee arthritis is simple: go through your X-ray with you until it makes sense, lay out every rung of the ladder, and never rush a decision you don’t need to make. He grew up on a farm north of Pasco and treats patients the way he’d want his own family treated — with a straight answer and a plan.

He also keeps same-day and same-week visit opportunities available. A painful, swollen, or undependable knee deserves answers soon — request a visit and ask about same-week openings.