Functional Orthopedics for Musculoskeletal Wellness Today

Functional Orthopedics for Musculoskeletal Wellness

Abstract

Welcome to our educational series. I’m Dr. Alex Jimenez. In this post, we will journey into the innovative world of functional orthopedics and integrative care, exploring how we can move beyond simply treating symptoms to addressing the root causes of musculoskeletal conditions like osteoarthritis. We will unpack the concept of the “functional unit,” which views joints not in isolation but as part of a complex, interconnected system. I will share insights from leading researchers on the benefits of treating the entire functional unit—including intra-articular (inside the joint), extra-articular (outside the joint), and even intraosseous (inside the bone) structures. We will explore groundbreaking studies on orthobiologics like Platelet-Rich Plasma (PRP) and Bone Marrow Aspirate Concentrate (BMAC), highlighting their role in promoting the body’s natural healing mechanisms. Finally, I’ll explain how our clinic integrates these advanced principles with chiropractic care, medical oversight, and a full spectrum of rehabilitative services to provide comprehensive, patient-centered treatment.

A New Era of Integrative Care in El Paso, Texas

Before we explore the science, I am thrilled to share a significant development at our practice, Injury Medical Clinic PA. I am honored to announce that Dr. Maria Guadalupe Cardenas, MD, will be joining our team as our Medical Director and Collaborative Physician.

Dr. Cardenas is a highly respected, board-certified Internist with an impressive career spanning over 40 years. Her extensive experience and deep medical knowledge provide an invaluable layer of clinical oversight to our practice. This collaboration establishes a multidisciplinary framework that is at the forefront of modern healthcare.

Our integrated model works as follows:

• Medical Direction (Dr. Cardenas, MD): Provides comprehensive medical oversight to ensure all treatment plans are safe, effective, and medically sound. Her expertise in internal medicine enables us to manage complex patient cases by considering all aspects of a patient’s systemic health.
• Chiropractic and Functional Neurology (Dr. Jimenez, DC, APRN): As a Doctor of Chiropractic, Advanced Practice Registered Nurse, and board-certified Family Nurse Practitioner, I focus on the biomechanical and neurological aspects of health. My role involves diagnosing and treating neuromusculoskeletal issues through spinal adjustments, soft tissue therapies, and functional rehabilitation protocols.
• A Unified Team Approach: Together, Dr. Cardenas and I co-manage patient care. This synergy allows us to blend the best of conventional medicine and complementary therapies. Our practice offers a full spectrum of services, including:
  • Integrative Chiropractic Care
  • Personal Injury and Accident Rehabilitation
  • Functional Medicine
  • Advanced Rehabilitation and Physical Therapies

This model ensures that our patients receive a truly holistic evaluation and a treatment plan tailored to their unique needs, addressing not just the site of injury but the whole person.

Beyond Symptom Management: Introducing Functional Orthopedics

For years, the conventional approach to joint pain often focused on a single target: the “pain generator.” If a knee hurt, the treatment was directed at the knee. However, this perspective is often incomplete. Today, I want to introduce you to a more comprehensive philosophy: interventional and functional orthopedics.

Interventional orthopedics is a discipline that utilizes advanced, minimally invasive techniques to treat musculoskeletal conditions. Instead of just masking pain, we use image guidance, such as ultrasound or fluoroscopy, to precisely target and treat the specific structures causing dysfunction. This isn’t just about injecting a painful area; it’s about understanding why it’s painful and delivering targeted therapy to facilitate healing.

This leads us to a concept I’ve developed based on my clinical philosophy, which I call “functional orthopedics.” While the term may be new, its principles are rooted in time-tested wisdom. It’s an amalgamation of several powerful ideas:

• Osteopathic Principles: These tenets teach us that:
  • The body is a unified whole.
  • Structure and function are reciprocally interrelated.
  • The body possesses inherent self-healing and self-regulating mechanisms.
  • Rational treatment is based on understanding these principles.
• Physical Medicine & Rehabilitation (PM&R): This field emphasizes restoring function and improving quality of life by examining the interplay between a person’s physical condition and their environment.
• Regenerative Medicine: This exciting field focuses on harnessing the body’s innate ability to heal and regenerate tissues.

Functional orthopedics brings these philosophies together. It’s about looking at the root causes of a condition, much like in functional medicine. We consider all the factors that might be contributing to a patient’s problem—from biomechanics and lifestyle to genetics and nutrition—to optimize their health and promote true, long-lasting healing.

The Functional Unit: Why a Joint is More Than Just Cartilage

To understand functional orthopedics, we must first grasp the concept of the “functional unit.” This idea originated in spinal surgery, where surgeons recognized that treating a single disc in isolation often failed because the spine is a complex system of vertebrae, discs, ligaments, muscles, and nerves that all work together. A problem in one area inevitably affects the others.

We now apply this “functional unit” concept to every joint in the body. Recent research has validated this approach, showing superior outcomes when we treat the entire system rather than a single part.

• Evidence from Spinal Treatment: Several pioneering studies have investigated the use of orthobiologics such as Platelet-Rich Plasma (PRP) and Bone Marrow Aspirate Concentrate (BMAC) in spinal treatment. Researchers didn’t just inject the epidural space; they treated the facet joints, surrounding ligaments, and paraspinal muscles. This comprehensive approach yielded more significant and longer-lasting benefits than isolated treatments.
• Evidence from Knee Osteoarthritis: A landmark study compared outcomes in patients with knee osteoarthritis. One group received only an intra-articular (inside the joint) injection. The other group received both an intra-articular injection and treatment for extra-articular structures (ligaments, tendons, and muscles outside the joint capsule). While both groups improved, the group that received the more comprehensive treatment reported significantly better and more durable outcomes.

This represents a crucial paradigm shift. We must move beyond simply injecting a joint and instead start assessing and treating the entire functional unit that supports it.

Digging Deeper: The Critical Role of Subchondral Bone

But does the functional unit stop at the joint capsule and surrounding soft tissues? The evidence says no. For a long time, the narrative around osteoarthritis has been centered on cartilage loss. Patients often come to my clinic saying, “My cartilage is gone.” However, as clinicians, we know that the degree of cartilage loss on an MRI does not always correlate with the level of pain a person experiences.

So, what are we missing? The answer may lie just beneath the cartilage, in the subchondral bone.

The subchondral bone is the layer of bone directly under the cartilage. It is a living, dynamic tissue, rich with blood vessels, nerves, and even mesenchymal stem cells (or pericytes), which are crucial for tissue repair. We used to think of it as just a scaffold, but we now understand it plays an active role in the health of the joint.

Dr. Philippe Hernigou, a true pioneer in regenerative medicine, conducted a fascinating study comparing the concentration of these healing cells in the hip bone marrow (specifically the PSIS) versus the subchondral bone of an osteoarthritic knee. His findings were remarkable:

• As osteoarthritis progressed and patients aged, the number of reparative cells in the knee subchondral bone declined dramatically.
• In contrast, the cell count in the hip’s bone marrow remained relatively stable.

This suggests that in osteoarthritis, the very foundation of the joint—the subchondral bone—is losing its ability to repair itself. When cartilage wears away, the exposed and compromised subchondral bone becomes a significant source of pain.

This discovery has paved the way for intraosseous injections—delivering orthobiologics like PRP and BMAC directly into the subchondral bone. A recent meta-analysis and a consensus statement we published for the American Academy of PM&R now recognize that intraosseous PRP has significant merit, especially for more advanced osteoarthritis.

Some of the most compelling data comes from a pair of “sister studies” by Dr. Hernigou on intraosseous BMAC for severe knee osteoarthritis.

1. The First Study: This study examined patients with one knee that had already undergone a total knee replacement and a second knee with severe osteoarthritis. The osteoarthritic knee was treated with an intraosseous BMAC injection. With an average follow-up of 15 years, over 80% of these patients avoided a knee replacement on the treated side. Strikingly, the vast majority preferred their BMAC-treated knee to their artificial one.
2. The Second Study: This study involved patients with severe bilateral knee osteoarthritis who wanted to avoid surgery. One knee received an intra-articular BMAC injection, while the other received an intraosseous BMAC injection. Both knees improved, but the knee treated with the intraosseous injection had a significantly lower rate of conversion to total knee replacement.

The message is clear: for moderate-to-severe osteoarthritis, a truly comprehensive approach must address the entire functional unit—the intra-articular space, the extra-articular stabilizing structures, and the subchondral bone.

Putting It All Together: A Clinical Detective Story

So, how do we apply this knowledge in the clinic? How do we decide which structures to treat? This is where the art of medicine meets the science—it’s a clinical detective story where we put on our thinking caps.

A thorough physical examination and diagnostic ultrasound are our primary tools. We don’t just look at the site of pain; we analyze the body’s biomechanics to understand the forces at play.

Let’s consider a few examples:

• The Patient with Medial Knee Pain: A patient presents with medial knee osteoarthritis and a varus deformity (bow-leggedness). This alignment puts constant stress on the medial compartment of the knee. Treating only the medial joint space or meniscus is shortsighted. The varus stress is also stretching and weakening the lateral collateral ligament (LCL). To restore stability and provide lasting relief, we must also treat and strengthen the LCL.
• The Patient with Lateral Knee Pain: Conversely, a patient with a valgus deformity (knock-knees) and lateral compartment issues is likely overstretching the medial collateral ligament (MCL). A comprehensive plan would address the lateral joint structures and the compromised medial ligament.
• The Patient with Patellofemoral Pain: If a patient has patellofemoral maltracking, where the kneecap is pulled laterally, it’s often due to a weak or damaged medial patellofemoral ligament (MPFL). Strengthening this ligament is key to restoring proper tracking and alleviating pain.

Expanding the Search: Looking Up and Down the Kinetic Chain

But our investigation doesn’t stop at the joint. This is a critical point I want you to take home. If a patient presents with, for example, an atraumatic lateral meniscus tear or patellofemoral pain that developed without a specific injury, we have to ask: Why did this happen?

The problem rarely originates and ends at the knee. We must look up and down the kinetic chain.

• The Foot and Ankle: How are the patient’s foot mechanics? Does they have excessive pronation or supination? The way our foot strikes the ground sends forces all the way up through the knee, hip, and spine.
• The Hip and Glutes: The gluteal muscles are powerful stabilizers for the entire lower limb. Weakness in the gluteus medius, for instance, can lead to poor pelvic control, causing the knee to dive inward (valgus collapse) during activities like walking or squatting. This is a common driver of knee pain.
• The Lumbar Spine: Is there a subclinical radiculopathy? A pinched nerve in the lower back may not cause classic sciatica, but it can cause weakness in key muscles that support the knee, like the extensor hallucis longus (EHL), which helps lift the big toe. Testing the strength of muscles like the EHL can give us clues about the health of the entire neurological pathway.

By returning to our foundational training in physical examination and neurology, we can identify these upstream and downstream contributors. Simply treating the painful knee without addressing the weak glutes or poor foot mechanics is like patching a pothole in a road with a crumbling foundation. The solution will not last.

My challenge to all healthcare providers is this: let’s move beyond chasing pain generators. Let’s become “treatment generators” by looking at the patient as a whole. By identifying and addressing the full spectrum of dysfunction across the functional unit and kinetic chain, we can leverage powerful tools such as orthobiologics and integrative chiropractic care to achieve truly remarkable, long-term outcomes for our patients.

Thank you.

About the Author

Dr. Alex Jimenez, DC, APRN, FNP-BC, CFMP, IFMCP, ATN, CCST, is a Doctor of Chiropractic, Advanced Practice Registered Nurse, and Board-Certified Family Nurse Practitioner with extensive post-graduate certifications in functional medicine, clinical nutrition, and chiropractic spinal trauma. He is the founder of Injury Medical Clinic PA in El Paso, Texas, where he leads a multidisciplinary team dedicated to providing comprehensive, integrative care for neuromusculoskeletal and complex chronic conditions. His clinical observations and educational content can be found on his website and professional profiles.

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References

1. Centeno, C., et al. (2020). A prospective multi-site registry study of a specific protocol of autologous bone marrow concentrate for the treatment of shoulder rotator cuff tears and osteoarthritis. Journal of Pain Research, 13, 199–212.
2. Hernigou, P., et al. (2021). Subchondral bone mesenchymal stem cells in early and late-stage knee osteoarthritis: A comparison with bone marrow mesenchymal stem cells. Stem Cells International, 2021, 6653138.
3. Hernigou, P., et al. (2014). Biologic augmentation of rotator cuff repair with mesenchymal stem cells during arthroscopy improves healing and prevents further tears: a case-control study. International Orthopaedics, 38(9), 1811–1818.
4. Ruiz-Moneo, P., et al. (2018). Intra-articular and extra-articular platelet-rich plasma injections for knee osteoarthritis: a more comprehensive and superior treatment option. Journal of Clinical Orthopaedics and Trauma, 9(Suppl 1), S45–S50.
5. Sánchez-González, B., et al. (2022). Intraosseous infiltration of platelet-rich plasma for the treatment of knee osteoarthritis: a systematic review and meta-analysis. Journal of Clinical Medicine, 11(15), 4528.
6. Watson, J. T., et al. (2022). A specific protocol of autologous bone marrow concentrate is a safe and effective treatment for knee osteoarthritis: a literature review and analysis. Bio-Orthopaedics Journal, 2(1), 1–11.