ORTHOBIOLOGICS DIGEST™
Updated: 4 days ago
ORTHOBIOLOGICS DIGEST™
September 28, 2026 | No. 4
Research. Evidence. Perspective.
Curated and interpreted by Deborah Westergaard, M.D.
Orthobiologics Digest™ brings together research and news about regenerative medicine, joint and spine preservation, and musculoskeletal health. I explain what the evidence shows, where its limits remain, and how I think about it as a physician in practice since 1989 with experience in anesthesiology and image-guided procedures.
This issue considers careful steroid use, an overlooked blood product, the capacity to rebuild strength with age, the growing medical engagement with orthobiologics, and bone health around menopause. The question connecting them is practical: How do we preserve the ability to move, exercise, and remain independent?
1. Steroid Injections: How Much Is Too Much?
Source: Expert Opinion on Drug Safety | July 21, 2026
Aricia J. Thirumaran and David J. Hunter — “Long-term efficacy and safety of intra-articular corticosteroid injections in patients with knee osteoarthritis”
Pain relief today deserves a plan for the joint’s future
What the research shows
Corticosteroid injections can reduce knee arthritis pain in the short term. Their benefits and possible structural effects deserve separate consideration, especially when injections become a recurring treatment.
A 2026 review by Aricia J. Thirumaran and David J. Hunter examines the long-term efficacy and safety of these injections. It raises concerns about cartilage toxicity and repeated exposure, while recognizing their role in short-term symptom relief.
One important earlier trial randomized 140 people with knee osteoarthritis to 40 mg of triamcinolone or saline every three months for two years. The steroid group lost more cartilage, without a significant advantage in pain at the scheduled assessments. That finding concerns a repeated regimen; it does not establish that every individual steroid injection causes clinically important damage.
Dose is another question. In a separate randomized trial of 84 patients, 10 mg of triamcinolone met the study’s criterion for noninferiority to 40 mg for pain improvement at 12 weeks. The trial did not measure cartilage preservation or identify the minimum effective dose. It supports questioning the usual dose, without proving that the lower dose protects cartilage.
My Take — Dr. Deborah Westergaard
Corticosteroids still have an appropriate place in medicine. There are circumstances in which they can be extremely useful. But I have become increasingly reluctant to expose a degenerating joint to repeated high doses when our objective is joint preservation.
The question I want physicians and patients to ask is: What is the lowest effective exposure for this particular problem?
If a smaller amount can accomplish the clinical objective, we should have a reason for choosing more. We also need to consider how often the treatment is repeated and what the longer-term plan will be.
For someone with knee arthritis who hopes to postpone or potentially avoid knee replacement, the discussion should extend beyond the next few weeks of pain relief. The knee we are treating today is the knee that person will still need years from now.
Read the sources
2. Why Would We Want Fewer Platelets?
Source: Clinical Journal of Sport Medicine | September 2026
Ryan C. Kruse, Kyle J. Biscoglia, and Krit Petrachaianan — “Platelet-Poor Plasma: A Novel Treatment for Acute Quadriceps Muscle Injuries”
Platelet-poor plasma may have a role in muscle treatment
What the research shows
Platelet-poor plasma, or PPP, is the blood-plasma fraction containing relatively few platelets. Although platelet-rich plasma, or PRP, receives more attention, PPP still contains biologically active components.
A 2026 cohort study by Ryan C. Kruse and colleagues followed 37 patients with acute quadriceps muscle injuries treated with PPP. Across injury grades, return to full activity averaged 30 days after injury. One recurrent quadriceps injury occurred within 12 months.
These findings are preliminary. Without a randomized comparison group, the study cannot determine whether PPP accelerated recovery beyond rehabilitation and natural healing.
Earlier laboratory work offers a possible rationale: certain platelet-poor preparations encouraged human muscle precursor cells to mature and form muscle-like structures in culture. That is a biological observation, not proof that an injection rebuilds an injured human muscle.
My Take — Dr. Deborah Westergaard
I do not think we should dismiss PPP as waste simply because it contains fewer platelets. The preparation that suits a tendon may not be the preparation that best supports muscle.
I am particularly interested in whether a preparation with fewer platelets could provide a less inflammatory environment for certain muscle applications. That remains a question to investigate; inflammation depends on the preparation, its white-cell content, and the tissue being treated.
For me, the potential connection to the multifidus muscles is especially interesting. These small spinal muscles help stabilize individual spinal segments. In evaluating chronic back pain, I consider the spine as a functional system that includes the discs, facets, ligaments, nerves, and supporting muscles.
Plasma also contains naturally occurring extracellular vesicles, tiny membrane-bound particles involved in cellular communication. Exosomes are one category of extracellular vesicles. A patient’s own platelet-poor plasma (PPP) may naturally contain extracellular vesicles, including exosomes, but PPP should not be confused with a commercially manufactured exosome product.
PRP and PPP are prepared from a patient’s own blood for use in that same patient. FDA specifically distinguishes autologous PRP from human cell and tissue products regulated under 21 CFR Part 1271 because PRP is a blood product. This does not mean that PRP or PPP is an “FDA-approved treatment”; rather, it reflects a different regulatory pathway for autologous blood-derived preparations.
Commercial donor-derived exosome products are different. They do not qualify simply as a patient’s own autologous blood product, and FDA states that exosome products intended to treat diseases or conditions generally require FDA approval. There are currently no FDA-approved exosome products.
For these regulatory considerations, and because I prefer autologous orthobiologic treatments, I do not use commercially marketed donor-derived exosome or birth-tissue-derived products. When appropriate, I use preparations derived from the patient’s own blood or bone marrow.
I am also interested in processing approaches such as SuperShot. Its distributor describes an additional step that concentrates a fraction of extracellular vesicles from the patient’s own PPP and returns it to the PRP. That is part of the discussion around recovering autologous exosomes, although an EV concentrate is not a purified exosome product. Whether this additional processing improves clinical outcomes still needs to be established.
This research gives us a reason to look more carefully at a fraction of blood that has often received less attention than it deserves.
Read the sources
3. Are You Ever Too Old to Get Stronger?
Source: JAMA | June 13, 1990
Maria A. Fiatarone and colleagues — “High-intensity strength training in nonagenarians. Effects on skeletal muscle.”
Source: BMC Geriatrics | June 16, 2026
Guo-Qi Li and colleagues — “The intervention effects of resistance exercise on sarcopenia in older adults: a systematic review and meta-analysis”
An older study and newer evidence challenge resignation about muscle loss
What the research shows
I found a very old article from a very new TikTok.
A random TikTok video pointed me to a 1990 JAMA study of strength training in nursing-home residents averaging approximately 90 years of age. Its message is still relevant: advanced age does not eliminate the capacity to improve strength.
Ten frail nursing-home residents, averaging approximately 90 years of age, entered eight weeks of high-intensity resistance training. Nine completed the program. Their average strength increased 174%, mid-thigh muscle area increased approximately 9%, and tandem gait speed improved 48%. The strength increase was not a 174% increase in muscle size. This was a tiny study, and those percentages should not be treated as expected results for everyone.
A June 2026 systematic review in BMC Geriatrics pooled 13 randomized trials with 546 participants who completed the interventions. In older adults with sarcopenia, a condition involving loss of muscle mass and function, resistance exercise improved grip strength, walking speed, a measure of muscle mass in the arms and legs, and repeated chair-rise performance. Differences among programs and limitations in the trials prevent the review from establishing one ideal routine for everyone.
Together, the studies support a practical message: muscle can remain responsive to training well into later life.
My Take — Dr. Deborah Westergaard
I can speak to this as a physician and as a woman in my mid-60s.
For much of my adult life, I was committed to strength training, jogging, and the StairMaster. If anything, I sometimes overtrained. In my later years, things changed. I had a hip replacement and exercised less afterward, partly because of recovery and partly because I worried about damaging the tissue around my artificial hip.
Later, I noticed muscle loss.
What I noticed very clearly was that when I lost muscle and trained less consistently, my joints felt worse. I have since returned to strength training. My muscle is coming back, and I feel considerably better.
I have also undergone orthobiologic treatment of my shoulder, knee, lumbar spine, cervical spine and wrists, which I believe has helped me remain functional. Those personal experiences do not establish what another patient should expect.
I exercise differently now. I respect recovery and pay attention to pain. When someone asks whether it is too late to rebuild strength, my answer is to begin gradually and build from the capacity they have today.
If something hurts, do not simply assume it is aging or push through it. Have it evaluated, with imaging when appropriate, so the exercise plan accounts for the condition of the joint or spine.
The goal is to maintain the strength and mobility to keep doing what matters at 65, 75, 85, and beyond.
Read the sources
4. Is Regenerative Medicine Becoming Mainstream?
Source: AAOS Now, American Academy of Orthopaedic Surgeons | September 18, 2026
Jennifer Lefkowitz — “Experts outline the evolving role of orthobiologics in athletes”
Established medical organizations are engaging with the evidence
What the article brings into focus
A patient recently told me she had searched Google for “Is orthobiologics legitimate?” and found information from the American Academy of Orthopaedic Surgeons. That encounter captures an important change in the public conversation.
Orthobiologics is receiving serious attention from established medical organizations, although that attention does not validate every treatment marketed as regenerative medicine.
A September 18, 2026 AAOS Now article describes how physicians caring for professional, collegiate, Olympic, and Paralympic athletes approach orthobiologics. It emphasizes that evidence differs by treatment and that formulation, patient selection, regulation, and realistic expectations matter.
The broader activity extends beyond sports medicine. AAOS maintains biologics educational resources and an orthobiologics registry. The American Society of Pain and Neuroscience, or ASPN, and the American Society of Interventional Pain Physicians, or ASIPP, have published regenerative-medicine guidance. The International Pain and Spine Intervention Society, or IPSIS, includes regenerative spine therapies in its educational programming.
These efforts show organized evaluation and education. They should not be interpreted as blanket endorsement of every PRP, bone marrow, stem-cell, or exosome claim.
My Take — Dr. Deborah Westergaard
I have watched orthobiologics move toward a more established place in the medical conversation. As that happens, I believe our responsibility to distinguish credible care from exaggerated claims becomes greater.
In practice since 1989, I bring a background in anesthesiology, an accredited pain-medicine fellowship, and experience with image-guided spine and joint procedures. I have also completed dedicated orthobiologics training through the Interventional Orthobiologics Foundation.
That combination matters because the biologic is only one part of the procedure. We need to understand the diagnosis, the structures contributing to symptoms, the evidence for treating those structures, and how to reach the intended target accurately.
This is particularly relevant in spine care. Experience with image-guided interventional procedures and an understanding of spinal anatomy remain central to my approach.
I favor careful evaluation of autologous treatments, prepared from the patient’s own blood or bone marrow, while recognizing that an autologous source alone does not prove safety or effectiveness for every use.
For patients considering regenerative medicine in Dallas or Plano, the useful questions are specific: What condition is being treated? What will be injected, and where? What does the evidence support? What are the alternatives?
The field’s increasing visibility is encouraging. Its credibility will depend on the quality of the care and evidence behind it.
Read the sources
5. Your Bones May Be Changing Before You Know It
Source: CBS News | September 23, 2026
Norah O’Donnell — “Bone density and the “silent disease”: 4 things women should know about bone health”
Menopause is a musculoskeletal event, too
What the article brings into focus
A September CBS News interview with Duke orthopaedic surgeon Jocelyn Wittstein brings earlier bone-health assessment into focus.
Osteoporosis can develop without symptoms before a fracture occurs, and declining estrogen around menopause accelerates bone loss. Bone health therefore deserves attention during the menopausal transition.
Earlier discussion does not mean that every woman needs a screening scan at 50. Current U.S. Preventive Services Task Force guidance recommends screening women 65 and older, and postmenopausal women younger than 65 whose clinical risk assessment indicates increased fracture risk. Previous fractures, medications, and other medical conditions can change the evaluation.
Resistance and suitable weight-bearing exercise, adequate nutrition, and correction of deficiencies support musculoskeletal health. Vitamin D helps regulate calcium and phosphate; its active form acts as a hormone. Exercise should be adapted to bone health, balance, and existing joint or spine problems.
The connection matters: painful knees, hips, shoulders, and backs can interfere with the activity we encourage women to maintain.
My Take — Dr. Deborah Westergaard
This subject is personal for me. I had my first DEXA scan 20 years ago and was surprised to find areas described as osteopenia.
At the time, I was studying hormone medicine. I became more proactive about hormone management, corrected a low vitamin D level, and remained committed to resistance exercise.
I did not have another DEXA for approximately 20 years. When I finally did, my bone density was excellent.
That is my experience. It does not prove that any single intervention caused the outcome, and that long interval should not be taken as a recommended monitoring schedule. Follow-up testing should reflect the individual’s findings and risks.
What the experience changed was my philosophy: I would rather identify declining bone density while there is an opportunity to address it than discover osteoporosis after a fracture.
Women interested in menopausal hormone therapy deserve an individualized discussion with a physician who has specific expertise in menopause and hormone management. The benefits and risks depend on the person and the treatment being considered.
For a woman in her 50s, 60s, or 70s, my message is to understand her bone-health risks, maintain appropriate strength training, and address the pain that limits her ability to exercise.
Healthy aging means preserving the bones, muscles, and joints that allow us to remain strong, mobile, and independent.
Read the sources
This Week’s Perspective
Across these stories, I see the same clinical priority: preserving function over time. That requires thoughtful treatment choices, honest interpretation of emerging research, and attention to the bones, muscles, joints, and spine as an interconnected system.
For me, the purpose of joint and spine preservation is to help people continue participating in the lives they want to lead.
Deborah Westergaard, M.D.
Double board-certified in Anesthesiology and Pain Medicine
Regen Experts | Dallas–Plano
Frequently Asked Questions
Can steroid injections damage knee cartilage?
Repeated corticosteroid injections can increase cartilage loss under some treatment regimens. In a two-year knee osteoarthritis trial, 40 mg of triamcinolone every three months caused greater cartilage loss than saline. That finding does not establish that every individual injection causes clinically important damage.
For patients who need alternatives to repeated steroid injections, autologous orthobiologic options such as platelet-rich plasma (PRP) or bone marrow concentrate may be considered depending on the severity of arthritis, imaging findings, and the structures involved. These treatments are intended to address the joint environment differently than corticosteroids and are selected on an individualized basis.
Can a lower steroid dose provide effective relief for knee arthritis?
A lower dose may provide adequate pain relief. In a randomized trial of 84 patients, 10 mg of triamcinolone was not inferior to 40 mg for pain improvement at 12 weeks. The study did not establish the minimum effective dose or show that the lower dose protects cartilage.
Can you still build muscle and get stronger after 70, 80, or 90?
Yes. Aging muscle can still respond to resistance training. A small 1990 JAMA study documented gains in strength and muscle size in nursing-home residents averaging about 90 years old. Training should begin at a manageable level and progress according to the individual’s capacity, health, and recovery.
Does strength training help if you already have sarcopenia or age-related muscle loss?
Yes. Resistance training can improve muscle strength and physical function in older adults who already have sarcopenia. The 2026 review discussed in this Digest found improvements in grip strength, walking speed, muscle mass index, and repeated chair-rise performance. Results and suitable training programs vary among individuals.
How can you rebuild strength when knee, hip, or back pain makes exercise difficult?
Persistent or limiting pain deserves evaluation and an exercise plan adapted to its cause. An examination, with imaging when appropriate, can help guide changes in movement, rehabilitation, or treatment. My goal is to help patients regain the ability to strengthen their muscles without repeatedly pushing through unexplained joint or spine pain.
Where can you discuss nonsurgical treatment for knee and back pain in Dallas or Plano?
Regen Experts offers evaluations with Dr. Deborah Westergaard in Dallas and Plano. She reviews symptoms, examination findings, relevant imaging, and previous treatments to discuss appropriate options for joint and spine care. If pain is limiting your ability to exercise, you can request an evaluation to discuss the next step.
Deborah Westergaard, M.D.
Double board-certified in Anesthesiology and Pain Medicine
Regen Experts | Dallas–Plano
Orthobiologics Digest™ | September 28, 2026
Comments