The ANOVA Joint and Back Pain Stem Cell Treatment Programme Germany

Low back pain is the leading cause of disability worldwide, and osteoarthritis affected about 595 million people in 2020.^[1],[2] Many changes seen on a standard MRI are also common in people without pain.^[3] We therefore look for the actual source of pain first, for example active inflammation, before recommending BMC or another treatment. BMC is then applied where the inflammation is, with the aim of reducing it and with it the pain. The programme is offered alongside — never instead of — established treatment such as physiotherapy and pain medication.

Joint and back pain can arise from cartilage, bone, ligaments, tendons, the small joints of the spine (facet joints), the vertebral bodies or compressed nerves. Cartilage, ligaments and intervertebral discs have a limited blood supply, so they heal slowly and often incompletely. Repeated strain, degeneration and inflammation can keep pain going even after physiotherapy, medication or other treatment.

Typical complaints are:

• Pain on movement or under load, in the joint or in the back
• Stiffness, especially in the morning or after rest
• Swelling or warmth of a joint
• Pain radiating into an arm or leg, numbness or weakness

A standard MRI shows structure, such as a disc bulge or wear of a joint. Such findings are common even in people without pain and do not always explain where the pain comes from.^[3] An MRI with contrast can additionally show areas of active inflammation, which may point to the source of pain.

More details can be found below in our scientific section on joint and back pain.

Osteoarthritis

Osteoarthritis is a progressive joint disease with degenerative changes in the cartilage and the underlying bone. It causes joint pain, stiffness and reduced mobility, and conventional treatment mainly relieves the symptoms. BMC injected into the affected joint is intended to reduce inflammation in the joint, relieve pain and, in the longer term, stabilise joint function. Learn more about our osteoarthritis programme.

Joints and sport injuries — shoulder, hip, knee and hand

Pain in the shoulder, hip, knee or hand can result from injury, overuse or degeneration of cartilage, ligaments and tendons, for example after sport. BMC injected into the affected joint is intended to reduce inflammation and to support the repair of cartilage, tendons and ligaments. If you wish, blood tests can also look for an autoimmune disease or a hormonal imbalance, which can play a part in joint pain. Learn more about our joints and sport injuries programme.

Spine — back and neck

Back and neck pain can come from the vertebral bodies, the facet joints, the spinal ligaments or a compressed nerve root. These causes can look similar on a standard scan but need different treatment. BMC is used for inflammation of the vertebral bodies, the facet joints or the spinal ligaments, with the aim of reducing the inflammation at its source and with it the pain. Where a disc presses on a nerve purely mechanically, however, BMC is not the right treatment, and we discuss other options with you. Learn more about our spine programme.

Rheumatoid arthritis

Rheumatoid arthritis is an autoimmune disease in which the immune system attacks the lining of the joints. Treatment by a rheumatologist with disease-modifying medication remains the basis. BMC can additionally be injected into individual affected joints, with the aim of reducing local inflammation and pain. Learn more about our rheumatoid arthritis programme.

ANOVA offers autologous bone marrow concentrate (BMC) for joint and back pain. The programme has two components: a diagnostic MRI and BMC injected into the affected joint (intra-articular). Each component is selected individually; the programme is not a fixed package.

In many painful joint conditions, chronic inflammation contributes to pain and to ongoing tissue damage. BMC contains the patient's own stem cells and signalling factors that research associates with the regulation of inflammation and with tissue repair. Injected directly into the joint, BMC is intended to reduce inflammation there, and with it pain, and to support the repair of the affected tissue. Further aims are to delay a joint replacement and to reduce the need for painkillers.

ANOVA IRM has not yet tested BMC for joint and back pain in a clinical study. The current state of research is described in the clinical and scientific section below.

With BMC, an MRI before treatment is not mandatory, but a diagnostic MRI is often very useful. It is often unclear where exactly the pain comes from. A good MRI with contrast can make inflammation visible, which often triggers the pain; BMC can then be applied at exactly the right site.

Your own bone marrow is collected from the pelvic bone under brief sedation, concentrated, tested and injected into the affected joint on the same day, during a two-day visit. External studies of bone marrow concentrate in the knee, mostly small, reported improvements in pain and function.^[4] BMC is intended to reduce inflammation at the site of pain.

As joint and back pain has many possible causes, a thorough diagnostic work-up is needed to find the source of the pain and, in turn, the right treatment.

Which tests are used to find the cause of joint and back pain?

Diagnosis starts with your medical history and a physical examination. MRI shows the structure of joints, discs and the spine; with contrast, it can also show active inflammation in the vertebral bodies, the facet joints, the ligaments or the joint lining. Blood tests are part of the preparation for treatment; if you wish, they can also look for signs of an autoimmune disease and assess your hormone status.

What do we review before joint and back pain treatment at ANOVA IRM?

Before any treatment decision we review whether your pain is mainly caused by inflammation, degeneration, an autoimmune disease or a purely mechanical problem. We also assess whether you are fit for the brief sedation required for the bone marrow collection.

With BMC:

• Standard: no MRI required.
• Optional, often useful: a diagnostic MRI with contrast to make inflammation visible and to locate the source of pain.
• Optional: further MRI or CT scans where your findings call for them.
• CT-guided application: always in the lumbar spine, sometimes in the shoulder and hip, and usually not in the knee.

All of these examinations can also be carried out by your own doctors at home; please send us the results. They can also be done in-house at the Prof. Dr. Stehling Institut für Bildgebende Diagnostik GmbH, which, like ANOVA IRM, belongs to Dr. Stehling and is located in the same building. The full diagnostic pathway is described on our diagnostics page.

For many years, orthopaedic surgeons in Germany prepared and used bone marrow concentrate in their practices without an official authorisation. Two changes to the German Medicines Act (AMG) ended this. In 2009, advanced therapy medicinal products were excluded from preparation without authorisation, and in 2012 the exemption for tissue preparations in Section 20d AMG was restricted, so that an authorisation became necessary. ANOVA took the demanding route of obtaining these authorisations and manufacturing under good manufacturing practice (GMP). ANOVA IRM has manufactured BMC in its own facility in Offenbach since 2018, with MRI and CT imaging in the same building. Why an autologous preparation used only for our own patients requires no marketing authorisation is set out on our regulatory status page.

Initial evaluation can begin remotely, by phone or video, without travel to Germany. Treatment itself requires an in-person visit to Offenbach am Main, less than 20 minutes from Frankfurt Airport. You receive an individual written cost estimate before any treatment decision.

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BMC treatment for joint and back pain at ANOVA IRM costs approximately €8,000–€9,000 and takes one two-day outpatient visit to Offenbach, Germany, for adults whose diagnostic work-up points to a cause that BMC may address.

1. 01
   Remote assessment

   Review of your medical history, images and blood tests by phone or video.

2. 02
   Day 1 in Offenbach

   Consultation and consent, blood tests and, where needed, an MRI with contrast.

3. 03
   Day 2 in Offenbach

   Bone marrow collection under brief sedation; BMC is concentrated, tested and injected into the affected joint the same day (about two to four hours).

4. 04
   Follow-up

   Review of your progress by phone or video; a repeat application is possible after assessment. Details are discussed with your doctor.

BMC may be considered for adults with chronic or degenerative joint or back pain, after a full diagnostic work-up. This includes osteoarthritis of the knee, hip, shoulder or hand, inflammation of the facet joints, vertebral bodies or spinal ligaments, and tendon and ligament injuries from sport or overuse. Many patients we see have tried physiotherapy, pain medication or injections with limited effect. BMC is intended to reduce the inflammation behind the pain at its source. You need to be medically fit for the bone marrow collection under brief sedation and able to travel to Offenbach.

Treatment decisions are based on your medical history and diagnostic findings, which you can send in advance or complete with us. Consultations can begin remotely, with an on-site evaluation where further diagnostics are needed.

What are the contraindications for joint and back pain treatment?

Our treatments are experimental. We treat only people for whom, after medical assessment, we consider the benefit-risk balance to support treatment.

Applies to all ANOVA treatments:

• Active cancer within the last two years
• Under the age of legal majority
• Pregnancy or breastfeeding
• Active infectious disease (hepatitis A, B, C, HIV, syphilis or other)

Specific to joint and back pain:

• Infection of the joint or of the skin at the injection site
• Disc prolapse with purely mechanical compression of a nerve root — here a different treatment is more suitable
• Unable to breathe unaided, or difficulty breathing in the supine position (sedation for the bone marrow collection)
• Psychiatric disorder that would prevent informed consent or cooperation

A blood clotting disorder or blood-thinning medication is not a contraindication, but please tell us about it before your visit.

What screening is needed before you travel for joint and back pain treatment?

Before you travel, a preliminary screening in your home country helps to avoid an unnecessary journey. This is usually a blood test for medical or infectious reasons against treatment, together with your existing images and the letters of your treating doctors.

What happens at your joint and back pain visit to Offenbach, Germany?

The visit takes two days in Offenbach and is outpatient. On the first day your doctor explains the treatment and obtains your consent; blood tests and, where needed, an MRI with contrast are carried out. On the second day, bone marrow is collected from the pelvic bone under brief sedation. It is concentrated, tested and injected into the affected joint the same day, which takes about two to four hours.

How is your BMC for joint and back pain produced and quality-controlled?

BMC is prepared from your bone marrow on the day of collection in our own facility, under a manufacturing authorisation and good manufacturing practice (GMP), following defined protocols for consistency, quality control and traceability. Part of the quality control takes place on the same day, before the application; further tests are completed afterwards.

How is BMC applied in joint and back pain?

BMC for joint and back pain is usually given once, during a two-day visit; in chronic conditions such as osteoarthritis, the treatment may need to be repeated. The schedule is set individually for each patient, for example:

• BMC: one application on the second day of the visit; a repeat is possible after assessment.
• Several joints: they can be treated during the same visit, usually with a double BMC. Details are discussed with your doctor.
• Standard route: injection into the affected joint (intra-articular). This is intended to bring BMC directly to the inflamed tissue.
• CT guidance: always in the lumbar spine, sometimes in the shoulder and hip, and usually not needed in the knee.
• No intravenous use: BMC is applied only locally.

BMC treatment for joint and back pain costs approximately €8,000 to €9,000 and is billed according to the German Medical Fee Schedule (GOÄ). With a CT-guided injection the cost is closer to €9,000, without one closer to €8,000. CT guidance is always used in the lumbar spine, sometimes in the shoulder and hip, and usually not in the knee. The total also depends on additional examinations, such as an MRI with contrast, and on your sedation or anaesthesia preferences. You receive an individual written estimate before any treatment decision. If several joints are treated during one visit, a double BMC is usually prepared; the cost is correspondingly higher and is shown in your individual estimate. Travel, accommodation and other personal expenses are separate. Treatment is generally self-funded; you can still ask your insurer about possible reimbursement. Our blog post on treatment cost explains the main cost factors. All prices are subject to change.

Why does the cost of joint and back pain treatment vary?

All treatments at ANOVA IRM are billed according to the German Medical Fee Schedule (Gebührenordnung für Ärzte, GOÄ). Within it, the cost varies mainly with the number of joints treated, with CT guidance of the injection and with any diagnostic MRI before treatment. The exact cost of your treatment plan is set out in your individual written cost estimate.

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Orthopaedic conditions affect joints, cartilage, ligaments, tendons and the structures of the spine. Some injuries occur suddenly, but many develop gradually through degeneration, mechanical stress and incomplete healing. As this continues, the affected area becomes less stable and more prone to further damage.

What causes joint and back pain, and what are the risk factors?

Joint and back pain has many causes. They include wear of cartilage and discs, inflammation of joints, vertebral bodies or ligaments, and injuries from sport or accidents. Autoimmune diseases such as rheumatoid arthritis and a compressed nerve root are further causes. Often no single cause can be found, especially in back pain.^[1] Risk factors include:

• Older age and excess weight
• Physically demanding work, overload and earlier injuries
• Low physical activity and smoking
• Hereditary factors, for example in osteoarthritis

What drives the progression of joint and back pain?

Most of these conditions share several underlying processes that keep them going:

• progressive degeneration of tissue within joints and supporting structures
• inflammation that contributes to ongoing tissue damage and slows healing
• repetitive stress and overuse, particularly in active people and athletes
• incomplete healing after injury, leading to long-term structural changes

These processes can continue over time, which is why many joint and spine conditions are difficult to resolve with conventional treatment alone. Our programme is aimed at the inflammation among them, not at the original cause.

Why do imaging findings not always explain the pain?

In a systematic review of MRI and CT findings in people without back pain, disc degeneration was found in 37% of 20-year-olds and in 96% of 80-year-olds; disc bulges were also common.^[3] Such findings therefore do not by themselves explain where pain comes from. An MRI with contrast can additionally show active inflammation, for example in the vertebral bodies, the facet joints or the joint lining, which may help to locate the source of pain.

Treatment starts with information, exercise and physiotherapy, weight management and pain medication; guidelines for low back pain put active, non-drug treatment first.^[1] Further options include injections of cortisone or hyaluronic acid into joints and, in rheumatoid arthritis, disease-modifying medication from a rheumatologist. In advanced osteoarthritis, a joint replacement is an established option.

For back and neck pain, specialised procedures such as test injections, radiofrequency denervation of the facet joints or spinal surgery can also be considered; they are described on our spine page.

What if a joint replacement becomes necessary?

Conventional joint replacements made of metal and plastic have a limited lifespan, and a later revision operation becomes more difficult. Implants that are 3D-printed for the individual patient from natural materials such as bone and cartilage are being researched; they are intended to integrate into the body but are not yet in routine clinical use. Where it is medically reasonable to postpone a joint replacement, this is a further reason to discuss treatment options that may help to bridge the time.

How is joint and back pain diagnosed, and what do we not do ourselves?

Joint and back pain is diagnosed from the medical history, a physical examination, imaging and blood tests. Physiotherapy, the treatment of autoimmune diseases by a rheumatologist and surgery stay with your treating doctors and specialists. We carry out MRI with or without contrast and CT ourselves at the Institut für Bildgebende Diagnostik in the same building.

Bone marrow concentrate (BMC)

ANOVA IRM has not yet tested BMC for joint and back pain in a clinical study. BMC is prepared from the patient's own bone marrow and contains a small proportion of mesenchymal stem cells (MSCs), together with other cells and growth factors.^[4] A systematic review of mostly small external studies in knee cartilage injuries and osteoarthritis reported good overall clinical results; the quality of the studies was low.^[4] In small external placebo-controlled studies reviewed by the American Academy of Orthopaedic Surgeons in 2021, a benefit over placebo could not yet be demonstrated, and the evidence was rated as limited.^[5] To our knowledge, there is no phase 3 study of BMC in joint and back pain.

What is the efficacy hypothesis behind BMC in joint and back pain?

MSCs are thought to act mainly through the factors they release, which laboratory studies associate with the regulation of inflammation and with the activity of the cells involved in repair.^[6],[7] Inflammation contributes to pain and to ongoing tissue damage in many joint and spine conditions. BMC is injected directly into the affected joint so that these factors reach the inflamed tissue. It is intended to reduce inflammation and pain and, in the longer term, to stabilise joint function and delay further wear.

Mesenchymal stem cells and secretome — analogous evidence

Laboratory and animal studies with mesenchymal stem cells and the vesicles they release have shown effects on cartilage cells and on inflammation in joint models.^[8],[9],[10] These studies used cultured cells or cell-free preparations, not BMC. They provide background for the rationale, not direct evidence for BMC.^[11],[12]

What can blood tests show in joint pain?

Joint pain sometimes has causes that BMC alone cannot address, such as an autoimmune disease or a hormonal imbalance. If you wish, we can additionally analyse signs of an autoimmune disease and your hormone status in the blood. If the results point to another cause, we discuss them with you and, with your consent, with your treating doctors.

Talk to us about current changes or additions to the joint and back pain programme.

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ANOVA IRM does not yet have an evaluated dataset for joint and back pain. In our experience, a reduction of pain is more likely when the pain is caused by inflammation. Stem cells cannot cure a condition such as osteoarthritis, and any improvement achieved is always limited in time. These observations have not been systematically evaluated and do not allow a prediction for you.

Individual patients describe their experiences on our testimonials page. These are personal accounts of single cases, and results differ from person to person.

What the published evidence does not yet tell us

• Laboratory and animal studies report effects on cartilage and inflammation, but they cannot show whether a treatment helps patients.
• Human studies of bone marrow concentrate are mostly small and of limited quality; in placebo-controlled studies, a benefit over placebo could not yet be demonstrated.
• The products studied differ from BMC at ANOVA IRM in preparation and dose.
• No stem cell-based treatment for joint and back pain is an approved standard treatment in Germany or the EU.

BMC is an advanced therapy medicinal product; ANOVA IRM manufactures it under a procurement authorisation (Section 20b AMG) and a manufacturing authorisation under Section 13 AMG. Both authorisations were issued and are regularly inspected by the Hessian State Office for Health and Care (HLfGP). The individual treatment attempt (individueller Heilversuch) concerns the administration only and follows full disclosure and informed consent. Because BMC is used only for ANOVA IRM's own patients, no authorisation under Section 4b, no marketing authorisation under Section 21 and no approval under Section 21a AMG is required. The full derivation is on our regulatory status page.

Questions people usually ask next. Each is answered in full on its own page.

• Who are we?
• Is ANOVA legal?
• Is stem cell therapy safe?
• What is BMC (Bone Marrow Concentrate)?
• What are stem cells?
• What should I ask when looking for a stem cell treatment?
• Which conditions do we treat?
• Osteoarthritis treatment options — standard and emerging
• Rheumatoid arthritis treatment options — standard and emerging

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ANOVA IRM shares its premises in Offenbach with two further institutions owned by Dr. Stehling: the Institut für Bildgebende Diagnostik (IBDO), providing MRI and CT imaging, and the VITUS PRIVATKLINIK Prof. Dr. Stehling GmbH. Because imaging is carried out in the same building, condition-specific diagnostics — including MRI with contrast and MRI- or CT-guided injections — can be performed in-house rather than referred elsewhere. See diagnostics at ANOVA IRM.

Specific literature is maintained on the pages for osteoarthritis, joints, spine and rheumatoid arthritis, and general literature on bone marrow on the BMC page.

Joint and back pain — burden and imaging

• [1] Hartvigsen J, Hancock MJ, Kongsted A, et al. What low back pain is and why we need to pay attention. Lancet. 2018;391(10137):2356–2367. doi:10.1016/S0140-6736(18)30480-X. PMID: 29573870.
• [2] GBD 2021 Osteoarthritis Collaborators. Global, regional, and national burden of osteoarthritis, 1990–2020 and projections to 2050: a systematic analysis for the Global Burden of Disease Study 2021. Lancet Rheumatol. 2023;5(9):e508–e522. doi:10.1016/S2665-9913(23)00163-7. PMID: 37675071. PMCID: PMC10477960.
• [3] Brinjikji W, Luetmer PH, Comstock B, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015;36(4):811–816. doi:10.3174/ajnr.A4173. PMID: 25430861.

Bone marrow concentrate in joints

• [4] Chahla J, Dean CS, Moatshe G, et al. Concentrated bone marrow aspirate for the treatment of chondral injuries and osteoarthritis of the knee: a systematic review of outcomes. Orthop J Sports Med. 2016;4(1):2325967115625481. doi:10.1177/2325967115625481. PMID: 26798765.
• [5] American Academy of Orthopaedic Surgeons. Concentrated Bone Marrow Aspirate for Knee Osteoarthritis: Technology Overview. Rosemont, IL: AAOS; adopted 3 December 2021. https://www.aaos.org/globalassets/quality-and-practice-resources/biologics/technology-overview-concentrated-bone-marrow-aspirate-for-knee-osteoarthritis.pdf

Mesenchymal stem cells and secretome — analogous evidence, not BMC itself

• [6] Caplan AI, Correa D. The MSC: an injury drugstore. Cell Stem Cell. 2011;9(1):11–15. doi:10.1016/j.stem.2011.06.008. PMID: 21726829.
• [7] da Silva Meirelles L, Fontes AM, Covas DT, et al. Mechanisms involved in the therapeutic properties of mesenchymal stem cells. Cytokine Growth Factor Rev. 2009;20(5–6):419–427. doi:10.1016/j.cytogfr.2009.10.002. PMID: 19926330.
• [8] Maumus M, Jorgensen C, Noël D. Mesenchymal stem cells in regenerative medicine applied to rheumatic diseases: role of secretome and exosomes. Biochimie. 2013;95(12):2229–2234. doi:10.1016/j.biochi.2013.04.017. PMID: 23685070.
• [9] Toh WS, Lai RC, Hui JHP, et al. MSC exosome as a cell-free MSC therapy for cartilage regeneration: implications for osteoarthritis treatment. Semin Cell Dev Biol. 2017;67:56–64. doi:10.1016/j.semcdb.2016.11.008. PMID: 27871993.
• [10] Malda J, Boere J, van de Lest CHA, et al. Extracellular vesicles — new tool for joint repair and regeneration. Nat Rev Rheumatol. 2016;12(4):243–249. doi:10.1038/nrrheum.2015.170. PMID: 26729461.
• [11] Freitag J, Bates D, Boyd R, et al. Mesenchymal stem cell therapy in the treatment of osteoarthritis: reparative pathways, safety and efficacy — a review. BMC Musculoskelet Disord. 2016;17:230. doi:10.1186/s12891-016-1085-9. PMID: 27229856.
• [12] Murphy MB, Moncivais K, Caplan AI. Mesenchymal stem cells: environmentally responsive therapeutics for regenerative medicine. Exp Mol Med. 2013;45:e54. doi:10.1038/emm.2013.94. PMID: 24232253.

Approval status

• [13] Ministry of Food and Drug Safety (MFDS), Republic of Korea. Bio & Cosmetics — Manufactures: CARTISTEM (human umbilical cord blood-derived mesenchymal stem cells), approved by MFDS in January 2012 for knee articular cartilage defects in patients with osteoarthritis. https://mfds.go.kr/eng/brd/m_30/view.do?seq=69798 (accessed 7 October 2026).