What is the role of oral steroids, such as prednisone, in treating knee pain related to soft tissue injury?

Oral Steroids for Knee Pain from Soft Tissue Injury

Oral corticosteroids are NOT routinely recommended for knee pain from soft tissue injury; intra-articular corticosteroid injections are the preferred steroid delivery method when steroids are indicated, specifically for acute exacerbations with effusion. 1

Evidence for Oral vs. Intra-articular Steroids

The guideline evidence consistently supports intra-articular corticosteroid administration over oral routes for knee conditions:

• Intra-articular corticosteroids provide clinically significant pain reduction with effect sizes up to 1.27 compared to placebo at one week, translating to approximately 1.0 cm improvement on a 10-cm visual analogue scale 1, 2, 3
• Benefits from intra-articular injection are most pronounced at 1-2 weeks post-injection, with moderate effects at 4-6 weeks, small effects at 13 weeks, and no evidence of benefit at 26 weeks 3
• Oral prednisolone (7.5 mg/day for 6 weeks) showed efficacy in one randomized trial for knee osteoarthritis, with pain reduction of 10.9 points on a 100mm scale and sustained effects at 12 weeks 4

When Steroids Are Appropriate (Intra-articular Route)

Use intra-articular corticosteroids for:

• Acute exacerbations of knee pain, especially when accompanied by effusion 1
• Patients who have failed acetaminophen (up to 4g/day) and NSAIDs 1
• Short-term pain relief needs (1-4 weeks) rather than long-term management 2, 3

Critical Safety Concerns with Oral Steroids

Avoid oral corticosteroids for soft tissue knee injuries due to:

• Systemic side effects including osteoporosis and potential osteonecrosis with prolonged use 5
• Lack of guideline support for oral route in soft tissue injuries 1
• Superior risk-benefit profile of localized intra-articular delivery 1

Treatment Algorithm for Soft Tissue Knee Injury

First-line: Acetaminophen up to 4g/day plus non-pharmacological approaches (rest, ice, compression, elevation) 1

Second-line: NSAIDs (oral or topical) for patients unresponsive to acetaminophen, particularly if effusion present 1

Third-line: Intra-articular corticosteroid injection for acute exacerbations with significant inflammation or effusion 1

NOT recommended: Routine oral corticosteroids for soft tissue knee injuries

Administration Details for Intra-articular Injections

• Imaging guidance is NOT required for knee injections 1
• Avoid overuse of the injected joint for 24 hours following injection 1
• Do NOT inject within 3 months prior to planned knee replacement surgery due to infection risk 1
• Monitor glucose levels for 1-3 days post-injection in diabetic patients 1

Common Pitfalls

• Expecting long-term benefits: Corticosteroid effects are short-lived (1-4 weeks maximum), not a solution for chronic pain management 2, 3
• Using oral steroids routinely: No guideline support exists for oral corticosteroids in soft tissue knee injuries; this route carries systemic risks without localized benefit 1
• Repeated frequent injections: Concerns exist about potential cartilage damage with frequent repeated injections, though clinical significance remains uncertain 6, 5
• Injecting without effusion assessment: While some evidence suggests better outcomes with effusion present, the presence of acute inflammation and pain are the key clinical indicators 1