What is the treatment for olecranon bursitis?

Treatment of Olecranon Bursitis

The treatment of olecranon bursitis should primarily be conservative, including rest, ice, anti-inflammatory medications, and occasionally aspiration, with surgical intervention reserved only for cases that fail to respond to conservative management. 1

Clinical Presentation and Diagnosis

Olecranon bursitis presents as swelling at the posterior aspect of the elbow over the olecranon process. It can be categorized into:

• Nonseptic (aseptic) bursitis: Often caused by repetitive trauma, microtrauma, or systemic conditions
• Septic bursitis: Caused by bacterial infection, typically through skin penetration

Key diagnostic features include:

• Visible swelling over the olecranon
• Pain that may worsen with movement or pressure
• Redness and warmth (more prominent in septic cases)
• Limited range of motion in severe cases

Treatment Algorithm

First-Line Treatment (Conservative Management)

1. Rest and Activity Modification

   • Avoid pressure on the affected elbow
   • Avoid activities that aggravate symptoms

2. Ice Application

   • Apply ice for 10-minute periods through a wet towel 2
   • Use several times daily, especially after activity

3. NSAIDs

   • Oral NSAIDs like naproxen are effective for reducing inflammation and pain 3
   • Consider cardiovascular risk when prescribing NSAIDs, especially in patients with heart disease 2
   • Use the lowest effective dose for the shortest duration

4. Compression/Padding

   • Protective padding to prevent further trauma
   • Elastic compression to reduce swelling

Second-Line Treatment

1. Aspiration

   • Consider for significant swelling or pain that doesn't respond to initial measures
   • Simple aspiration without steroid injection has fewer complications 4
   • Should be performed with sterile technique

2. Corticosteroid Injections

   • Use with caution due to potential complications
   • Complications include skin atrophy (20%), infection (12%), and chronic local pain (28%) 4
   • Recent evidence suggests avoiding intrabursal injections as initial treatment 5

Third-Line Treatment (Refractory Cases)

1. Immobilization

   • Short-term immobilization with a cast or fixed-ankle walker-type device 2
   • Typically for 1-2 weeks in cases not responding to other conservative measures

2. Surgical Management

   • Reserved for cases that fail conservative treatment
   • Options include:
     • Open bursectomy: Complete removal of the bursal tissue
     • Arthroscopic bursectomy: Minimally invasive approach with potentially fewer wound complications 1
   • Consider referral to a specialist if symptoms persist beyond 6-8 weeks 2

Special Considerations

Septic Bursitis

• Requires prompt antibiotic therapy
• May need more aggressive drainage and debridement
• Consider hospitalization for severe cases or immunocompromised patients

Systemic Conditions

• Evaluate for underlying conditions like gout or rheumatoid arthritis 6
• Treatment of the underlying condition may be necessary

Common Pitfalls and Caveats

1. Avoid corticosteroid injections as initial therapy due to high complication rates 4

2. Don't mistake septic for nonseptic bursitis - look for:

   • Fever
   • Significant erythema
   • Rapid onset
   • Systemic symptoms

3. Don't rush to surgical intervention - recent evidence favors conservative management over surgical intervention for initial treatment 6, 5

4. Recognize that spontaneous resolution is common - patience with conservative measures is often rewarded 4

5. Don't ignore recurrent bursitis - may indicate an underlying systemic condition or occupational issue requiring specific intervention

The management of olecranon bursitis should follow a stepwise approach, starting with conservative measures and progressing to more invasive interventions only when necessary. Most cases will resolve with proper conservative care, making surgery a last resort for persistent cases.