What is the treatment for olecranon bursitis?

Treatment of Olecranon Bursitis

The treatment of olecranon bursitis should follow a conservative approach first, with aspiration alone being preferred over corticosteroid injections due to fewer complications and similar outcomes. 1

Diagnosis and Classification

Before initiating treatment, it's essential to determine whether the olecranon bursitis is:

1. Septic (infectious):

   • Characterized by more severe pain, significant erythema, warmth
   • Often accompanied by systemic symptoms (fever)
   • Requires aspiration with fluid analysis (Gram stain and culture)

2. Aseptic (non-infectious):

   • May follow trauma or repetitive pressure
   • Usually less painful with minimal erythema
   • More common (approximately two-thirds of cases) 2

Treatment Algorithm

Step 1: Initial Conservative Management for Aseptic Bursitis

• Rest and activity modification
• Ice application (20 minutes several times daily)
• NSAIDs (e.g., naproxen 500 mg twice daily) 3
• Padding to avoid direct pressure on the olecranon
• Avoidance of leaning on the elbow

Step 2: Aspiration (for significant swelling or diagnostic purposes)

• Perform aspiration under sterile conditions
• Send fluid for cell count, Gram stain, and culture if infection is suspected
• Simple aspiration without corticosteroid injection is preferred 1

Step 3: Management Based on Type

For Aseptic Bursitis:

• Continue conservative measures
• Repeat aspiration if fluid reaccumulates
• Avoid corticosteroid injections due to increased risk of complications including skin atrophy (5 cases), chronic local pain (7 cases), and potential infection (3 cases) 4

For Septic Bursitis:

• Antibiotic therapy based on culture results (empiric coverage for Staphylococcus aureus initially)
• May require repeated aspirations
• Consider referral if not improving with conservative management
• In severe cases, percutaneous suction-irrigation systems may be beneficial 5

When to Consider Surgery

Surgery should be considered only when conservative management fails, as it is associated with:

• Lower clinical resolution rates
• Higher overall complication rates
• Increased risk of persistent drainage
• Higher risk of bursal infection 1

Indications for surgical referral include:

• Recurrent bursitis despite multiple aspirations
• Persistent infection despite appropriate antibiotics
• Bursal thickening causing mechanical symptoms

Important Caveats

1. Avoid corticosteroid injections in most cases as they are associated with significant complications including skin atrophy and infection without improving outcomes 1

2. Aseptic bursitis may have a more complicated clinical course than septic bursitis despite seeming less severe initially 1

3. Recovery from septic olecranon bursitis can take months, and patients should be counseled accordingly 2

4. Always aspirate when there is significant swelling or diagnostic uncertainty about infection 2

By following this stepped approach with emphasis on conservative management first, most cases of olecranon bursitis can be successfully treated without the need for more invasive interventions.