What is the initial treatment for olecranon bursitis?

Initial Treatment for Olecranon Bursitis

The initial treatment for olecranon bursitis should include rest, ice application, NSAIDs, and activity modification to reduce pressure on the affected elbow (RICE protocol), with these conservative measures recommended for the initial 1-2 weeks. 1

Conservative Management (First-Line)

Non-Pharmacological Measures

• Rest and activity modification: Reduce pressure on the affected elbow
• Ice application: Apply for 10-minute periods through a wet towel
• Compression: Use an elastic bandage to reduce swelling
• Elevation: Keep the affected elbow elevated when possible
• Protective padding: Consider using elbow padding to prevent further irritation

Pharmacological Therapy

• NSAIDs (e.g., naproxen): Recommended for management of acute bursitis 2
  • Typical dosing: 500 mg initially, followed by 250 mg every 6-8 hours as needed
  • Do not exceed 1250 mg on first day and 1000 mg on subsequent days
  • Use the lowest effective dose for the shortest duration

Diagnostic Considerations

When to Suspect Infection

• Look for cardinal signs of infection:
  • Erythema
  • Warmth
  • Tenderness
  • Fluctuant swelling
  • Systemic symptoms (fever, chills)

Diagnostic Procedures

• Aspiration: Essential for definitive diagnosis if infection is suspected 1
  • Send fluid for cell count, Gram stain, cultures, and crystal analysis
  • Note: Aspiration alone may be sufficient for non-septic cases

Treatment Algorithm Based on Presentation

Non-Septic Olecranon Bursitis

1. RICE protocol + NSAIDs for 1-2 weeks
2. If no improvement, consider aspiration (without corticosteroid injection)
3. For persistent cases, continue conservative management with protective padding

Septic Olecranon Bursitis

1. Immediate aspiration of bursal fluid for diagnosis
2. Empiric antibiotic therapy targeting Staphylococcus aureus and streptococci
3. Adjust antibiotics based on culture results
4. Continue antibiotics for at least 14 days
5. Perform serial aspirations every 3-5 days if reaccumulation occurs

Important Cautions and Pitfalls

• Avoid corticosteroid injections: Associated with increased complications including infection, skin atrophy, and chronic local pain 3, 4
• Avoid surgical management as initial treatment: Nonsurgical management is significantly more effective and safer than surgical management 4
• Recognize that aseptic bursitis may have a more complicated clinical course than septic bursitis 4
• Surgery should be reserved for refractory cases that fail conservative management 1

Prevention of Recurrence

• Address underlying mechanical factors
• Use protective padding over susceptible areas
• Correct biomechanical abnormalities
• Modify activities that cause repetitive trauma

By following this evidence-based approach, most cases of olecranon bursitis will resolve without the need for more invasive interventions.