What is the management of elbow bursitis?

Management of Elbow Bursitis

The management of elbow bursitis should follow a stepwise approach, with initial conservative treatment for aseptic bursitis and more aggressive intervention for septic bursitis, including aspiration, antibiotics, and possible surgical intervention when indicated. 1

Diagnosis and Classification

Aseptic vs. Septic Bursitis

• Aseptic bursitis: Non-infectious inflammation, typically from trauma, repetitive pressure, or inflammatory conditions
• Septic bursitis: Infection of the bursa, most commonly caused by Staphylococcus aureus 2

Diagnostic Evaluation

• Physical examination: Look for erythema, warmth, tenderness, fluctuance over the olecranon
• Aspiration: Indicated when infection is suspected or for symptomatic relief
• Fluid analysis: Cell count, Gram stain, culture
  • WBC >3000 cells/mm³ suggests infection 2
  • Presence of bacteria on Gram stain or culture confirms infection

Treatment Algorithm

1. Aseptic Bursitis

• Initial management:

  • RICE protocol (Rest, Ice, Compression, Elevation) 3
  • Activity modification to avoid pressure on the elbow
  • NSAIDs for pain and inflammation
  • Protective padding to prevent recurrence

• For persistent or recurrent aseptic bursitis:

  • Aspiration for symptomatic relief 4
  • Consider corticosteroid injection (intrabursal) 4
    • Limit to 2-3 injections with 4-6 weeks between injections 3
  • Compression wrap after aspiration

• For chronic or refractory cases:

  • Referral to orthopedic specialist
  • Consider bursectomy for recurrent cases

2. Septic Bursitis

• Initial management:

  • Aspiration of bursal fluid for diagnosis 1
  • Send fluid for cell count, Gram stain, and culture
  • Start empiric antibiotics targeting Staphylococcus aureus 1, 2
    • First-line: Anti-staphylococcal penicillin (e.g., dicloxacillin) or first-generation cephalosporin (e.g., cephalexin)
    • For MRSA risk or penicillin allergy: Trimethoprim-sulfamethoxazole, doxycycline, or clindamycin

• Treatment based on severity:

  • Mild cases (outpatient):

    • Oral antibiotics for 7-10 days
    • Close follow-up within 48-72 hours
    • Repeat aspiration as needed for symptom relief

  • Moderate to severe cases (consider hospitalization):

    • Parenteral antibiotics
    • Serial aspirations or surgical intervention
    • Indications for hospitalization:
      • Systemic symptoms (fever, chills)
      • Immunocompromised patient
      • Failed outpatient therapy
      • Surrounding cellulitis

• Surgical intervention:

  • Indications:
    • Failed conservative treatment
    • Recurrent or persistent infection
    • Loculated fluid collections
  • Options:
    • One-stage bursectomy with primary closure (preferred) 5
    • Two-stage bursectomy (higher rate of wound dehiscence for olecranon bursitis) 5

Special Considerations

Unusual Pathogens

• Consider fungal infection in immunocompromised patients or those not responding to antibacterial therapy 6
• Mycobacterial infection should be considered in chronic cases

Athletes

• Higher risk of septic bursitis even without obvious skin lesions 7
• May require more aggressive early intervention to minimize recovery time
• Protective padding upon return to activities

Follow-up and Prevention

Follow-up

• For aseptic bursitis: 1-2 weeks after initial treatment
• For septic bursitis: 48-72 hours after starting antibiotics, then weekly until resolution

Prevention

• Protective padding for athletes or workers with repetitive pressure on elbows
• Prompt treatment of skin infections
• Avoid leaning on elbows for prolonged periods

Complications

• Recurrent bursitis
• Chronic inflammation and thickening of the bursa
• Spread of infection to adjacent structures or bloodstream

By following this systematic approach to the management of elbow bursitis, clinicians can effectively treat both aseptic and septic cases while minimizing complications and optimizing outcomes for patients.