What is the appropriate evaluation and treatment for elbow bursitis?

Evaluation and Treatment of Elbow Bursitis

For elbow bursitis, start with radiographs to rule out fractures or other bony abnormalities, then use conservative management including rest, ice, NSAIDs, and activity modification as first-line treatment. 1

Diagnostic Evaluation

Clinical Assessment

• Look for swelling, erythema, and tenderness over the olecranon bursa
• Assess for mechanical symptoms such as locking or catching
• Evaluate for signs of infection: warmth, erythema, fever, or rapid onset of symptoms
• Determine if trauma or chronic microtrauma (leaning on elbows) is the cause 2
• Check for systemic conditions that may cause bursitis (gout, rheumatoid arthritis) 2

Imaging

1. Plain radiographs should be the initial imaging modality 3, 1

   • Anteroposterior (AP) and lateral views of the elbow
   • Helps rule out fractures, loose bodies, osteoarthritis, or calcifications

2. Advanced imaging (if needed):

   • Ultrasound: Useful for showing bursal thickening, fluid collection, and heterogeneous echogenicity 3
   • MRI: Consider for persistent symptoms to evaluate for associated tendon pathology 3, 1

Laboratory Studies (if infection suspected)

• Bursal aspiration with fluid analysis:
  • Gram stain, culture
  • Cell count (WBC >3000 cells/mm³ suggests infection) 4
  • Crystal analysis to rule out gout
  • Glucose measurement

Treatment Approach

Non-Septic Bursitis

1. First-line treatment (0-6 weeks) 1:

   • Rest and activity modification (avoid leaning on elbow)
   • Ice application for 10-minute periods through a wet towel 3
   • NSAIDs for pain and inflammation (use lowest effective dose for shortest duration) 5
   • Protective padding or elbow sleeve to prevent recurrence

2. If symptoms persist (6-12 weeks):

   • Consider corticosteroid injection (limit to 1-2 injections) 1
   • Continue activity modification
   • Physical therapy with eccentric strengthening exercises 3, 1

3. Recalcitrant cases (>3 months):

   • Reassessment with advanced imaging
   • Consider surgical referral for bursal excision 6

Septic Bursitis

1. Immediate management:

   • Bursal aspiration for diagnosis
   • Antibiotics effective against Staphylococcus aureus (most common pathogen) 2, 4
   • For mild cases: oral antibiotics with close follow-up
   • For severe cases or systemic symptoms: hospitalization with IV antibiotics

2. Follow-up:

   • Re-evaluate within 48-72 hours
   • If worsening despite antibiotics, consider surgical drainage 4

Prevention of Recurrence

• Use elbow pads during activities that put pressure on the elbow
• Avoid leaning on elbows for prolonged periods
• Maintain proper ergonomics at workstations
• Address underlying conditions that may contribute to bursitis

Common Pitfalls to Avoid

1. Failing to distinguish between septic and non-septic bursitis
2. Overuse of corticosteroid injections, which can lead to skin atrophy or tendon weakening
3. Missing underlying conditions like gout or rheumatoid arthritis
4. Premature return to activities that caused the initial bursitis
5. Inadequate treatment of septic bursitis, which can lead to serious complications

Remember that most cases of elbow bursitis respond well to conservative management, but prompt recognition and treatment of septic bursitis is essential to prevent complications 2.