What is the assessment and management for elbow bursitis?

Assessment and Management of Elbow Bursitis

Elbow bursitis (olecranon bursitis) should be managed with a stepwise approach starting with conservative measures including rest, activity modification, NSAIDs, and physical therapy, with aspiration reserved for diagnostic purposes or symptomatic relief, and surgery only considered after 3-6 months of failed conservative treatment. 1

Assessment

Clinical Evaluation

• Determine if acute or chronic presentation
• Assess for:
  • History of trauma or repetitive microtrauma (most common cause) 2
  • Signs of infection (fever, significant erythema, warmth)
  • Inflammatory conditions (gout, rheumatoid arthritis)
  • Occupational factors (leaning on elbows)

Diagnostic Imaging

• Standard radiographs (anteroposterior and lateral views) should be the first imaging study 3
  • Can identify calcifications, heterotopic ossification, or underlying bone abnormalities
  • Comparison with asymptomatic side often useful
• Ultrasound can help distinguish bursitis from cellulitis 2
• Advanced imaging (MRI or CT) is rarely needed for simple bursitis but may be necessary for complex cases 1

Diagnostic Aspiration

• Indicated when infection is suspected 2
• Bursal fluid should be examined for:
  • Gram stain and culture
  • Crystal analysis
  • Cell count
  • Glucose measurement
• Septic bursitis is present in approximately one-third of olecranon bursitis cases 4

Management

Non-Septic Bursitis

Acute Traumatic/Hemorrhagic Bursitis

1. Conservative treatment:
   • Ice application
   • Elevation
   • Rest and activity modification
   • NSAIDs (e.g., naproxen 500mg twice daily or ibuprofen 1.2g daily) 1
   • Protective padding or compression
2. Aspiration may be performed to relieve symptoms 5
   • Use aseptic technique
   • Avoid repeated aspirations due to risk of iatrogenic infection

Chronic Microtraumatic Bursitis

1. Conservative management:
   • Address underlying cause (e.g., avoid leaning on elbows)
   • NSAIDs for pain relief
   • Protective padding
   • Physical therapy with focus on eccentric strengthening exercises 1
2. Corticosteroid injections:
   • May be considered but should be limited to 2-3 injections 1
   • High-quality evidence demonstrating benefit is lacking 2
   • Use proper aseptic technique and patient positioning 1
   • Post-injection care: avoid overuse of injected area for 24 hours 1

Septic Bursitis

1. Antibiotic therapy:
   • Initial coverage should target Staphylococcus aureus 2
   • Outpatient oral antibiotics for mild cases
   • Hospitalization and IV antibiotics for acutely ill patients
2. Aspiration:
   • May need to be repeated to drain purulent material 4
   • Monitor response to treatment
3. Surgical intervention:
   • Reserved for cases not responsive to antibiotics
   • Or for recurrent infections 2

Chronic Inflammatory Bursitis

• Treat underlying condition (gout, rheumatoid arthritis)
• Intrabursal corticosteroid injections often used 2

Follow-up and Referral

• Regular assessment at 2,6, and 12 weeks to evaluate:
  • Pain levels
  • Range of motion
  • Functional improvement
• Consider specialist referral if no improvement after 6-8 weeks of conservative treatment 1
• Surgical excision of the bursa should only be considered for recalcitrant cases that fail 3-6 months of well-managed conservative treatment 1, 5

Return to Activity

• Permitted when patient demonstrates:
  • Complete resolution of pain
  • Full range of motion
  • Strength symmetry >90% compared to uninjured side
  • Successful completion of occupation-specific functional tests 1

Common Pitfalls and Caveats

• Avoid bursal aspiration in non-septic cases unless necessary, due to risk of iatrogenic infection 2
• Do not immobilize the joint completely as this may lead to stiffness 1
• Recovery from septic olecranon bursitis can take months 4
• Distinguish bursitis from other conditions like arthritis, fracture, tendinitis, and nerve pathology 6
• Trauma can cause both septic and non-septic bursitis; clinical features alone may not reliably distinguish between them 4