What are the management options for elbow bursitis?

Management of Elbow Bursitis

The management of elbow bursitis should follow a stepwise approach beginning with conservative measures including rest, activity modification, NSAIDs, and ice application, with surgical intervention reserved only for cases that fail to respond to 6-12 months of appropriate conservative management. 1, 2

Diagnosis

• Initial evaluation should include plain radiographs of the elbow to rule out other causes of elbow pain such as fractures, heterotopic ossification, or osteoarthritis 3
• MRI may be considered if radiographs are normal or nonspecific and there is suspicion of associated tendon or ligament pathology 3
• Clinical diagnosis is based on the presence of a fluid-filled swelling over the olecranon process, which may be tender to palpation 2
• If infection is suspected (erythema, warmth, severe pain), bursal aspiration should be performed with fluid sent for Gram stain, crystal analysis, cell count, and culture 2

Conservative Management (First-Line)

• Relative rest and activity modification to prevent ongoing damage and promote healing 1, 4
• Ice application (cryotherapy) for 10-minute periods through a wet towel to provide short-term pain relief 1, 2
• NSAIDs (oral or topical) for pain relief - naproxen 500 mg twice daily is FDA-approved for bursitis 5
• Compression and padding of the affected area to reduce swelling and prevent further trauma 6, 2
• Avoidance of direct pressure on the olecranon (e.g., avoiding leaning on elbows) 2, 4

Second-Line Treatments

• Bursal aspiration may be considered for acute traumatic/hemorrhagic bursitis to shorten the duration of symptoms 2
• Caution: Aspiration of non-septic chronic bursitis is generally not recommended due to the risk of iatrogenic infection 2
• Corticosteroid injections may provide short-term relief but should be used with caution due to potential complications including skin atrophy, infection, and tendon weakening 1, 2
• Antibiotics (typically targeting Staphylococcus aureus) are indicated for septic bursitis 2, 4
  • Outpatient oral antibiotics for mild cases
  • Intravenous antibiotics and possible hospitalization for severe cases or systemic symptoms

Surgical Management

• Surgical intervention should be considered only after failure of 6-12 months of appropriate conservative management 1, 4
• Indications for surgery include:
  • Recurrent or chronic bursitis unresponsive to conservative measures 7, 8
  • Septic bursitis not responsive to antibiotics 2, 7
• Surgical options include:
  • Open bursal excision - allows complete removal of pathological bursal tissue 8
  • Arthroscopic bursal excision - minimally invasive alternative that may reduce wound complications 8

Treatment Algorithm

1. Initial phase (0-4 weeks):

   • Rest, activity modification, ice application, NSAIDs, and padding 1, 6
   • If septic bursitis is suspected, immediate aspiration and antibiotics 2

2. For persistent symptoms (4-12 weeks):

   • Continue conservative measures
   • Consider aspiration for significant swelling (only if necessary) 6, 2
   • Consider corticosteroid injection in select non-septic cases 2, 7

3. For refractory cases (>6-12 months):

   • Surgical consultation for possible bursal excision 4, 8

Common Pitfalls and Caveats

• Failure to distinguish septic from non-septic bursitis can lead to serious complications 2
• Repeated corticosteroid injections may lead to skin atrophy and increased risk of infection 1, 2
• Bursal aspiration carries risk of introducing infection and should not be performed routinely for chronic cases 2
• Surgical excision should be reserved for truly refractory cases, as recent evidence supports conservative management over surgical intervention 4