What is the treatment for olecranon bursitis?

Treatment of Olecranon Bursitis

The first-line treatment for olecranon bursitis is conservative management including rest, activity modification, ice application, and NSAIDs, with more invasive interventions reserved for persistent or recurrent cases. 1

Conservative Management (First-Line)

Non-pharmacological Approaches

• Rest and activity modification, including avoiding pressure on the affected elbow 1
• Use of open-backed elbow protection to reduce pressure on the affected area 1
• Ice application through a wet towel for 10-minute periods to reduce swelling and pain 1
• Radiographs are recommended as the initial imaging modality to exclude fractures, dislocations, or bony abnormalities 2, 1

Pharmacological Approaches

• NSAIDs such as naproxen are indicated for the relief of signs and symptoms of bursitis 3
• The recommended dose for acute bursitis is naproxen 500 mg initially, followed by 500 mg every 12 hours or 250 mg every 6-8 hours as required 3
• The initial total daily dose should not exceed 1250 mg of naproxen, with subsequent daily doses not exceeding 1000 mg 3
• Topical NSAIDs may be effective with fewer systemic side effects 1
• Use the lowest effective dose for the shortest duration consistent with treatment goals 3

Second-Line Interventions

For Persistent or Recurrent Cases

• Immobilization with a splint or brace may be beneficial for acute or refractory cases 1
• Bursal aspiration may be considered, though it carries a risk of complications 4
• Corticosteroid injections should be used cautiously as they are associated with significant risks including infection, skin atrophy, and chronic local pain without improving outcomes 5, 4

Surgical Management

• Surgical intervention should be reserved for cases that fail conservative management 1, 6
• Nonsurgical management has been shown to be significantly more effective and safer than surgical management 4
• When surgery is necessary, arthroscopic approaches are increasingly considered as they avoid wound problems often occurring following open excision 6
• Newer techniques such as hydrothermal ablation (irrigation with heated saline at 50-52°C) may be a safe alternative for recurrent or chronic cases with fewer complications than open bursectomy 7

Special Considerations

Cardiovascular Risk

• For patients with cardiovascular disease or risk factors, follow a stepped care approach starting with acetaminophen or non-acetylated salicylates before considering NSAIDs 2
• When NSAIDs are necessary for these patients, use the lowest effective dose for the shortest duration 2, 3

Elderly Patients

• Lower doses of NSAIDs should be considered in elderly patients as the unbound plasma fraction of naproxen is increased in the elderly 3
• It is prudent to use the lowest effective dose in elderly patients 3

Renal Impairment

• Naproxen is not recommended for use in patients with moderate to severe renal impairment (creatinine clearance < 30 mL/min) 3

Treatment Algorithm

1. Begin with rest, activity modification, ice application, and over-the-counter NSAIDs 1
2. If symptoms persist, consider prescription-strength NSAIDs at appropriate dosing 3
3. For refractory cases, consider immobilization with a splint or brace 1
4. Aspiration may be considered but does not increase risk of infection in aseptic bursitis 4
5. Avoid corticosteroid injections when possible due to increased complication rates 5, 4
6. Reserve surgical management for cases that fail all conservative measures 1, 6, 4