What is the treatment for olecranon bursitis?

Treatment of Olecranon Bursitis

Conservative management with rest, activity modification, ice application, and topical NSAIDs is the first-line treatment for olecranon bursitis, as this approach is significantly more effective and safer than surgical management or corticosteroid injections. 1, 2, 3

Initial Diagnostic Workup

• Obtain radiographs as the initial imaging modality to exclude fractures, dislocations, or bony abnormalities before initiating treatment 1, 2
• Ultrasound can demonstrate bursal thickening and heterogeneous echogenicity in chronic cases if diagnosis remains unclear 2

First-Line Conservative Management

All patients should begin with conservative measures:

• Rest and avoid direct pressure on the affected elbow (e.g., no leaning on hard surfaces) 1, 2
• Apply ice through a wet towel for 10-minute periods to reduce swelling and pain 1, 2
• Use open-backed elbow protection to minimize pressure on the bursa during daily activities 1, 2
• Topical NSAIDs are preferred over systemic NSAIDs due to fewer systemic side effects 1, 2

Systemic NSAID Use (When Topical NSAIDs Insufficient)

If systemic NSAIDs are needed for acute bursitis or tendonitis, naproxen is FDA-approved for this indication 4:

• Starting dose: 500 mg naproxen, followed by 500 mg every 12 hours or 250 mg every 6-8 hours 4
• Initial total daily dose should not exceed 1250 mg; thereafter, do not exceed 1000 mg daily 4
• Use the lowest effective dose for the shortest duration 1, 4

For patients with cardiovascular disease or risk factors:

• Start with acetaminophen or non-acetylated salicylates before considering NSAIDs 1
• If NSAIDs are necessary, use the lowest effective dose for the shortest duration 1

Second-Line Management for Persistent Cases

If conservative measures fail after several weeks:

• Immobilization with a splint or brace may benefit acute or refractory cases 2
• Aspiration alone (without corticosteroid injection) does not increase infection risk in aseptic bursitis and may provide symptomatic relief 3, 5

Critical Pitfall: Avoid Corticosteroid Injections

Intrabursal corticosteroid injections should be avoided despite rapid symptom resolution, as they are associated with significant complications 6, 3:

• Increased overall complication rates compared to conservative management 3
• Skin atrophy in up to 20% of patients 6, 3
• Bursal infection risk 6
• Chronic local pain in up to 28% of patients 6
• No improvement in long-term outcomes compared to aspiration alone 3

Surgical Evaluation (Third-Line)

Reserve surgical bursectomy only for chronic or recurrent cases that fail all conservative measures 2, 7:

• Surgical management is significantly less likely to achieve clinical resolution than nonsurgical management 3
• Surgery carries higher rates of complications, persistent drainage, and bursal infection compared to conservative treatment 3
• Arthroscopic approaches may reduce wound complications compared to open excision, though both carry risks 7

Special Considerations

• In patients with inflammatory arthritis, evaluate for systemic disease involvement as the underlying cause 2
• Septic bursitis requires different management: aspiration with microscopy, Gram staining, culture, and prolonged antibiotics; some cases require admission or surgical drainage 5
• Aseptic bursitis has a more complicated clinical course than septic bursitis, contrary to common assumptions 3
• Most cases of olecranon bursitis are self-limited and resolve with conservative measures alone 8, 5