What is the optimal treatment for olecranon bursitis?

Optimal Treatment of Olecranon Bursitis

For aseptic olecranon bursitis, conservative management with NSAIDs, rest, ice, and aspiration (without corticosteroid injection) is the optimal first-line treatment, as nonsurgical approaches are significantly more effective and safer than surgical management or steroid injection. 1

Initial Assessment and Diagnosis

The critical first step is distinguishing septic from aseptic bursitis, as this fundamentally changes management 2, 1:

• Septic bursitis indicators: Fever, severe erythema, warmth, systemic symptoms, or immunocompromised state 3
• Diagnostic aspiration: Perform bursal fluid aspiration for Gram stain, culture, and cell count when infection is suspected 3, 2
• Imaging: Plain radiography may reveal underlying bony abnormalities; ultrasonography can assess bursal volume and guide aspiration 2

Important caveat: The term "cellulitis" should not be used for inflammation surrounding the bursa—this is "septic bursitis with surrounding inflammation" if infected, which requires different treatment than cellulitis alone 3.

First-Line Conservative Management (Aseptic Bursitis)

Conservative therapy should be the initial approach for all aseptic cases 2, 1:

Core Conservative Measures

• Rest and activity modification: Avoid direct pressure on the elbow; use elbow pads for protection 2
• Ice application: Apply for pain relief and reduction of swelling 2
• NSAIDs: Naproxen 500 mg initially, followed by 250 mg every 6-8 hours as needed for acute bursitis 4. NSAIDs are FDA-approved specifically for bursitis treatment 4
• Aspiration alone: Bursal aspiration without steroid injection is safe and effective, with delayed but complete recovery expected (mean 31 months follow-up showed no complications) 5

What NOT to Do

Avoid corticosteroid injection as first-line therapy. Despite rapid symptom resolution (often within one week), intrabursal corticosteroid injection carries significant risks 1, 5, 6:

• Increased overall complication rates compared to aspiration alone 1
• Skin atrophy (documented in 20% of cases in one series) 1, 5
• Bursal infection risk 5
• Chronic local pain (documented in 28% of cases) 5

The evidence is contradictory here: One older randomized trial found methylprednisolone acetate 20 mg intrabursal injection most effective at 6 weeks 6, but longer-term follow-up studies demonstrate substantial complications that outweigh short-term benefits 5. A systematic review of 1,278 patients confirmed corticosteroid injection increases complications without improving outcomes 1.

Second-Line Treatment (Refractory Aseptic Bursitis)

If conservative management fails after 6-8 weeks 3:

Corticosteroid Injection (Use With Extreme Caution)

Only consider if conservative measures completely fail and patient cannot tolerate continued symptoms 6:

• Dosing: Methylprednisolone acetate 20 mg intrabursal injection 6
• Patient counseling: Warn about skin atrophy risk (20%), infection risk, and chronic pain (28%) 5
• Monitoring: Close follow-up for complications

Surgical Options (Last Resort)

Surgery should be reserved for truly refractory cases, as it demonstrates lower clinical resolution rates and higher complication rates than nonsurgical management 1:

• Arthroscopic bursectomy: Increasingly preferred over open excision; minimally invasive with fewer wound complications 2
• Open bursectomy: Complete removal of pathological tissue but high rates of wound problems, persistent drainage, and infection 2, 1
• Hydrothermal ablation: Emerging technique showing 75% success rate with irrigation at 50-52°C for 180 seconds; fewer complications than open bursectomy 7

Surgical complication rates include persistent drainage, bursal infection (significantly higher than nonsurgical management), and wound healing problems 1.

Management of Septic Olecranon Bursitis

Septic bursitis requires a fundamentally different approach 3:

Antibiotic Selection

• Empiric coverage: Target Staphylococcus aureus, including MRSA if risk factors present 3
• MRSA coverage: Vancomycin IV or daptomycin 6 mg/kg IV once daily for at least 2 weeks 3
• Oral alternatives (if stable, no bacteremia): TMP-SMX, doxycycline, or linezolid based on susceptibilities 3
• Culture-directed therapy: Adjust based on aspirate culture results 3

Drainage

• Aspiration: Initial therapeutic aspiration is appropriate 3
• Surgical drainage: Consider if no improvement after 48 hours of antibiotics, or if loculated/complex fluid collection 3

Hospitalization Criteria

Admit patients with 3:

• Concern for deeper or necrotizing infection
• Severe immunocompromise
• Systemic toxicity or sepsis
• Failed outpatient management

Special Considerations

Mycobacterial bursitis: Rare but documented cause of olecranon bursitis (M. szulgai, M. terrae complex) requiring prolonged multi-drug antimycobacterial therapy 3. Consider in immunocompromised patients or those with chronic, culture-negative bursitis.

Gouty bursitis: Acute bursal inflammation from gout should follow similar management strategies as gouty arthritis 3. Naproxen 750 mg initially, then 250 mg every 8 hours until attack subsides 4.

Clinical Outcome Data

Aseptic bursitis paradoxically has a more complicated clinical course than septic bursitis 1. Nonsurgical management achieves clinical resolution in the majority of cases without the 15-30% complication rates seen with surgery 1. Spontaneous resolution can be expected with conservative therapy, supporting a patient, non-interventional approach 5.