What is the treatment for elbow bursitis?

Treatment for Elbow Bursitis

Initial treatment of elbow bursitis should begin with conservative management including rest, ice application for 10-minute periods, NSAIDs, activity modification, and padding for 0-4 weeks, with aspiration reserved for acute traumatic cases only. 1

Initial Diagnostic Considerations

Before initiating treatment, obtain plain radiographs of the elbow to exclude fractures, heterotopic ossification, or osteoarthritis 1. If radiographs are normal but clinical suspicion remains for associated tendon or ligament pathology, consider MRI 1.

Distinguish septic from non-septic bursitis immediately, as this fundamentally changes management. If infection is suspected based on warmth, erythema, fever, or systemic symptoms, perform bursal aspiration with Gram stain, culture, glucose measurement, blood cell count, and crystal analysis 2. Patients who are acutely ill with septic bursitis require hospitalization and intravenous antibiotics effective against Staphylococcus aureus, while those who are not acutely ill may be treated with outpatient oral antibiotics 2.

Conservative Management (First-Line: 0-4 Weeks)

For non-septic bursitis, implement the following measures:

• Relative rest and activity modification to prevent ongoing damage and promote healing, though complete immobilization should be avoided 1
• Ice application (cryotherapy) for 10-minute periods through a wet towel to provide short-term pain relief 1
• NSAIDs (oral or topical) for pain relief 1, 3
  • Naproxen dosing for acute bursitis: 500 mg initially, followed by 500 mg every 12 hours or 250 mg every 6-8 hours, with initial daily dose not exceeding 1250 mg 3
  • Topical NSAIDs can reduce pain while avoiding gastrointestinal risks of oral formulations 4
• Padding to protect the bursa from further trauma 1

Critical Pitfall: Aspiration in Non-Septic Cases

Avoid routine aspiration of chronic microtraumatic (non-septic) bursitis due to the significant risk of introducing iatrogenic septic bursitis 2. Aspiration is appropriate only for acute traumatic/hemorrhagic bursitis, where it may shorten symptom duration 2, or when infection must be ruled out 2.

Second-Line Treatment (4-12 Weeks)

If symptoms persist after 4 weeks of conservative management:

• Continue conservative measures including rest, ice, NSAIDs, and activity modification 1
• Corticosteroid injections may be considered for short-term relief, but use with extreme caution 1
  • These provide temporary benefit but do not alter long-term outcomes 4
  • Potential complications include skin atrophy, infection, and tendon weakening 1
  • The evidence supporting their use is low quality 1

Surgical Management (>6-12 Months)

Surgical intervention should only be considered after failure of 6-12 months of appropriate conservative management 1. Surgery typically involves bursal excision 1, 5.

Surgical options include:

• Open excisional bursectomy, which completely removes pathological bursal tissue but carries risk of wound complications 6
• Arthroscopic bursectomy, an increasingly popular minimally invasive alternative that avoids wound problems common with open excision, though not complication-free 6

Surgery is reserved for recalcitrant cases that do not respond to prolonged conservative treatment 5, 7.

Treatment Algorithm Summary

Phase 1 (0-4 weeks): Rest, ice, NSAIDs, padding, activity modification 1

Phase 2 (4-12 weeks): Continue conservative measures; consider corticosteroid injection only if conservative treatment fails and infection has been excluded 1

Phase 3 (>6-12 months): Surgical consultation for possible bursal excision if all conservative measures have failed 1

Key Clinical Caveats

• Never inject corticosteroids if any possibility of infection exists, as this can lead to catastrophic outcomes 2
• Aspiration of chronic non-septic bursitis introduces infection risk and should generally be avoided 2
• Most cases of non-septic olecranon bursitis respond to conservative treatment alone 6, 7
• Patients successfully self-treat mild symptoms through activity modification and conservative measures in many cases 8