Management of Olecranon Bursitis
Nonsurgical management with rest, ice, compression, and NSAIDs is the first-line treatment for olecranon bursitis, with surgical intervention reserved only for truly refractory cases, as surgery demonstrates significantly higher complication rates and lower resolution rates than conservative management. 1
Initial Assessment: Septic vs. Aseptic
The critical first step is distinguishing septic from aseptic bursitis, as management differs substantially:
- Septic bursitis presents with erythema, warmth, tenderness, and systemic signs (fever, elevated white blood cell count) 2
- Aseptic bursitis typically results from repetitive microtrauma or direct pressure without signs of infection 3, 2
- Importantly, aseptic bursitis demonstrates a more complicated clinical course with higher overall complication rates than septic bursitis 1
Management of Aseptic Olecranon Bursitis
First-Line Conservative Treatment
All patients should begin with conservative measures: 3, 2, 4
- Rest and activity modification to eliminate repetitive trauma
- Ice application for 10-minute periods through a wet towel 5
- Compression with elastic bandages or orthosis wear 4
- NSAIDs for pain and inflammation control 5, 6
What NOT to Do
Avoid corticosteroid injections for initial management - they are associated with significantly increased overall complications (p=0.0458) and skin atrophy (p=0.0261) without improving clinical outcomes 1. While older literature suggested benefit, more recent evidence demonstrates adverse effects compared to noninvasive management 4.
Avoid routine aspiration - aspiration does not increase infection risk but provides no therapeutic benefit in aseptic bursitis 1. The condition is often self-limited and resolves with conservative methods alone 4.
Refractory Cases
If symptoms persist after 6-8 weeks of conservative management: 5
- Continue conservative measures
- Consider immobilization with a cast or fixed-ankle walker-type device 5
- Surgical bursectomy may be considered, though surgery demonstrates significantly lower resolution rates (p=0.0476) and higher complication rates (p=0.0117) than nonsurgical management 1
- Arthroscopic bursectomy is increasingly preferred over open excision to minimize wound complications 3
Management of Septic Olecranon Bursitis
Empirical Antibiotic Treatment Without Aspiration
For uncomplicated septic bursitis, empirical oral antibiotics without aspiration is highly effective and avoids complications: 7
- Empirical management resolved 84% of cases with a single antibiotic course 7
- Aspiration had a number needed to harm of 1.46 - meaning nearly every aspiration caused complications including chronic draining sinuses and progression to bursectomy 7
- Of aspirated cases, 73% required bursectomy versus 0% in the empirical management group 7
Antibiotic Selection
- Oral antibiotics targeting Staphylococcus aureus (most common pathogen) 5, 2
- Consider MRSA coverage in areas with high community-acquired MRSA prevalence 5
- Duration typically 10-14 days, with 16% requiring a second course 7
When to Aspirate
Aspiration should be reserved for: 5
- Patients with severe systemic features (high fever, hypotension)
- Immunocompromised patients (malignancy, neutropenia, severe cell-mediated immunodeficiency)
- Failure to respond to empirical antibiotics after 48-72 hours
Critical distinction: The term "septic bursitis with surrounding inflammation" should be used rather than "septic bursitis with surrounding cellulitis" - the primary treatment is antibiotics for the infected bursa, not the surrounding tissue inflammation 5.
Common Pitfalls to Avoid
- Do not inject corticosteroids into or around the olecranon bursa for initial aseptic bursitis - complications outweigh benefits 1, 4
- Do not routinely aspirate uncomplicated septic bursitis - empirical treatment is safer and more effective 7
- Do not rush to surgery - surgical management has significantly worse outcomes than conservative treatment for both septic and aseptic bursitis 1
- Do not confuse bursitis with arthritis - bursitis involves the bursa, not the joint itself, and requires different management 5, 2