What is the initial management for a patient with elbow bursitis?

Initial Management of Elbow Bursitis

Begin with conservative management including rest, activity modification, ice application, NSAIDs, and padding, as this is the first-line treatment for elbow bursitis. 1

Diagnostic Evaluation

Initial Imaging

• Obtain plain radiographs of the elbow to exclude fractures, heterotopic ossification, osteoarthritis, intra-articular bodies, soft tissue calcification, or osteochondral lesions 1, 2
• Radiographs are mandatory first-line imaging and should be performed before initiating treatment 3
• Consider comparison views with the asymptomatic side if findings are equivocal 3

Rule Out Septic Bursitis

• Perform bursal aspiration with culture if infection is suspected based on systemic signs (fever, elevated inflammatory markers) or acute presentation 2, 4
• Aspirated fluid should undergo Gram stain, crystal analysis, glucose measurement, blood cell count, and culture 4
• This distinction is critical as septic bursitis requires urgent antibiotic treatment, typically targeting Staphylococcus aureus 4
• Ultrasonography can help distinguish bursitis from cellulitis if the diagnosis is unclear 4

Conservative Management (First-Line Treatment)

Acute Phase (0-4 weeks)

• Apply ice (cryotherapy) for 10-minute periods through a wet towel, 3-4 times daily to reduce pain and swelling 1, 5
• Relative rest and activity modification to prevent ongoing trauma and promote healing 1, 2
• Padding over the olecranon to protect against further microtrauma 1
• NSAIDs for pain relief and inflammation control - naproxen 500 mg twice daily or 250 mg every 6-8 hours (not exceeding 1250 mg on day 1, then 1000 mg daily thereafter) 6
• Avoid direct ice contact with skin to prevent cold injury 5

Persistent Symptoms (4-12 weeks)

• Continue conservative measures including rest, activity modification, ice, NSAIDs, and padding 1
• Bursal aspiration may be considered for acute traumatic/hemorrhagic bursitis to shorten symptom duration, but is generally not recommended for chronic microtraumatic bursitis due to risk of iatrogenic infection 7, 4

Second-Line Treatment

Corticosteroid Injection

• Consider intrabursal corticosteroid injection only for persistent symptoms despite 4-12 weeks of appropriate conservative management 1, 2
• Use with caution due to potential complications including skin atrophy, infection, and tendon weakening 1, 5
• Note that high-quality evidence demonstrating benefit for microtraumatic bursitis is lacking 4

Surgical Management

Indications for Surgery

• Surgical consultation for bursal excision should be reserved for refractory cases that fail to respond after 6-12 months of appropriate conservative management 1, 2
• Arthroscopic excision is increasingly preferred over open procedures to avoid wound complications 8
• Surgery may also be indicated for recurrent septic bursitis not responsive to antibiotics 4, 9

Common Pitfalls to Avoid

• Do not perform bursal aspiration routinely for chronic microtraumatic bursitis, as this increases the risk of iatrogenic septic bursitis without clear benefit 4
• Do not skip radiographs, even if the diagnosis seems clinically obvious, as they may reveal underlying pathology requiring different management 1, 2
• Do not use compression wraps that compromise circulation - ensure adequate blood flow is maintained 5
• Do not proceed to corticosteroid injection or surgery without an adequate trial of conservative management (minimum 4-12 weeks for injection, 6-12 months for surgery) 1