What is the treatment for large olecranon bursitis?

Treatment of Large Olecranon Bursitis

For large olecranon bursitis, begin with conservative management including rest, elbow protection, ice application, and topical NSAIDs, reserving aspiration and immobilization for persistent cases, while avoiding corticosteroid injections due to significant complication risks. 1, 2, 3

Initial Conservative Management (First-Line Treatment)

The treatment algorithm starts with non-invasive measures that should be maintained for 6-8 weeks before escalation:

• Avoid direct pressure on the affected elbow through activity modification and use of open-backed elbow protection devices 1, 2
• Apply ice through a wet towel for 10-minute periods to reduce swelling and pain through decreased tissue metabolism 1, 2
• Use topical NSAIDs as first-line pharmacotherapy due to effectiveness with fewer systemic side effects compared to oral formulations 1, 2
• Consider oral NSAIDs or acetaminophen if topical agents are insufficient, using the lowest effective dose for the shortest duration 2

Second-Line Interventions for Persistent Cases

If conservative measures fail after 6-8 weeks, escalate treatment systematically:

• Perform bursal aspiration as the next step, which may need to be repeated and allows for fluid analysis to rule out septic bursitis 4, 5
• Apply immobilization with a splint or brace for acute or refractory cases to reduce mechanical irritation 1, 2
• Obtain bursal fluid for microscopy, Gram staining, and culture if infection cannot be clinically excluded, as one-third of olecranon bursitis cases are septic 5

Critical Pitfall: Avoid Corticosteroid Injections

Do not use intrabursal corticosteroid injections despite their rapid effect. A long-term follow-up study demonstrated that while 25 patients treated with triamcinolone hexacetonide had rapid recovery within one week, they suffered significant complications including infection (12%), skin atrophy (20%), and chronic local pain (28%), whereas 22 patients treated with aspiration alone had delayed but uncomplicated recovery 3. The risk-benefit profile strongly favors conservative management.

Surgical Considerations for Refractory Cases

For chronic or recurrent bursitis failing 2-3 months of conservative management:

• Consider arthroscopic bursectomy over open excision as it avoids wound complications common with open procedures while allowing complete removal of pathological tissue 4
• Evaluate hydrothermal ablation as an emerging option with 75% success rates and minimal complications in recent prospective studies, though this requires specialized equipment 6
• Reserve open surgical excision for cases where minimally invasive options have failed or are unavailable 4

Special Population Considerations

• In patients with inflammatory arthritis (rheumatoid arthritis, gout), evaluate for systemic disease involvement as the underlying cause 1, 7
• In patients with cardiovascular disease or risk factors, use acetaminophen or non-acetylated salicylates before NSAIDs, and if NSAIDs are necessary, use the lowest effective dose for the shortest duration 2
• Obtain radiographs initially to exclude fractures, dislocations, or bony abnormalities that may alter management 1, 2

Clinical Distinction: Septic vs. Non-Septic Bursitis

While clinical features help differentiate these conditions, local erythema can occur in both:

• Septic bursitis requires aspiration with repeated drainage if necessary and prolonged antibiotic therapy (recovery can take months) 5
• Non-septic bursitis can be managed with aspiration alone without antibiotics 5
• When in doubt, always aspirate and send fluid for analysis to guide appropriate treatment 5