Treatment of Olecranon Bursitis
Conservative management with rest, activity modification, ice application, and topical NSAIDs is the first-line treatment for olecranon bursitis, with surgical intervention reserved only for chronic cases that fail conservative therapy. 1, 2
Initial Diagnostic Workup
Before initiating treatment, obtain radiographs to exclude fractures, dislocations, or bony abnormalities, as recommended by the American College of Radiology 1, 2. In chronic cases, ultrasound can demonstrate bursal thickening and heterogeneous echogenicity 2.
First-Line Conservative Management
The American Academy of Family Physicians recommends the following stepwise approach 2:
- Rest and avoid direct pressure on the affected elbow - this is the cornerstone of initial management 1, 2
- Apply ice through a wet towel for 10-minute periods to reduce swelling and pain through decreased tissue metabolism 1, 2
- Use open-backed elbow protection to minimize pressure on the bursa during daily activities 1, 2
- Topical NSAIDs are preferred over systemic NSAIDs due to fewer systemic side effects 1, 2
Systemic NSAID Use When Necessary
If systemic NSAIDs are required, naproxen is FDA-approved for bursitis at 500 mg twice daily 3. For patients with cardiovascular disease or risk factors, the American Heart Association recommends starting with acetaminophen or non-acetylated salicylates before NSAIDs, and using the lowest effective dose for the shortest duration 1.
Second-Line Management for Persistent Cases
- Immobilization with a splint or brace may benefit acute or refractory cases 2
- Aspiration alone does not increase infection risk in aseptic bursitis and may provide symptomatic relief 4
Critical Pitfall: Avoid Corticosteroid Injection
Do not inject corticosteroids into the olecranon bursa. Despite historical use, corticosteroid injection is associated with significantly increased complications including infection (12% of cases), skin atrophy (20% of cases), and chronic local pain (28% of cases), without improving clinical outcomes 5, 4. A systematic review of 1,278 patients demonstrated that corticosteroid injection significantly increases overall complications and skin atrophy compared to conservative management alone 4.
Surgical Intervention (Third-Line Only)
Surgical bursectomy should be reserved for chronic or recurrent cases failing conservative management 2. However, surgery is associated with significantly worse outcomes than conservative management, including higher rates of persistent drainage, bursal infection, and overall complications 4. When surgery is necessary, arthroscopic techniques may reduce wound complications compared to open excision 6.
Special Population Considerations
- Patients with inflammatory arthritis require evaluation for systemic disease involvement 2
- Elderly patients should receive the lowest effective NSAID dose due to increased unbound plasma fraction 3
- Patients with moderate to severe renal impairment (creatinine clearance <30 mL/min) should avoid naproxen-containing products 3
Key Clinical Distinction: Septic vs. Aseptic Bursitis
Aseptic bursitis paradoxically has a more complicated clinical course than septic bursitis, with higher overall complication rates 4. However, both respond better to conservative management than surgical intervention 4.