What is the management of olecranon bursitis?

Management of Olecranon Bursitis

Conservative management with rest, activity modification, ice application, and NSAIDs is the first-line treatment for olecranon bursitis, with aspiration reserved for diagnostic purposes or persistent cases. 1, 2

Initial Assessment and Diagnosis

The critical first step is distinguishing septic from non-septic bursitis, as this fundamentally changes management:

• Obtain radiographs initially to exclude fractures, dislocations, or bony abnormalities per the American College of Radiology recommendations 1, 2
• Aspirate the bursa in all cases to determine if infection is present through microscopy, Gram staining, and culture 3
• Clinical features help differentiate septic from non-septic causes, though local erythema can occur in both 3
• Ultrasound can demonstrate bursal thickening and heterogeneous echogenicity in chronic cases 2

Non-Septic Olecranon Bursitis Management

First-Line Conservative Treatment

Rest and activity modification is the cornerstone, specifically avoiding direct pressure on the affected elbow 1, 2

Physical measures:

• Use open-backed elbow protection to reduce pressure on the affected area 1, 2
• Apply ice through a wet towel for 10-minute periods to reduce swelling and pain 1, 2

Pharmacologic treatment:

• Topical NSAIDs are effective with fewer systemic side effects 1, 2
• For patients requiring systemic NSAIDs, naproxen is FDA-approved for bursitis at 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 4
• In patients with cardiovascular disease or risk factors, the American Heart Association recommends starting with acetaminophen or non-acetylated salicylates before NSAIDs, using the lowest effective dose for the shortest duration 1

Aspiration alone produces delayed recovery (taking months) but has no complications 3, 5

Second-Line Treatment for Persistent Cases

• Immobilization with splint or brace may benefit acute or refractory cases 2
• Repeated aspiration if fluid reaccumulates 3

Avoid Corticosteroid Injection

Do not use intrabursal corticosteroids despite rapid resolution within one week, as long-term follow-up reveals significant complications including infection (12% of cases), skin atrophy (20%), and chronic local pain (28%) 5. Since spontaneous resolution occurs with conservative management, this risk is not justified 5.

Septic Olecranon Bursitis Management

The IDSA clarifies that when purulent collections exist with surrounding inflammation, the primary treatment is drainage, not antibiotics alone 6:

• Aspiration is the primary treatment, which may need to be repeated 3
• Long course of antibiotics is required, with recovery potentially taking months 3
• Admission may be necessary for severe cases or patients with poor adherence 3
• Surgical treatment is reserved for cases failing aspiration and antibiotics 3

Surgical Options for Refractory Cases

For chronic or recurrent cases failing conservative management:

• Arthroscopic bursectomy is increasingly preferred over open excision, avoiding wound complications common with open procedures 7
• Hydrothermal ablation at 50-52°C shows 75% success rate with 91.9% reduction in bursal volume, fewer complications than open bursectomy, and full return to work within 6 weeks 8
• Open excisional bursectomy completely removes pathological tissue but carries higher wound complication rates 7

Special Populations

• 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 4
• Patients with moderate to severe renal impairment (creatinine clearance <30 mL/min) should not receive naproxen 4

Common Pitfalls

The most critical error is using intrabursal corticosteroids for traumatic/non-septic bursitis—while resolution appears rapid, the high rate of long-term complications (infection, skin atrophy, chronic pain) makes this approach inadvisable when conservative management achieves resolution without these risks 5.