What is the treatment for bursitis of the elbow?

Treatment of Elbow Bursitis (Olecranon Bursitis)

For nonseptic olecranon bursitis, begin with compression bandaging and NSAIDs as first-line treatment, as this approach offers the best balance of safety and efficacy without the risks of aspiration or injection. 1

Initial Assessment: Rule Out Septic Bursitis

Before initiating treatment, you must distinguish septic from nonseptic bursitis, as management differs dramatically. 2

Signs suggesting septic bursitis requiring immediate evaluation:

• Acute illness or fever 2
• Marked erythema extending beyond the bursa 2
• Severe warmth and tenderness 2

If infection is suspected:

• Perform bursal aspiration with Gram stain, culture, glucose measurement, blood cell count, and crystal analysis 2
• Start antibiotics effective against Staphylococcus aureus immediately 2
• Hospitalize acutely ill patients for IV antibiotics; outpatient oral antibiotics may be considered for those not acutely ill 2

Treatment Algorithm for Nonseptic Olecranon Bursitis

First-Line Treatment (Weeks 0-4)

Compression bandaging with NSAIDs is the recommended initial approach because it avoids the risk of iatrogenic septic bursitis from aspiration while providing comparable resolution rates. 1

• Apply compression bandaging to the affected elbow 1
• Prescribe NSAIDs: naproxen 500 mg initially, then 500 mg every 12 hours or 250 mg every 6-8 hours (maximum 1250 mg first day, then 1000 mg daily thereafter) 3
• Add ice application, elevation, rest, and activity modification 2, 4
• Address underlying causes such as repetitive trauma or pressure (e.g., modify work activities, use elbow padding) 2

Expected timeline: Most cases resolve by 3.2 weeks with this approach 1

Critical caveat: Longer symptom duration before treatment is associated with treatment failure—patients with symptoms lasting 6+ weeks are less likely to respond by 4 weeks compared to those with 4 weeks of symptoms. 1

Second-Line Treatment (If No Improvement by Week 4)

If substantial fluid collection persists after 4 weeks of conservative management, consider aspiration with or without corticosteroid injection. 1

Aspiration with steroid injection provides the fastest resolution (2.3 weeks) compared to aspiration alone (3.1 weeks) or compression alone (3.2 weeks). 1

• Aspirate the bursal fluid 1
• Consider intrabursal corticosteroid injection after aspiration 2, 4
• Continue compression bandaging 1

Important warning: Aspiration carries risk of iatrogenic septic bursitis, which is why it should not be first-line for microtraumatic bursitis. 2

Refractory Cases

For chronic bursitis not responding to 4+ weeks of conservative management and aspiration/injection:

• Surgical excision of the bursa may be indicated 5, 4
• Surgery is reserved only for recalcitrant cases that fail all conservative measures 5, 6

Special Considerations

For inflammatory bursitis (gout, rheumatoid arthritis):

• Treat the underlying systemic condition 2
• Intrabursal corticosteroid injections are often used in this context 2
• Crystal analysis of aspirated fluid helps confirm gout 2

Acute traumatic/hemorrhagic bursitis:

• Treat conservatively with ice, elevation, rest, and analgesics 2
• Aspiration may shorten symptom duration in acute traumatic cases 2

Common Pitfalls to Avoid

• Do not routinely aspirate microtraumatic bursitis as first-line treatment due to infection risk 2
• Do not perform incision and drainage unless absolutely necessary for septic cases not responding to antibiotics 5
• Do not rush to surgery—recent evidence increasingly supports conservative management over surgical intervention 6
• Do not ignore duration of symptoms—patients with longer symptom duration before presentation are more likely to fail treatment and may need earlier escalation 1