What is the treatment for olecranon bursitis?

Treatment of Olecranon Bursitis

Initial Approach: Conservative Management First-Line

Conservative management with rest, activity modification, ice application, and NSAIDs should be the initial treatment for aseptic olecranon bursitis, as this approach is significantly more effective and safer than invasive interventions. 1, 2

Non-Pharmacological Interventions

• Avoid direct pressure on the affected elbow through activity modification and use of open-backed elbow protection to reduce mechanical irritation 1, 3
• Apply ice through a wet towel for 10-minute periods to reduce swelling and pain through decreased tissue metabolism 1, 3
• Consider compression bandaging as an effective first-line option that demonstrates comparable efficacy to invasive procedures 4

Pharmacological Management

• Start with topical NSAIDs as they provide effective relief with fewer systemic side effects 1, 3
• Oral naproxen is FDA-approved for bursitis at a starting dose of 500 mg followed by 500 mg every 12 hours or 250 mg every 6-8 hours, with initial daily dose not exceeding 1250 mg 5
• For patients with cardiovascular disease or risk factors, use acetaminophen or non-acetylated salicylates first, and if NSAIDs are necessary, use the lowest effective dose for the shortest duration 3

Imaging Considerations

• Obtain radiographs initially to exclude fractures, dislocations, or bony abnormalities 1, 3
• Ultrasound can demonstrate bursal thickening and heterogeneous echogenicity in chronic cases 1

Second-Line Management for Persistent Cases

When to Escalate Treatment

Conservative management should be continued for at least 4 weeks before considering invasive interventions, as longer symptom duration before treatment is the primary factor associated with treatment failure 4

Immobilization

• Use splinting or bracing for acute or refractory cases that fail initial conservative measures after 4-6 weeks 1

Aspiration and Injection: Use With Caution

Aspiration with or without corticosteroid injection should be reserved for refractory cases only, not as first-line treatment, due to higher complication rates. 2, 6

Key Evidence on Invasive Procedures:

• Aspiration with steroid injection achieves fastest resolution (median 2.3 weeks) compared to aspiration alone (3.1 weeks) or compression with NSAIDs (3.2 weeks), but this must be weighed against complications 4
• Corticosteroid injection is associated with significantly higher complications including skin atrophy and bursal infection compared to conservative management 2, 6
• Aspiration alone does not increase infection risk for aseptic bursitis 2
• Overall resolution rates at 4 weeks are similar across all treatment modalities (compression: 83%, aspiration: 65%, aspiration with steroid: 85%), suggesting no clear superiority of invasive approaches 4

Surgical Management

Surgery should be reserved only for chronic, recurrent cases that fail all conservative and minimally invasive treatments. 1, 2

• Surgical management is significantly less effective than nonsurgical management for both septic and aseptic bursitis 2
• Surgery demonstrates higher rates of complications including persistent drainage, bursal infection, and wound problems compared to conservative treatment 2, 7
• Arthroscopic bursectomy may be considered over open excision if surgery is necessary, as it avoids wound complications common with open procedures 8

Special Consideration: Septic Bursitis

If septic olecranon bursitis is suspected, drainage is the primary treatment rather than antibiotics alone for cases with purulent collections and surrounding inflammation 1

Critical Pitfalls to Avoid

• Do not use corticosteroid injections as first-line treatment - they increase complications without improving overall resolution rates 2, 6
• Do not proceed to surgery without adequate trial of conservative management - surgical outcomes are inferior to nonsurgical approaches 2
• Earlier intervention is more effective - longer symptom duration before treatment predicts failure, so initiate conservative management promptly 4
• In patients with inflammatory arthritis, evaluate for systemic disease involvement before attributing symptoms solely to mechanical bursitis 1