What is the best treatment approach for a patient with bursitis of the elbow?

Treatment of Elbow Bursitis

Start with conservative management including relative rest, ice application for 10 minutes through a damp towel, padding for protection, and NSAIDs for pain control—this is the first-line approach for all patients with elbow bursitis. 1, 2, 3

First-Line Conservative Treatment (0-4 weeks)

• Relative rest is essential, but avoid complete immobilization to prevent muscle atrophy 1, 3
• Modify activities that worsen symptoms while continuing those that don't exacerbate pain 1
• Ice application (cryotherapy) for 10-minute periods through a wet towel provides effective short-term pain relief 1, 2
• Padding of the affected area prevents additional irritation 1, 2
• NSAIDs are indicated for bursitis and should be used at the lowest effective dose for the shortest duration 4
  • For acute bursitis, naproxen 500 mg initially, followed by 500 mg every 12 hours or 250 mg every 6-8 hours (not to exceed 1250 mg on day 1, then 1000 mg daily thereafter) 4
  • Topical NSAIDs are preferred when only localized involvement exists, as they minimize systemic side effects 2

Important Caveat on Aspiration

• Do NOT routinely aspirate chronic microtraumatic bursitis due to the risk of introducing infection 3, 5
• Aspiration should only be performed if septic bursitis is suspected, with fluid sent for Gram stain, culture, cell count, glucose, and crystal analysis 5

Second-Line Treatment (4-12 weeks of persistent symptoms)

If conservative measures fail after 4-12 weeks, consider:

• Corticosteroid injections may be more effective than NSAIDs for acute phase relief 1
• However, use with extreme caution due to potential complications including skin atrophy, infection, and tendon weakening 1, 2
• The evidence supporting corticosteroid injections is low quality, and high-quality evidence demonstrating benefit is unavailable 2, 5

Critical Warning

• Avoid oral corticosteroids for localized olecranon bursitis, as systemic steroids are not indicated and expose patients to unnecessary systemic side effects 2

Surgical Treatment (After 6-12 months of failed conservative therapy)

• Surgical excision of the bursa should only be considered after failure of 6-12 months of appropriate conservative management 1, 2, 3
• Surgery is reserved for refractory cases that do not respond to conservative treatment 3, 6, 7
• Arthroscopic techniques are increasingly considered as minimally invasive alternatives to open excision, though not free from complications 8

Special Populations

Elderly Patients

• NSAIDs (oral or topical) are recommended but use with caution due to gastrointestinal, renal, and cardiovascular risks 2
• Use the lowest effective dose in elderly patients, as the unbound plasma fraction of naproxen increases with age 4
• Early intervention is critical, as longer symptom duration before treatment is associated with treatment failure 2

Patients with Cardiovascular Disease

• Follow a gradual approach to pharmacological treatment in patients with cardiovascular risk factors 1
• Consider cardiovascular risks when using NSAIDs, particularly in those with ischemic heart disease 1

Septic Bursitis (Distinct Management)

If infection is suspected based on clinical presentation:

• Aggressive evaluation with bursal aspiration and fluid analysis is mandatory 6, 5
• Start antibiotics effective against Staphylococcus aureus immediately 5
• Outpatient oral antibiotics may be considered for patients who are not acutely ill 5
• Hospitalization with IV antibiotics is required for acutely ill patients 5
• Incision and drainage is rarely needed but may be indicated for non-responsive cases 6