What is the recommended treatment for olecranon bursitis, considering various patient scenarios, including those with rheumatoid arthritis or gout?

Treatment of Olecranon Bursitis

For non-septic olecranon bursitis, conservative management with rest, ice, NSAIDs, and aspiration (if needed) is the recommended first-line approach, while septic bursitis requires aspiration with antibiotics targeting Staphylococcus aureus. 1, 2, 3

Initial Assessment: Distinguishing Septic from Non-Septic Bursitis

The critical first step is determining whether the bursitis is infectious or non-infectious, as this fundamentally changes management:

• Septic bursitis occurs in approximately one-third of cases and can present with local erythema similar to non-septic bursitis, making clinical distinction challenging 3
• Aspiration should be performed in all cases where infection is suspected, with fluid sent for Gram stain, culture, cell count, glucose measurement, and crystal analysis 2, 3
• Ultrasonography can help distinguish bursitis from cellulitis when the diagnosis is unclear 2
• Blood testing including white blood cell count and inflammatory markers can help differentiate infectious from non-infectious causes 2

Non-Septic Olecranon Bursitis Management

First-Line Conservative Treatment

Conservative management is the cornerstone of non-septic bursitis treatment and includes:

• Ice, elevation, rest, and analgesics for acute traumatic or hemorrhagic bursitis 1, 2
• NSAIDs are indicated and likely hasten symptomatic improvement 4, 3
• Aspiration may shorten symptom duration in acute traumatic/hemorrhagic bursitis but is generally not recommended for chronic microtraumatic bursitis due to iatrogenic infection risk 2, 5

Role of Corticosteroid Injection

The evidence regarding intrabursal corticosteroid injection is mixed and warrants caution:

• A 1984 study showed rapid recovery (usually within one week) with 20 mg triamcinolone hexacetonide injection, but significant complications occurred including infection (3/25 patients), skin atrophy (5/25 patients), and chronic local pain (7/25 patients) 5
• Patients treated with aspiration alone had delayed recovery but no complications 5
• High-quality evidence demonstrating benefit of intrabursal corticosteroids for microtraumatic bursitis is unavailable 2
• The 1984 study concluded that since spontaneous resolution can be expected, a conservative approach is suggested rather than corticosteroid injection 5

Special Consideration: Gout-Related Bursitis

When olecranon bursitis is caused by gout, treatment follows acute gout management principles:

• The 2012 ACR guidelines explicitly state that acute bursal inflammation due to gout (e.g., in the olecranon bursa) should have comparable recommendations to gouty arthritis management 6
• First-line options include colchicine, NSAIDs, or glucocorticoids (oral, intraarticular, or intramuscular) 6, 7
• For gout-related olecranon bursitis, intrabursal corticosteroid injection is appropriate as this represents inflammatory rather than microtraumatic bursitis 2
• Low-dose colchicine (1.2 mg immediately followed by 0.6 mg one hour later) is strongly recommended over high-dose colchicine when colchicine is chosen 6
• Treatment should be initiated within 24 hours of symptom onset for optimal efficacy 6, 7

Rheumatoid Arthritis-Related Bursitis

• Chronic inflammatory bursitis from rheumatoid arthritis is treated by addressing the underlying condition 2
• Intrabursal corticosteroid injections are often used for inflammatory causes like rheumatoid arthritis 2

Septic Olecranon Bursitis Management

Antibiotic Therapy

• Antibiotics effective against Staphylococcus aureus are the initial treatment 2
• Outpatient oral antibiotics may be considered for patients who are not acutely ill 2
• Acutely ill patients should be hospitalized and treated with intravenous antibiotics 2
• A long course of antibiotics is required, and recovery can take months 3

Aspiration and Surgical Intervention

• Repeated aspiration may be necessary 3
• Surgery is reserved for cases not responsive to antibiotics or recurrent septic bursitis 2

Surgical Management for Refractory Cases

When conservative management fails:

• Open excisional bursectomy allows complete removal of pathological bursal tissue but carries risk of wound complications 1, 8
• Arthroscopic bursectomy is increasingly considered as a minimally invasive alternative that avoids wound problems associated with open excision, though not free from complications 1, 8

Common Pitfalls to Avoid

• Do not perform aspiration routinely for chronic microtraumatic bursitis due to risk of introducing infection 2
• Do not use intrabursal corticosteroids for traumatic bursitis given the complication profile (infection, skin atrophy, chronic pain) and lack of high-quality evidence 2, 5
• Do not assume erythema indicates infection—both septic and non-septic bursitis can present with local erythema 3
• Do not delay aspiration when infection is suspected—this is essential for diagnosis and guides antibiotic selection 2, 3