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

Treatment of Olecranon Bursitis

For aseptic olecranon bursitis, begin with conservative management including rest, ice application, and NSAIDs; reserve aspiration and corticosteroid injection for refractory cases, as initial invasive treatment shows adverse effects compared to conservative management. 1, 2

Initial Conservative Management (First-Line Treatment)

Aseptic olecranon bursitis should be treated conservatively first:

• Rest and activity modification to eliminate repetitive trauma is the cornerstone of initial treatment 1
• Ice application for 10-minute periods through a wet towel to reduce inflammation 1
• NSAIDs (such as naproxen) at the lowest effective dose for the shortest duration to control pain and inflammation 1, 3
  • Naproxen is FDA-approved specifically 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 3
  • Onset of pain relief typically begins within 1 hour 3

Important caveat: Recent literature demonstrates that invasive management (injections, surgery) for initial treatment of nonseptic olecranon bursitis shows adverse effects compared to noninvasive management 2. This represents a shift from older treatment paradigms that favored earlier intervention.

Management of Refractory Cases

If conservative measures fail after an appropriate trial:

• Continue conservative measures and consider immobilization with a cast or fixed-ankle walker-type device 1
• Aspiration may be considered, though older studies showing benefit with intrabursal corticosteroid injections have been challenged by more recent evidence of adverse effects 2

Septic Olecranon Bursitis (Critical Distinction)

You must differentiate septic from aseptic bursitis, as management differs significantly:

• Oral antibiotics targeting Staphylococcus aureus for uncomplicated septic bursitis, with MRSA coverage in high-prevalence areas 1, 4
• Aspiration should be reserved for:
  • Patients with severe systemic features 1
  • Immunocompromised patients 1
  • Those failing empirical antibiotics after 48-72 hours 1

Common pitfall: Do not inject corticosteroids into potentially infected bursae, as this can worsen septic bursitis. Always consider aspiration for diagnostic purposes if infection is suspected before proceeding with steroid injection 4.

Surgical Intervention

Surgery is reserved for truly refractory cases that fail all conservative measures, though arthroscopic approaches are increasingly preferred over open excision to avoid wound complications 5, 4.