What is the recommended treatment for a patient with olecranon bursitis, possibly with a history of rheumatoid arthritis or gout?

Management of Olecranon Bursitis

Initial Approach Based on Etiology

The treatment of olecranon bursitis depends critically on distinguishing between septic, inflammatory (gout/rheumatoid arthritis), and traumatic/microtraumatic causes, with conservative management preferred for most cases and corticosteroid injection reserved specifically for inflammatory etiologies. 1, 2

Septic vs. Aseptic Differentiation

• If infection is suspected (fever, severe erythema, warmth, systemic symptoms), perform bursal aspiration immediately with fluid analysis including Gram stain, culture, cell count with differential, glucose, and crystal analysis 2
• Septic bursitis requires antibiotics effective against Staphylococcus aureus as initial treatment, with outpatient oral therapy acceptable for non-acutely ill patients and intravenous antibiotics for those who are acutely ill 2
• Ultrasonography can help distinguish bursitis from cellulitis when the diagnosis is unclear 2

Treatment Algorithm by Etiology

Gout-Related Olecranon Bursitis

For gout-related bursitis, initiate anti-inflammatory therapy within 24 hours of symptom onset using colchicine, NSAIDs, or glucocorticoids as first-line options. 1, 3

• Low-dose colchicine (1.2 mg immediately followed by 0.6 mg one hour later) is strongly preferred over high-dose regimens due to similar efficacy with fewer adverse effects 1, 4
• NSAIDs are highly effective when initiated promptly; naproxen is FDA-approved for acute gout and bursitis 5
• Glucocorticoids (oral prednisone 0.5 mg/kg/day for 5-10 days, or intrabursal injection) are appropriate alternatives, particularly when NSAIDs are contraindicated 1, 4
• Intrabursal corticosteroid injection is appropriate for gout-related olecranon bursitis, as this represents inflammatory rather than microtraumatic bursitis 1, 2
• Address the underlying condition by initiating or optimizing urate-lowering therapy, with anti-inflammatory prophylaxis continued for at least 3-6 months 1

Rheumatoid Arthritis-Related Bursitis

• Treat the underlying inflammatory condition with disease-modifying antirheumatic drugs (DMARDs) as per standard rheumatoid arthritis management 3
• Intrabursal corticosteroid injections are often used for chronic inflammatory bursitis related to rheumatoid arthritis 2
• Glucocorticoid injections may be helpful at the elbow for inflammatory bursitis, with ultrasound guidance if needed 3

Traumatic/Microtraumatic (Aseptic) Bursitis

Conservative management is the first-line treatment for traumatic olecranon bursitis, with aspiration potentially shortening symptom duration but corticosteroid injection NOT recommended due to significant complication risks. 6, 2, 7

• Initial conservative therapy: ice, elevation, rest, and analgesics (NSAIDs) 6, 2
• Aspiration alone may shorten symptom duration for acute traumatic/hemorrhagic bursitis without increasing infection risk 2, 7
• Avoid corticosteroid injection for microtraumatic bursitis—it is associated with significantly increased complications including infection (3/25 patients), skin atrophy (5/25 patients), and chronic local pain (7/25 patients) without improving outcomes 7, 8, 9
• Address underlying repetitive trauma or occupational factors (e.g., prolonged leaning on elbows) 2

Critical Pitfalls to Avoid

• Do not inject corticosteroids into microtraumatic/traumatic bursitis: A 1984 study showed that while corticosteroid injection provided rapid recovery (within one week), it resulted in infection in 12%, skin atrophy in 20%, and chronic pain in 28% of patients, whereas aspiration alone had no complications 8
• Do not aspirate microtraumatic bursitis routinely: Repeated aspiration increases the risk of iatrogenic septic bursitis without clear benefit 2
• Surgical management should be avoided: Surgery is associated with significantly lower clinical resolution rates and higher complication rates (persistent drainage, infection) compared to nonsurgical management for both septic and aseptic bursitis 7
• Reserve surgery only for: septic bursitis unresponsive to antibiotics or recurrent cases 2

When Conservative Management Fails

• For refractory aseptic bursitis unresponsive to 6-8 weeks of conservative treatment, corticosteroid injection may be considered, but only after excluding infection and with full patient counseling about complication risks 9
• Arthroscopic bursectomy is increasingly considered as a minimally invasive option for truly refractory cases, avoiding wound complications of open excision 6