What is the recommended treatment for a patient with elbow bursitis?

Treatment of Elbow Bursitis

Conservative treatment with relative rest, ice application, activity modification, and padding is the first-line approach for elbow bursitis, with aspiration avoided in chronic microtraumatic cases due to infection risk. 1, 2

Initial Conservative Management (First-Line Treatment)

The treatment approach depends on the type of bursitis, but conservative measures form the foundation:

• Relative rest is essential—avoid complete immobilization as this leads to muscle atrophy and deconditioning 1, 2
• Ice application (cryotherapy) for 10-minute periods through a damp towel provides effective short-term pain relief 2
• Activity modification: Continue activities that don't exacerbate pain, but modify or temporarily stop those that worsen symptoms 2
• Padding/protection of the affected area helps prevent additional irritation 2

Pain Management Options

• NSAIDs (oral or topical) effectively relieve pain, with topical formulations preferred in elderly patients to avoid gastrointestinal risks 2
• Naproxen can be used at 500 mg initially, followed by 500 mg every 12 hours or 250 mg every 6-8 hours for acute bursitis, with initial daily dose not exceeding 1250 mg 3

Critical Decision Point: To Aspirate or Not

Avoid routine aspiration in chronic microtraumatic bursitis due to the significant risk of introducing iatrogenic infection 1, 4

However, aspiration is indicated when:

• Septic bursitis is suspected: Perform bursal aspiration with fluid analysis including Gram stain, crystal analysis, glucose measurement, blood cell count, and culture 4
• Acute traumatic/hemorrhagic bursitis: Aspiration may shorten symptom duration 4

Signs Requiring Aggressive Evaluation for Infection

Inflamed bursae should be aggressively evaluated and treated, as some may require aspiration and decompression with oral or intravenous antibiotics to prevent septicemia 5

Second-Line Treatments (After 4-12 Weeks of Failed Conservative Care)

• Local corticosteroid injections may be more effective than NSAIDs for acute phase relief 2
• Use with extreme caution: Corticosteroids carry risks of skin atrophy, infection, and tendon weakening 2

Surgical Intervention (Last Resort)

Surgery should only be considered after 6-12 months of appropriate conservative treatment failure 2

• Surgical excision of the bursa is recommended only for refractory cases that do not respond to conservative treatment 1, 5
• Arthroscopic procedures are increasingly considered as minimally invasive alternatives to open excision, though not free from complications 6

Special Considerations for Septic Bursitis

• Antibiotics effective against Staphylococcus aureus are the initial treatment 4
• Outpatient antibiotics may be considered for patients who are not acutely ill 4
• Acutely ill patients should be hospitalized and treated with intravenous antibiotics 4
• Surgery is reserved for cases not responsive to antibiotics or recurrent infections 4

Common Pitfalls to Avoid

• Never completely immobilize the elbow—this causes muscle atrophy 1, 2
• Don't routinely aspirate chronic microtraumatic bursitis—the infection risk outweighs benefits 1, 4
• Don't rush to corticosteroid injections—high-quality evidence for benefit in microtraumatic bursitis is lacking, and complications are real 4
• Don't proceed to surgery prematurely—ensure at least 6-12 months of well-managed conservative treatment first 2