What's the next step for a patient with olecranon bursitis on anticoagulation (blood thinners) who shows no improvement after a Medrol (methylprednisolone) dose pack and doxycycline (100 mg BID for 10 days)?

Management of Refractory Olecranon Bursitis on Anticoagulation

Aspirate the bursa immediately and send fluid for cell count with differential, Gram stain, and culture to definitively distinguish septic from aseptic bursitis, as clinical features alone are unreliable in this distinction. 1, 2

Critical Reassessment Required

Your patient has received both steroids and antibiotics without improvement, which demands urgent clarification of whether this is truly septic bursitis or an aseptic process that was inappropriately treated with steroids.

Diagnostic Aspiration is Mandatory

• Physical examination findings overlap significantly between septic and aseptic olecranon bursitis: tenderness occurs in 88% of septic cases but also 36% of aseptic cases; erythema/cellulitis in 83% septic vs 27% aseptic; warmth in 84% septic vs 56% aseptic 2
• Aspiration with microscopy, Gram staining, and culture is the only reliable method to distinguish septic from aseptic bursitis when clinical features are equivocal 1
• The fact that your patient is on anticoagulation is not a contraindication to aspiration—this is a superficial bursa and the diagnostic information is critical 1

If Aspiration Confirms Septic Bursitis

Antibiotic Adjustment

• Continue doxycycline 100 mg BID but extend the total duration to at least 3-4 weeks (not just 10 days), as recovery from septic olecranon bursitis can take months 1
• Consider adding ciprofloxacin if atypical mycobacteria (such as Mycobacterium goodii) are suspected, particularly if there was prior trauma or the patient received intrabursal steroids before infection was recognized 3
• Tailor antibiotics based on culture and sensitivity results from the aspirate 1

Repeated Aspiration Strategy

• Perform serial aspirations every 3-7 days until fluid reaccumulation stops—this is the cornerstone of septic olecranon bursitis management 1
• Each aspiration should be as complete as possible to remove infected fluid 1

Admission Criteria

• Consider hospital admission if the patient develops fever (present in 38% of septic cases), has systemic signs of infection, or shows progressive cellulitis despite appropriate antibiotics 2
• Surgical consultation for bursectomy is reserved only for cases failing repeated aspiration plus prolonged antibiotics (typically after 4-6 weeks of appropriate treatment) 1

If Aspiration Confirms Aseptic Bursitis

Immediate Steroid Cessation

Stop all corticosteroids immediately—the Medrol dose pack was inappropriate if this is aseptic bursitis, and continuing steroids increases infection risk and causes skin atrophy 4

Conservative Management Algorithm

• Implement rest, ice, compression, and an elbow orthosis to offload the bursa 5
• Prescribe indomethacin 50 mg three times daily (rather than continuing with less effective NSAIDs), as this provides more rapid symptomatic improvement in inflammatory bursitis 6, 1
• Continue this regimen for 7-14 days and reassess 6

Aspiration Without Injection

• Perform therapeutic aspiration to drain the bursa completely, but do NOT inject corticosteroids 5, 4
• Recent literature demonstrates that intrabursal corticosteroid injections have a higher complication rate (including bursal infection and skin atrophy) compared to aspiration alone, despite faster symptom resolution 4
• Repeated aspiration alone (without steroid injection) every 5-7 days is preferred until fluid reaccumulation stops 1, 4

Refractory Aseptic Cases

• If conservative management plus repeated aspiration fails after 4-6 weeks, refer for surgical bursectomy 1, 5
• Surgery should be reserved for truly refractory cases, as conservative methods resolve most aseptic olecranon bursitis if implemented early 4

Critical Pitfalls to Avoid

• Never inject intrabursal corticosteroids in a patient on anticoagulation without first ruling out infection definitively—this can convert aseptic bursitis to septic bursitis or worsen existing infection 3, 4
• Do not assume the bursitis is aseptic just because the patient is on antibiotics—doxycycline alone may be inadequate coverage, and 10 days is too short for septic olecranon bursitis 1
• Avoid repeating oral corticosteroids (like another Medrol dose pack) without a definitive diagnosis, as this increases infection risk and causes systemic side effects without proven benefit in olecranon bursitis 4
• Do not rush to surgery—most cases resolve with appropriate medical management and repeated aspiration 1, 5

Monitoring Plan

• Reexamine the patient in 3-5 days after initiating the above management to assess for reduction in swelling, tenderness, and warmth 2
• If septic: monitor for fever, progressive cellulitis, or systemic signs requiring admission 2
• If aseptic: expect gradual improvement over 3-5 days with swelling resolution, though complete resolution may take weeks 1