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

Treatment for Elbow Bursitis

Start with conservative management including relative rest, ice application for 10-minute periods through a wet towel, activity modification, and NSAIDs for pain control, reserving corticosteroid injections for cases that fail initial therapy after 4-12 weeks, and consider surgery only after 6-12 months of failed conservative treatment. 1, 2

Initial Conservative Management (0-4 Weeks)

First-line therapy should focus on:

• Relative rest and activity modification to prevent ongoing damage and promote healing, though complete immobilization must be avoided to prevent muscle atrophy 1, 2
• Cryotherapy application using melting ice water through a wet towel for 10-minute periods to provide effective short-term pain relief 3, 1, 2
• Padding and protection of the affected elbow to prevent additional irritation 1, 2
• NSAIDs for pain control: Use oral naproxen 500 mg initially, followed by 500 mg every 12 hours or 250 mg every 6-8 hours as needed (initial daily dose should not exceed 1250 mg, with subsequent daily doses not exceeding 1000 mg) 4
  • In elderly patients, topical NSAIDs are preferred to avoid gastrointestinal, renal, and cardiovascular risks 1
  • NSAIDs provide short-term pain relief but do not alter long-term outcomes 3

Obtain plain radiographs of the elbow to rule out fractures, heterotopic ossification, or osteoarthritis 1

Second-Line Treatment for Persistent Symptoms (4-12 Weeks)

If symptoms persist despite adequate conservative therapy:

• Local corticosteroid injections (such as 24 mg betamethasone with 1% lidocaine) may be more effective than oral NSAIDs for acute-phase pain relief 3, 2, 5
• Critical caveat: Corticosteroid injections should be used with extreme caution due to potential complications including skin atrophy, infection, and tendon weakening 1, 2
• Important limitation: Corticosteroids do not alter long-term outcomes 3, 2

Evaluation for Septic Bursitis

Always consider infection, particularly if there is:

• Erythema, warmth, or fever 6, 7
• Aspirate bursal fluid if infection is suspected: fluid analysis showing WBC count >3000 cells/mm³ or presence of bacteria indicates septic bursitis 7
• Treat septic bursitis aggressively with aspiration, decompression, and oral or intravenous antibiotics (most commonly Staphylococcus aureus) 6, 7

Surgical Management for Refractory Cases (>6-12 Months)

Surgery should only be considered after failure of 6-12 months of appropriate conservative treatment 1, 2

• Surgical options include bursal excision, which can be performed via open or arthroscopic techniques 8
• Arthroscopic procedures are increasingly favored as they avoid wound complications common with open excision 8
• Surgery is effective but should be reserved for carefully selected patients who have failed conservative therapy 3

Special Considerations

In elderly patients:

• Use the lowest effective NSAID dose due to increased risk of adverse effects 1
• Early intervention is crucial, as longer symptom duration before treatment is associated with treatment failure 1

Common pitfall to avoid: Do not use oral corticosteroids for localized olecranon bursitis, as systemic steroids expose patients to unnecessary systemic side effects without benefit 1