Management of Olecranon Bursitis
Initial Assessment
Start with conservative management for all cases of aseptic olecranon bursitis, reserving invasive interventions only for refractory cases or when septic bursitis is confirmed. 1, 2
Obtain radiographs initially to exclude fractures, dislocations, or bony abnormalities before proceeding with treatment. 1, 2, 3 Ultrasound can demonstrate bursal thickening and heterogeneous echogenicity in chronic cases if diagnosis remains uncertain. 1, 3
Treatment Algorithm
First-Line Conservative Management (Aseptic Cases)
Implement all of the following measures immediately:
- Rest and strict activity modification, specifically avoiding any pressure on the affected elbow. 1, 2
- Open-backed elbow protection to eliminate direct pressure on the bursa during daily activities. 1, 2
- Ice application through a wet towel for 10-minute periods to reduce swelling and pain through decreased tissue metabolism. 1, 2
- Topical NSAIDs as first-line pharmacologic therapy, which provide effective pain relief with fewer systemic side effects compared to oral formulations. 1, 2
For patients with cardiovascular disease or risk factors, use acetaminophen or non-acetylated salicylates before considering NSAIDs, and if NSAIDs are necessary, use the lowest effective dose for the shortest duration. 2
Second-Line Management (Persistent Cases After 4-6 Weeks)
- Immobilization with a splint or brace for acute or refractory cases that fail initial conservative measures. 1
- Bursal aspiration alone is an acceptable option that allows delayed but complete recovery without complications. 4, 5
Avoid corticosteroid injections except as a last resort before surgery. Although corticosteroid injection reduces symptom duration more rapidly than other treatments, it carries significantly higher complication rates including bursal infection (12% in one series), skin atrophy (20%), and chronic local pain (28%). 6, 5 Reserve this intervention only for truly refractory cases where conservative management has definitively failed. 6
Third-Line Management (Chronic/Recurrent Cases)
For cases failing 3+ months of conservative management:
- Surgical evaluation for bursectomy should be considered, with arthroscopic approaches increasingly preferred over open excision to avoid wound complications. 1, 4
- Hydrothermal ablation (irrigation with heated saline at 50-52°C) is an emerging option with 75% success rate and fewer complications than open bursectomy, though this requires specialized equipment. 7
Septic Olecranon Bursitis
Drainage is the primary treatment for septic olecranon bursitis with purulent collections and surrounding inflammation, not antibiotics alone. 1, 3 This represents a fundamentally different treatment paradigm from aseptic bursitis and requires immediate procedural intervention.
Special Populations
In patients with inflammatory arthritis (rheumatoid arthritis, gout, etc.), evaluate for systemic disease involvement as the bursitis may represent a manifestation of underlying systemic inflammation rather than isolated mechanical irritation. 1, 3
Common Pitfalls
The most critical error is premature use of corticosteroid injection. 6, 5 While it provides faster symptom resolution, the 12-28% complication rate makes it inappropriate for first-line management when spontaneous resolution occurs with conservative measures in most cases. 5 The allure of rapid improvement must be weighed against the real risk of converting a benign condition into one complicated by infection or chronic pain.
Another pitfall is treating all olecranon bursitis surgically when conservative management succeeds in the majority of cases if implemented early in the disease course. 6