What is the appropriate evaluation and management of olecranon (elbow) bursitis?

Olecranon Bursitis: Evaluation and Management

Initial Evaluation

Start with plain radiographs to exclude fractures, dislocations, or bony abnormalities, then determine if the bursitis is septic or aseptic through clinical assessment and bursal aspiration. 1, 2

Clinical Assessment

• Distinguish septic from aseptic bursitis through clinical features, though local erythema can occur in both presentations 3
• Trauma can cause both septic and non-septic olecranon bursitis, so mechanism alone is insufficient for diagnosis 3
• Aspirate the bursa in all cases and send fluid for microscopy, Gram staining, and culture when infection is suspected 3
• One-third of olecranon bursitis cases are septic, making this distinction critical for management 3

Imaging

• Radiographs are the initial imaging modality to rule out bony pathology 4, 1, 2
• Ultrasound can demonstrate bursal thickening and heterogeneous echogenicity in chronic cases 1, 5
• The olecranon fossa is a common location for synovitis detectable with ventral longitudinal ultrasound scans 5

Management Algorithm

For Septic Olecranon Bursitis

Drainage is the primary treatment, not antibiotics alone, particularly when purulent collections and surrounding inflammation are present. 1, 5

• Perform aspiration, which may need to be repeated 3
• Initiate a long course of antibiotics after drainage 3
• Some cases require hospital admission 3
• Surgical treatment is reserved for cases failing repeated aspiration and antibiotics 3
• Recovery can take months even with appropriate treatment 3

For Aseptic Olecranon Bursitis

Conservative management is first-line and significantly more effective than surgical intervention. 6

First-Line Conservative Treatment

• Rest and activity modification, specifically avoiding pressure on the affected elbow 1, 2
• Open-backed elbow protection to reduce pressure on the affected area 1, 2
• Ice application through a wet towel for 10-minute periods to reduce swelling and pain 1, 2
• Topical NSAIDs are effective with fewer systemic side effects 1, 2
• For patients with cardiovascular disease or risk factors, use a stepped approach starting with acetaminophen or non-acetylated salicylates before NSAIDs, and use the lowest effective dose for the shortest duration 2

Aspiration Considerations

• Aspiration alone can be effective for managing non-septic olecranon bursitis 3
• Aspiration does not increase the risk of bursal infection in aseptic bursitis 6
• Patients treated with bursal aspiration alone had delayed recovery but no complications 7

What to Avoid

Do not use intrabursal corticosteroid injections as routine treatment. 7, 6

• Corticosteroid injection is associated with significantly increased overall complications and skin atrophy without improving outcomes 6
• While corticosteroid injection produces rapid resolution (usually within one week), complications include infection (12%), skin atrophy (20%), and chronic local pain (28%) 7
• A conservative approach is preferred since spontaneous resolution can be expected 7

Second-Line Treatment

• Immobilization with a splint or brace may benefit acute or refractory cases 1
• NSAIDs probably hasten symptomatic improvement 3

For Chronic, Recurrent, or Refractory Cases

Nonsurgical management remains superior to surgical intervention even in persistent cases. 6

• Surgical management is less likely to achieve clinical resolution (p = 0.0476) and demonstrates higher rates of overall complications (p = 0.0117), persistent drainage (p = 0.0194), and bursal infection (p = 0.0060) compared to nonsurgical management 6
• Consider advanced interventions or surgical evaluation only after conservative management fails 1
• Hydrothermal ablation at 50-52°C is emerging as a safe alternative to open bursectomy with 75% success rate and fewer complications, though this requires specialized equipment 8
• Open excisional bursectomy allows complete removal of pathological bursal tissue but carries significant wound complications 9
• Arthroscopic approaches are increasingly considered as minimally invasive alternatives, though not free from complications 9

Special Populations

• In patients with inflammatory arthritis, evaluate for systemic disease involvement 1, 5
• Athletes such as javelin throwers and baseball pitchers are predisposed to olecranon pathology from repetitive high-force extension movements 5

Key Clinical Pearls

• Aseptic bursitis has a more complicated clinical course than septic bursitis, with higher overall complication rates (p = 0.0108) 6
• The primary pitfall is using corticosteroid injection for rapid symptom relief without considering long-term complications 7, 6
• Always aspirate when the diagnosis is uncertain, as clinical features alone may be insufficient to distinguish septic from aseptic bursitis 3