Management of Olecranon Bursitis
Conservative management with rest, activity modification, ice application, and topical NSAIDs should be the first-line treatment for olecranon bursitis, with surgical intervention reserved only for chronic refractory cases that fail conservative therapy. 1, 2
Initial Diagnostic Approach
- Obtain plain radiographs first to exclude fractures, dislocations, or bony abnormalities before initiating treatment 1, 2
- Ultrasound can demonstrate bursal thickening and heterogeneous echogenicity in chronic cases if diagnosis remains uncertain 1
- Distinguish septic from aseptic bursitis clinically, as management differs significantly 3
First-Line Conservative Management (Aseptic Bursitis)
Start with these non-invasive measures for all patients:
- Rest and strict avoidance of pressure on the affected elbow 1, 2
- Use open-backed elbow protection to reduce direct pressure on the bursa 1, 2
- Apply ice through a wet towel for 10-minute periods to reduce swelling and pain 1, 2
- Topical NSAIDs as first-line pharmacologic therapy, which provide fewer systemic side effects than oral formulations 1, 2
For patients with cardiovascular disease or risk factors, use acetaminophen or non-acetylated salicylates before NSAIDs, and if NSAIDs are necessary, use the lowest effective dose for the shortest duration 2
What NOT to Do
Avoid corticosteroid injections as routine treatment. The most recent systematic review (2023) and high-quality evidence demonstrate that while CSI may reduce symptom duration, it significantly increases complications including bursal infection (documented in multiple studies), skin atrophy, and chronic local pain without improving overall clinical resolution 4, 3, 5. A 1984 study showed 3 infections, 5 cases of skin atrophy, and 7 cases of chronic local pain in just 25 patients treated with intrabursal triamcinolone 4. The 2014 systematic review of 1,278 patients confirmed CSI increases overall complications (p=0.0458) and skin atrophy (p=0.0261) 3.
Aspiration alone is acceptable and does not increase infection risk in aseptic bursitis, though it typically results in delayed recovery compared to conservative measures 4, 3.
Second-Line Management (Persistent or Recurrent Cases)
If conservative management fails after 4-6 weeks:
- Consider immobilization with a splint or brace for acute or refractory cases 1
- Reserve corticosteroid injection only for truly refractory cases after weighing the significant complication risks 5
- Evaluate for underlying inflammatory arthritis if recurrent or persistent despite appropriate conservative care 1
Surgical Considerations (Third-Line)
Surgery should be avoided whenever possible as it demonstrates significantly worse outcomes than conservative management 3. The 2014 systematic review showed surgical management was less likely to achieve clinical resolution (p=0.0476) and had higher rates of overall complications (p=0.0117), persistent drainage (p=0.0194), and bursal infection (p=0.0060) compared to nonsurgical treatment 3.
If surgery becomes necessary for chronic refractory cases:
- Arthroscopic techniques are preferred over open excision to minimize wound complications 6
- Hydrothermal ablation (irrigation with 50-52°C saline) shows promise with 75% success rate and minimal complications in a 2024 prospective study, though this remains investigational 7
Septic Olecranon Bursitis
Drainage is the primary treatment for septic bursitis with purulent collections, not antibiotics alone 1. This represents a fundamentally different treatment paradigm than aseptic bursitis.
Key Clinical Pitfalls
- Aseptic bursitis has a more complicated clinical course than septic bursitis contrary to common assumptions 3
- Spontaneous resolution commonly occurs with conservative management alone, making aggressive early intervention unnecessary 4, 5
- Earlier implementation of conservative methods improves outcomes, so avoid delay in starting basic measures 5
- Most patients achieve full return to work within 6 weeks with appropriate conservative management 7