Olecranon Bursitis: Clinical Presentation and Management
Clinical Features
Olecranon bursitis presents with swelling over the posterior elbow, which may be accompanied by pain, warmth, and erythema; distinguishing septic from aseptic causes is critical as approximately one-third of cases are infected. 1
Key Symptoms and Signs
- Visible swelling over the olecranon process is the hallmark finding, representing fluid accumulation in the bursa 2
- Pain that worsens with direct pressure or elbow flexion 3
- Erythema and warmth can occur in both septic and non-septic cases, making clinical differentiation challenging 1
- Tenderness on palpation of the bursal area 4
- Limited range of motion may occur in severe cases, though the joint itself typically remains functional 3
Distinguishing Septic from Aseptic Bursitis
Clinical features alone are insufficient to reliably separate septic from non-septic cases, though they provide helpful clues. 1 The presence of fever, surrounding cellulitis, and systemic symptoms should raise suspicion for infection. 3 Aspiration with microscopy, Gram staining, and culture is mandatory when infection cannot be excluded clinically. 1
Initial Diagnostic Approach
Radiographs are the recommended first-line imaging to exclude fractures, dislocations, or bony abnormalities. 5, 6 Plain films can also detect heterotopic ossification and soft-tissue calcifications associated with chronic bursitis. 5
Ultrasound demonstrates bursal thickening and heterogeneous echogenicity in chronic cases and can measure bursal volume, though it is not required for initial diagnosis. 7 The olecranon fossa is a common location for synovitis detectable on ultrasound. 7
Management Algorithm
First-Line Conservative Treatment (Aseptic Cases)
Conservative management should be initiated first for aseptic olecranon bursitis, as it is significantly more effective and safer than surgical intervention. 8
- Rest and activity modification, specifically avoiding direct pressure on the affected elbow 5, 6
- Open-backed elbow protection to reduce pressure on the bursa 5, 6
- Ice application through a wet towel for 10-minute periods to reduce swelling and pain 5, 6
- Topical NSAIDs as first-line pharmacotherapy, offering effectiveness with fewer systemic side effects 5, 6
- Aspiration alone can be performed for aseptic cases and does not increase infection risk 8
Second-Line Treatment (Persistent or Refractory Cases)
- Immobilization with splint or brace for acute or refractory cases 5
- Avoid corticosteroid injection as first-line therapy—while CSI may shorten symptom duration, it is associated with significantly higher complication rates including bursal infection and skin atrophy 4, 8
- Reserve CSI for refractory cases that fail conservative management, given the elevated risk profile 4
Septic Olecranon Bursitis Management
Drainage is the primary treatment for septic olecranon bursitis rather than antibiotics alone, particularly when purulent collections and surrounding inflammation are present. 5, 7
- Aspiration should be performed and may need to be repeated 1
- Long course of antibiotics (oral or intravenous depending on severity) to prevent septicemia 3, 1
- Admission may be required for severe cases 1
- Incision and drainage is rarely needed but indicated for non-responsive cases 3
- Recovery can take months even with appropriate treatment 1
Surgical Intervention
Surgical excision should be reserved only for recalcitrant cases that fail all conservative measures. 3 Surgical management demonstrates significantly lower resolution rates and higher complication rates including persistent drainage and bursal infection compared to nonsurgical approaches. 8 When surgery is necessary, arthroscopic techniques are increasingly preferred over open excision to minimize wound complications. 2
Special Considerations
In patients with inflammatory arthritis, evaluation for systemic disease involvement is necessary as the bursitis may represent a manifestation of underlying rheumatologic disease. 5, 7
For patients with cardiovascular disease or risk factors, use acetaminophen or non-acetylated salicylates before NSAIDs, and when NSAIDs are necessary, use the lowest effective dose for the shortest duration. 6
Common Pitfalls
The most significant pitfall is premature use of corticosteroid injection, which increases overall complications and skin atrophy without improving outcomes. 8 Another critical error is treating suspected septic bursitis with antibiotics alone without drainage, which is inadequate for source control. 5, 7 Finally, rushing to surgical excision before exhausting conservative measures leads to worse outcomes and higher complication rates. 8