How should olecranon (elbow) bursitis be treated?

Treatment of Olecranon (Elbow) Bursitis

The treatment of olecranon bursitis depends critically on whether it is septic or aseptic: septic bursitis requires drainage as the primary treatment (not antibiotics alone), while aseptic bursitis should be managed conservatively with rest, ice, NSAIDs, and activity modification as first-line therapy. 1, 2

Initial Assessment: Septic vs. Aseptic

The most crucial first step is distinguishing septic from aseptic bursitis, as this fundamentally changes management:

• Aspiration should be performed in all cases to determine if infection is present, with fluid sent for microscopy, Gram staining, and culture 3
• Clinical features help differentiate the two, though local erythema can occur in both septic and aseptic cases 3
• Radiographs are the recommended initial imaging to exclude fractures, dislocations, or bony abnormalities 1
• Ultrasound can demonstrate bursal thickening, measure bursal volume, and show heterogeneous echogenicity in chronic cases 1

Treatment Algorithm for Aseptic Olecranon Bursitis

First-Line Conservative Management

• Rest and activity modification to eliminate repetitive trauma 2
• Ice application for 10-minute periods through a wet towel 2
• NSAIDs (such as naproxen) at the lowest effective dose for the shortest duration to control pain and inflammation 2
• Aspiration alone can be sufficient for non-septic cases and may hasten recovery 3, 4

Refractory Cases

For patients who fail initial conservative treatment:

• Continue conservative measures and consider immobilization with a cast or fixed-ankle walker-type device 2
• Intrabursal corticosteroids produce rapid resolution, though concern remains over long-term local effects 3
• Arthroscopic bursectomy is increasingly considered as a minimally invasive option that avoids wound complications common with open excision 4, 5
• Hydrothermal ablation (irrigation with heated saline at 50-52°C) shows 75% success rate with fewer complications than open bursectomy and may be considered for chronic or recurrent cases 6

Treatment Algorithm for Septic Olecranon Bursitis

Primary Treatment Strategy

• Drainage is the primary treatment, not antibiotics alone, particularly when purulent collections and surrounding inflammation are present 1
• Repeated aspiration may be necessary and should be the mainstay of treatment 3

Antibiotic Therapy

• Oral antibiotics targeting Staphylococcus aureus should be used for uncomplicated septic bursitis 2
• Consider MRSA coverage in areas with high community-acquired MRSA prevalence 2
• A long course of antibiotics is typically required, as recovery can take months 3

Indications for More Aggressive Management

Aspiration should be reserved for (or admission/surgical intervention considered):

• Patients with severe systemic features 2
• Immunocompromised patients 2
• Those who fail to respond to empirical antibiotics after 48-72 hours 2
• Cases with persistent soft-tissue defects, fistulas, or recurrent wound healing disorders 7

Special Considerations and Pitfalls

• Do not confuse with inflammatory arthritis: In patients with known inflammatory arthritis, evaluation for systemic disease involvement is necessary 1
• Trauma can cause both septic and non-septic bursitis, so mechanism of injury alone cannot determine infection status 3
• Open bursectomy has high complication rates, particularly wound problems, making minimally invasive approaches preferable when surgery is needed 4, 5
• Positive bursal fluid cultures are uncommon even in clinically infected cases (only 1 of 24 in one series), so clinical judgment remains important 6