Treatment of Olecranon Bursitis
The first critical step is distinguishing septic from aseptic olecranon bursitis through diagnostic aspiration with Gram stain, culture, and cell count, as this fundamentally determines whether conservative management or antibiotic therapy is required. 1
Initial Diagnostic Approach
Perform diagnostic aspiration when infection is suspected, particularly if the patient presents with fever, severe erythema, warmth, systemic symptoms, or is immunocompromised. 1 Clinical features alone can be misleading—while fever, tenderness, peribursal cellulitis, and overlying skin involvement are more common in septic cases, local erythema can occur in both septic and aseptic bursitis. 2, 3
Key laboratory findings that distinguish septic from aseptic bursitis include: 3
- High leukocyte count in bursal fluid
- Low bursal-to-serum glucose ratio
- Positive Gram stain
The most common pathogen is Staphylococcus aureus, including penicillin-resistant strains. 4, 3
Management of Aseptic Olecranon Bursitis
For aseptic bursitis, conservative management is the first-line approach and is significantly more effective and safer than surgical intervention. 1, 5
Conservative Treatment Protocol:
- Rest and activity modification, specifically avoiding direct pressure on the elbow 1
- Aspiration alone is appropriate and does not increase infection risk 5
- NSAIDs likely hasten symptomatic improvement 2
Critical Pitfall - Avoid Corticosteroid Injection:
Do not use intrabursal corticosteroids for aseptic bursitis. While they produce rapid resolution (often within one week), they are associated with significantly increased complications including: 6, 5
- Skin atrophy (20% of cases)
- Chronic local pain (28% of cases)
- Infection risk (12% of cases)
- No improvement in overall clinical outcomes
Aseptic bursitis typically resolves spontaneously with conservative management, though recovery may take weeks to months. 2, 6
Management of Septic Olecranon Bursitis
Initiate empiric antibiotic coverage targeting Staphylococcus aureus, including MRSA if risk factors are present. 1
Antibiotic Regimen:
- Vancomycin IV or daptomycin 6 mg/kg IV once daily for at least 2 weeks 1
- Adjust therapy based on culture results 1
- Duration of treatment should be proportional to the length of time infection has been present—expect an average of 12 days for successful therapy, though some cases require longer courses 3
Adjunctive Measures:
- Therapeutic aspiration, which may need to be repeated 1, 2
- Recovery can take months even with appropriate treatment 2
Indications for Hospitalization: 1
- Concern for deeper or necrotizing infection
- Severe immunocompromise
- Systemic toxicity or sepsis
- Failed outpatient management
Surgical Management
Surgery should be reserved only for cases that fail conservative or antibiotic therapy. 5 Surgical management (whether open excision or arthroscopic bursectomy) is associated with: 5
- Lower clinical resolution rates compared to nonsurgical management
- Higher overall complication rates
- Increased persistent drainage
- Higher bursal infection rates
When surgery is necessary, arthroscopic techniques are increasingly preferred over open excision to minimize wound complications. 7
Special Clinical Scenarios
Gouty Bursitis:
Manage similarly to gouty arthritis with naproxen 750 mg initially, then 250 mg every 8 hours until the attack subsides. 1
Mycobacterial Bursitis:
Consider in immunocompromised patients or those with chronic, culture-negative bursitis; requires prolonged multi-drug antimycobacterial therapy. 1
Rheumatologic Causes:
Rheumatoid arthritis and gout may be accompanied by nonseptic bursitis and should be managed accordingly. 3