eMedicine Specialties > Physical Medicine and Rehabilitation > Upper Limb Musculoskeletal Conditions
Olecranon Bursitis: Treatment & Medication
Updated: Sep 30, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Rehabilitation Program
Physical Therapy
In general, physical and occupational therapy are not needed for this condition. In some cases of nonseptic bursitis, however, the physician may recommend a course of physical or occupational therapy to speed recovery time. Individuals who exhibit olecranon bursitis often are advised to apply the RICE (rest, ice, compression, elevation) method of treatment. Physical therapy modalities (eg, phonophoresis, electrical stimulation) also may be helpful in further reducing pain and inflammation, although these modalities are not necessary for most patients with this condition. The therapist can also complete patient education and present compensatory strategies for resting the involved upper extremity while healing takes place. If the patient's condition becomes severe and does not respond to conservative treatment, surgery may be indicated. For the patient who undergoes bursal excision (bursectomy), physical therapy may be recommended postoperatively for regaining or maintaining the elbow's ROM and strength.
Medical Issues/Complications
- Complications of the disease process include persistent pain and associated decreased functional use of the affected upper extremity.
- Potential complications of aspiration/injection are as follows:
- Swelling - This may recur, particularly if the patient does not maintain adequate pressure or icing at the site or if an infection was present at the time of the initial aspiration.
- Infection
- Persistent drainage through the injection tract
- Ulnar nerve injury - This theoretically may occur if a medial approach is used for the aspiration/injection.
Surgical Intervention
Usually, no surgical intervention is required; however, very severe cases of recalcitrant bursitis may require bursectomy.14
Consultations
- Consultation with a physiatrist (physical medicine and rehabilitation physician) or with another qualified musculoskeletal specialist may be considered by physicians without the training, comfort, or procedural office supplies necessary for aspiration.
- Consultation with a rheumatologist may be helpful if findings are consistent with inflammatory arthropathy.
- Consultation with an orthopedist is generally required only if a fracture is present or in very severe cases of recalcitrant bursitis requiring excision (bursectomy). Some cases may require incision and drainage.
Other Treatment
- Oral nonsteroidal anti-inflammatory drugs (NSAIDs) may be helpful. See Medication.
- Focal corticosteroid injection may be an option, but only if the clinician is confident that no local infection is present.
- A retrospective study by Weinstein and colleagues showed that in 47 patients with traumatic olecranon bursitis, almost all cases resolved via aspiration, with or without intrabursal glucocorticoid injection.15 The 25 patients who did receive glucocorticoid injection (20 mg of triamcinolone) in addition to the bursal aspiration resolved much more rapidly, usually within 1 week. However, glucocorticoid injection seemed to be more highly associated with complications, such as infection and skin atrophy.
- The injection should be on the lateral side of the elbow, so as to avoid the ulnar nerve. The target injection site is the soft-tissue center of the triangle formed by the lateral olecranon, the head of the radius, and the lateral epicondyle. As with most injections, the physician should first aspirate to ensure that the needle is not in a blood vessel and then inject using a slow, but consistent, pressure.16
- A compressive elbow sleeve (eg, a neoprene or elastic sleeve) may help to prevent the bursal fluid from re-accumulating after aspiration.
Medication
For this musculoskeletal condition, medications are used primarily to decrease pain and inflammation. Thus, the most commonly used medications are oral NSAIDs and focal corticosteroid injection in conjunction with the rest of the rehabilitation plan.17
Nonsteroidal anti-inflammatory drugs
Can help to decrease pain and inflammation. Various oral NSAIDs can be used. The choice of NSAID is largely a matter of the adverse effect profile, as well as convenience (how frequently doses must be taken to achieve adequate analgesic and anti-inflammatory effects), patient preferences, and cost.
Ibuprofen (Motrin, Advil, Nuprin, Rufen)
DOC for mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Adult
200-800 mg PO tid/qid
Pediatric
<6 months: Not established
6 months to 12 years: 4-10 mg/kg/dose PO tid/qid
>12 years: Administer as in adults
May decrease effects of loop diuretics with coadministration; coadministration with anticoagulants may increase PT (monitor and watch for signs of bleeding); may increase serum lithium levels and risk of methotrexate toxicity; probenecid may increase toxicity; may increase retention of sodium and fluid and may raise blood pressure
Documented hypersensitivity to other NSAIDs or aspirin; peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, and high risk of bleeding
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Minimize risks of adverse effects by not taking multiple NSAIDs concurrently; caution in patients on anticoagulants or systemic corticosteroids and with bleeding disorders or significant alcohol use; caution in aspirin/NSAID-induced asthma; hypertension, CHF, and advanced age
Naproxen (Anaprox, Naprelan, Naprosyn)
For relief of mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing activity of cyclooxygenase, which is responsible for prostaglandin synthesis.
Adult
500 mg PO followed by 250 mg PO q6-8h; not to exceed 1.25 g/d
Pediatric
<2 years: Not established
>2 years: 2.5 mg/kg PO; not to exceed 10 mg/kg/d
Probenecid may increase toxicity; coadministration with ibuprofen may decrease effects of loop diuretics; coadministration with anticoagulants may prolong PT (watch for signs of bleeding); may increase serum lithium levels and risk of methotrexate toxicity (eg, stomatitis, bone marrow suppression, nephrotoxicity)
Documented hypersensitivity, peptic ulcer disease, recent GI bleeding or perforation, and renal insufficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrant further evaluation and may require discontinuation of drug
Ketoprofen (Oruvail, Orudis, Actron)
For relief of mild to moderate pain and inflammation.
Small doses are indicated initially in patients with small body size, elderly patients, and those with renal or liver disease.
Adult
25-50 mg PO q6-8h prn; not to exceed 300 mg/d
Doses >75 mg do not increase therapeutic effects; administer high doses with caution and closely observe patient for response
Pediatric
<3 months: Not established
3 months to 12 years: 0.1 mg/kg PO q6-8h
>12 years: Administer as in adults
May decrease effects of loop diuretics with coadministration; coadministration with anticoagulants may increase PT (monitor and watch for signs of bleeding); may increase serum lithium levels and risk of methotrexate and phenytoin toxicity; probenecid may increase toxicity of NSAIDs
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in CHF, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy
Cyclooxygenase-2 (COX-2) inhibitors
Although increased cost can be a negative factor, the incidence of costly and potentially fatal gastrointestinal (GI) bleeds is clearly less with cyclooxygenase-2 (COX-2) inhibitors than with traditional NSAIDs. Ongoing analysis of cost avoidance of GI bleeds will further define the populations that will find COX-2 inhibitors the most beneficial.
Celecoxib (Celebrex)
Inhibits primarily COX-2. COX-2 is considered an inducible isoenzyme, induced during pain and inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, COX-1 isoenzyme is not inhibited; thus, GI toxicity may be decreased. Seek lowest dose of celecoxib for each patient.
Adult
200 mg/d PO qd; alternatively, 100 mg PO bid
Pediatric
Not established
Coadministration with fluconazole may cause increase in plasma concentrations because of inhibition of celecoxib metabolism; coadministration with rifampin may decrease celecoxib plasma concentrations
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
May cause fluid retention and peripheral edema; caution in compromised cardiac function, hypertension, conditions predisposing to fluid retention; severe heart failure and hyponatremia, because may deteriorate circulatory hemodynamics; NSAIDs may mask usual signs of infection; caution in presence of existing controlled infections; evaluate symptoms and signs suggesting liver dysfunction, or in abnormal liver lab results
Corticosteroids
In contrast to the widespread systemic distribution of an oral anti-inflammatory drug, a local corticosteroid injection can achieve focal placement of a potent anti-inflammatory agent at the site of maximal tenderness or inflammation. A variety of corticosteroid preparations are available for injection. Commonly, the corticosteroid is mixed with a local anesthetic agent prior to injection. Various local anesthetic agents also are available.
Methylprednisolone (Depo-Medrol, Solu-Medrol, Medrol, Adlone)
Corticosteroids, such as methylprednisolone, are commonly used for local injections of bursae or joints to provide a local anti-inflammatory effect while minimizing some of the GI and other risks of systemic medications.
Adult
40 mg (1 mL) intralesionally is common for injection at many sites, often mixed with a few mL of a local anesthetic, such as 1% lidocaine
Pediatric
Not established
Coadministration with anticoagulants may increase risk of hemorrhage or local bruising
Documented hypersensitivity to the medication; skin infection at the site of injection
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Local corticosteroid injections are not known to have the same degree of medication interactions as those seen with oral or other types of systemic administration of corticosteroids
Never inject corticosteroids through an infected area of skin
A diabetic patient may sometimes experience a transient elevation of blood glucose level after a local corticosteroid injection
More on Olecranon Bursitis |
| Overview: Olecranon Bursitis |
| Differential Diagnoses & Workup: Olecranon Bursitis |
 Treatment & Medication: Olecranon Bursitis |
| Follow-up: Olecranon Bursitis |
| Multimedia: Olecranon Bursitis |
| References |
| Further Reading |
| « Previous Page | Next Page » |
References
Snider RK. Olecranon bursitis. In: Snider RK, ed. Essentials of Musculoskeletal Care. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1997:156-9.
Wasserman AR, Melville LD, Birkhahn RH. Septic bursitis: a case report and primer for the emergency clinician. J Emerg Med. Jul 20 2007;[Medline].
Lass-Flörl C, Mayr A. Human protothecosis. Clin Microbiol Rev. Apr 2007;20(2):230-42. [Medline]. [Full Text].
Wagner C, Iking-Konert C, Hug F, et al. Cellular inflammatory response to persistent localized Staphylococcus aureus infection: phenotypical and functional characterization of polymorphonuclear neutrophils (PMN). Clin Exp Immunol. Jan 2006;143(1):70-7. [Medline]. [Full Text].
Senécal L, Leblanc M. Olecranon bursitis in chronic haemodialysis patients. Nephrol Dial Transplant. Sep 2001;16(9):1956-7. [Medline]. [Full Text].
Wessolossky M, Haran JP, Bagchi K. Paecilomyces lilacinus olecranon bursitis in an immunocompromised host: case report and review. Diagn Microbiol Infect Dis. Jul 2008;61(3):354-7. [Medline].
Turan H, Serefhanoglu K, Karadeli E, et al. A case of brucellosis with abscess of the iliacus muscle, olecranon bursitis, and sacroiliitis. Int J Infect Dis. Apr 23 2009;[Medline].
Malkin J, Shrimpton A, Wiselka M, et al. Olecranon bursitis secondary to Mycobacterium kansasii infection in a patient receiving infliximab for Behcet's disease. J Med Microbiol. Mar 2009;58:371-3. [Medline].
Blankstein A, Ganel A, Givon U, et al. Ultrasonographic findings in patients with olecranon bursitis. Ultraschall Med. Dec 2006;27(6):568-71. [Medline].
Floemer F, Morrison WB, Bongartz G, et al. MRI characteristics of olecranon bursitis. AJR Am J Roentgenol. Jul 2004;183(1):29-34. [Medline]. [Full Text].
Tran N, Chow K. Ultrasonography of the elbow. Semin Musculoskelet Radiol. Jun 2007;11(2):105-16. [Medline].
Olsen NK, Press JM, Young JL. Bursal injections. In: Lennard TA, ed. Physiatric Procedures in Clinical Practice. Philadelphia, Pa: Hanley & Belfus; 1995:36-43.
Schumacher HR. Arthrocentesis, synovial fluid analysis, and synovial biopsy. In: Schumacher HR, ed. Primer on Rheumatic Diseases. 10th ed. Atlanta, Ga: Arthritis Foundation; 1993:67-72.
Degreef I, De Smet L. Complications following resection of the olecranon bursa. Acta Orthop Belg. Aug 2006;72(4):400-3. [Medline].
Weinstein PS, Canoso JJ, Wohlgethan JR. Long-term follow-up of corticosteroid injection for traumatic olecranon bursitis. Ann Rheum Dis. Feb 1984;43(1):44-6. [Medline]. [Full Text].
Cardone DA, Tallia AF. Diagnostic and therapeutic injection of the elbow region. Am Fam Physician. Dec 1 2002;66(11):2097-100. [Medline].
Green SM. Nonsteroidal anti-inflammatory drugs (NSAIDs). In: Tarascon Pocket Pharmacopoeia 2000. Loma Linda, Calif: Tarascon; 2000:11-2.
Friedman ND, Sexton DJ. Bursitis due to Mycobacterium goodii, a recently described, rapidly growing mycobacterium. J Clin Microbiol. Jan 2001;39(1):404-5. [Medline]. [Full Text].
Brinker MR, Miller MD. The adult elbow. In: Fundamentals of Orthopaedics. Philadelphia, Pa: WB Saunders; 1999:153-64.
Lennard TA. Fundamentals of procedural care. In: Lennard TA, ed. Physiatric Procedures in Clinical Practice. Philadelphia, Pa: Hanley & Belfus; 1995:1-13.
McGee DJ. Elbow joints. In: Orthopedic Physical Assessment. 2nd ed. Philadelphia, Pa: WB Saunders; 1992:143-67.
Morgan WJ. Elbow and forearm. In: Steinberg GG, Akins CM, Baran DT, eds. Orthopaedics in Primary Care. 3rd ed. Baltimore, Md: Lippincott Williams & Wilkins; 1999:70-98.
Strakowski JA, Wiand JW, Johnson EW. Upper limb musculoskeletal pain syndromes. In: Braddom RL, ed. Physical Medicine and Rehabilitation. Philadelphia, Pa: WB Saunders; 1996:756-82.
Further Reading
Related eMedicine topics:
Bursitis [Emergency Medicine]
Bursitis [Orthopedic Surgery]
Gout [Ophthalmology]
Gout [Orthopedic Surgery]
Gout [Radiology]
Gout [Rheumatology]
Gout and Pseudogout
Olecranon Bursa Aspiration
Olecranon Bursitis [Sports Medicine]
The Approach to the Painful Joint
Clinical guidelines:
ACR Appropriateness Criteria® chronic elbow pain. American College of Radiology - Medical Specialty Society. 1998 (revised 2008). 8 pages. NGC:006997
Elbow (acute & chronic). Work Loss Data Institute - Public For Profit Organization. 2003 (revised 2008 May 28). 161 pages. NGC:006555
Elbow disorders. American College of Occupational and Environmental Medicine - Medical Specialty Society. 1997 (revised 2007). 67 pages. NGC:005681
Keywords
olecranon bursitis, bursitis olecranon, bursitis, bursitis elbow, elbow bursitis, elbow bursa, bursa elbow, septic bursitis, posterior elbow swelling, draftsman's elbow, student's elbow, miner's elbow
