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Olecranon Bursitis Treatment & Management

  • Author: J Michael Wieting, DO, MEd, FAOCPMR, FAAPMR; Chief Editor: Stephen Kishner, MD, MHA  more...
 
Updated: Jun 10, 2016
 

Approach Considerations

The patient’s physical condition and history should be taken into account when administering treatment for olecranon bursitis, as in the following cases:

  • Pregnant patient - Aspiration of the bursa and corticosteroid injection can be performed during pregnancy; oral nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided
  • Elderly patient with history of side effects from NSAIDs - It is necessary to be cautious when using NSAIDs in elderly patients; cyclo-oxygenase-2 (COX-2) inhibitors may be indicated
  • Patient with diabetes - Some patients with diabetes may experience a transient elevation in blood glucose levels after corticosteroid injection

In general, physical and occupational therapy are not needed for the treatment of olecranon bursitis. In some cases of nonseptic bursitis, however, the physician may recommend a course of physical or occupational therapy to speed recovery time.

Usually, no surgical intervention is required in cases of olecranon bursitis. If the patient's condition becomes severe and does not respond to conservative treatment, however, bursectomy may be indicated. A study by Ogilvie-Harris and Gilbart demonstrated that endoscopic bursal resection relieves pain symptoms and typically gives satisfactory results in patients with chronic olecranon bursitis.[20, 21]

Based on a literature review, Baumbach et al suggested that even in cases of septic olecranon bursitis, the evidence supports the initial use of conservative treatment rather than immediate bursectomy. They state that only patients with severe, refractory, chronic/recurrent olecranon bursitis should be treated via incision, drainage, or bursectomy. (They came to the same conclusions for prepatellar bursitis as well.)[22]

If surgical intervention is required in olecranon bursitis, endoscopic olecranon bursal excision is an effective alternative to open incision in either aseptic or septic cases. Endoscopic outcomes are excellent and can minimize wound healing problems.[23]

Prevention

A compressive elbow sleeve (eg, a neoprene or elastic sleeve) may help to prevent the bursal fluid from reaccumulating after aspiration, but the application of excessive pressure over the elbow should be avoided.

Avoiding further trauma to the olecranon bursa is the key to recovery and prevention of recurrence. Consider use of elbow pads to cushion the elbow.

For cases of olecranon bursitis in which there is repeated recurrence, consider use of a posterior plaster splint to limit elbow motion for 1-2 weeks following aspiration. For severely recalcitrant cases, consider referral to an orthopedic surgeon for possible bursal excision.

Monitoring

The patient should return for reevaluation within approximately 2 weeks after treatment. At that time, assessment should be made regarding reaccumulation of fluid, persistent drainage, and signs of infection.

Activity

The athlete with olecranon bursitis may be expected to return to play without restrictions after he/she has demonstrated resolution of symptoms and of any positive physical examination findings (eg, swelling, tenderness to palpation) and has shown adequate performance in sports-specific practice drills without recurrence of symptoms or physical examination findings.

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Aspiration

As previously mentioned, in the absence of infection most cases of olecranon bursitis respond very well to a series of 1-2 joint aspirations (with or without corticosteroid injection) combined with additional treatment.

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.[24] In the 25 patients who did receive glucocorticoid injection (20 mg of triamcinolone) in addition to bursal aspiration, the bursitis resolved much more rapidly than it did in the other patients, usually within 1 week. However, there seemed to be an association between the glucocorticoid injections and the development of complications, such as infection and skin atrophy.

A study by Kim et al reported that in the treatment of nonseptic olecranon bursitis, no difference in efficacy was found between the use of aspiration, the use of aspiration combined with steroid injections, and the use of compression bandaging combined with nonsteroidal anti-inflammatory drugs (NSAIDs), at 4-week follow-up. The investigators cautioned, however, that the study, which involved 83 patients, was powered to identify no less than a 30% difference between the three treatments, which means that if a smaller difference in efficacy existed, it may not have been detected.[25]

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Pharmacologic Therapy

Oral NSAIDs can help to reduce the pain and inflammation of olecranon bursitis, but these products probably should be avoided if joint aspiration reveals a hemorrhagic bursitis. Injectable corticosteroid can be beneficial in cases in which the history, physical examination, and joint aspiration do not raise a significant suspicion of infection.[26]

Focal corticosteroid injection may be an option, but only if the clinician is confident that no local infection is present.

The decision as to whether the patient should be treated with empiric antibiotics depends on the perceived likelihood of infection, as indicated by patient history, physical examination, and analysis of the bursal aspirate.

In a study of 343 episodes of infectious bursitis, including 237 episodes of olecranon bursitis and 106 of patellar bursitis, Perez et al found that 7 days or less of antibiotic treatment was as effective as antibiotic therapy lasting from 8 days to more than 2 weeks. The investigators also found that short-course antibiotic therapy was not associated with a recurrence of bursitis.[27]

Injection technique

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.[24, 26]

Corticosteroids should never be injected into a site that appears to be infected or through skin that appears to be infected.

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Physical Therapy

As previously mentioned, although physical and occupational therapy are generally not needed for olecranon bursitis, in some nonseptic cases 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. Icing of the posterior elbow for 15-20 minutes at a time, several times daily, is recommended during the acute period (2-5 days).

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.[28]

The therapist can also complete patient education and present compensatory strategies for resting the involved upper extremity while healing takes place. For the patient who undergoes bursal excision (bursectomy), physical therapy may be recommended postoperatively for regaining or maintaining the elbow's ROM and strength.

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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 joint aspiration.

Consultation with a rheumatologist may be helpful if the clinical findings are consistent with inflammatory arthropathy.

Consultation with an orthopedic surgeon is required if a fracture is present, if the patient has a very severe case of recalcitrant bursitis that requires excision (bursectomy), or if incision and drainage are required for septic bursitis.

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Contributor Information and Disclosures
Author

J Michael Wieting, DO, MEd, FAOCPMR, FAAPMR Senior Associate Dean, Associate Dean of Clinical Medicine, Consultant in Sports Medicine, Assistant Vice President of Program Development, Division of Health Sciences, DeBusk College of Osteopathic Medicine; Professor of Physical Medicine and Rehabilitation, Professor of Osteopathic Manipulative Medicine, Lincoln Memorial University-DeBusk College of Osteopathic Medicine

J Michael Wieting, DO, MEd, FAOCPMR, FAAPMR is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Association of Academic Physiatrists, American Osteopathic Academy of Sports Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Jared W Madden, DO Assistant Professor of Family Medicine and Osteopathic Manipulative Medicine, Departments of Family Medicine and Osteopathic Manipulative Medicine, Lincoln Memorial University-DeBusk College of Osteopathic Medicine

Disclosure: Nothing to disclose.

Chief Editor

Stephen Kishner, MD, MHA Professor of Clinical Medicine, Physical Medicine and Rehabilitation Residency Program Director, Louisiana State University School of Medicine in New Orleans

Stephen Kishner, MD, MHA is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine

Disclosure: Nothing to disclose.

Acknowledgements

Michael T Andary, MD, MS Professor, Residency Program Director, Department of Physical Medicine and Rehabilitation, Michigan State University College of Osteopathic Medicine

Michael T Andary, MD, MS is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, and Association of Academic Physiatrists

Disclosure: Allergan Honoraria Speaking and teaching; Pfizer Honoraria Speaking and teaching

Patrick M Foye, MD Associate Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, Director of Coccyx Pain Service (Tailbone Pain Service: www.TailboneDoctor.com), University of Medicine and Dentistry of New Jersey, New Jersey Medical School

Patrick M Foye, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists, and International Spine Intervention Society

Disclosure: Nothing to disclose.

Henry T Goitz, MD Academic Chair and Associate Director, Detroit Medical Center Sports Medicine Institute; Director, Education, Research, and Injury Prevention Center; Co-Director, Orthopaedic Sports Medicine Fellowship

Henry T Goitz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons and American Orthopaedic Society for Sports Medicine

Disclosure: Nothing to disclose.

Sherwin SW Ho, MD Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago

Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America

Disclosure: Breg, Inc. Consulting fee Consulting; Biomet, Inc. Consulting fee Consulting; GMV, Inc. Arthroscopy Simulator Evaluation and teaching; Smith and Nephew Grant/research funds Fellowship funding; DJ Ortho Grant/research funds Course funding

Robert L Sheridan, MD Assistant Chief of Staff, Chief of Burn Surgery, Shriners Burns Hospital; Associate Professor of Surgery, Department of Surgery, Division of Trauma and Burns, Massachusetts General Hospital and Harvard Medical School

Robert L Sheridan, MD is a member of the following medical societies: American Academy of Pediatrics, American Association for the Surgery of Trauma, American Burn Association, and American College of Surgeons

Disclosure: Nothing to disclose.

Andrew L Sherman, MD, MS Associate Professor of Clinical Rehabilitation Medicine, Vice Chairman, Chief of Spine and Musculoskeletal Services, Program Director, SCI Fellowship and PMR Residency Programs, Department of Rehabilitation Medicine, Leonard A Miller School of Medicine, University of Miami

Andrew L Sherman, MD, MS is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, and Association of Academic Physiatrists

Disclosure: Pfizer Honoraria Speaking and teaching

Todd P Stitik, MD Professor, Department of Physical Medicine and Rehabilitation, Director, Outpatient Occupational/Musculoskeletal Medicine, University of Medicine and Dentistry of New Jersey-New Jersey Medical School

Todd P Stitik, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Association of Academic Physiatrists, Phi Beta Kappa, and Physiatric Association of Spine, Sports and Occupational Rehabilitation

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Acknowledgments

The authors and editors of Medscape Reference would like to thank medical students Dena Abdelshahed and Craig Wells and Drs. Greg Gazzillo, Debra Ibrahim, Evish Kamrava, Jason Lee, and Dev Sinha for their help in previous revisions of the source articles.

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Olecranon bursitis, shown here with the elbow flexed. Image courtesy of UMDNJ-New Jersey Medical School, www.DoctorFoye.com, and www.TailboneDoctor.com.
Olecranon bursitis seen with the elbow extended; the focal olecranon swelling is more visible than it is when the elbow is flexed. Image courtesy of UMDNJ-New Jersey Medical School, www.DoctorFoye.com, and www.TailboneDoctor.com.
Olecranon bursitis seen with the elbow extended. Image courtesy of UMDNJ-New Jersey Medical School, www.DoctorFoye.com, and www.TailboneDoctor.com
Olecranon bursogram. This image shows a needle injecting contrast material into the olecranon bursa, under fluoroscopic guidance. Although olecranon bursa aspiration/injection usually does not require fluoroscopy or contrast, employing fluoroscopy here has demonstrated the outline of the involved bursa. Image ©2005, by Patrick M. Foye, MD, UMDNJ: New Jersey Medical School.
Needle aspiration in olecranon bursitis. Image courtesy of UMDNJ-New Jersey Medical School, www.DoctorFoye.com, and www.TailboneDoctor.com.
Aspiration of a hemorrhagic effusion in a patient with olecranon bursitis. Image courtesy of UMDNJ-New Jersey Medical School, www.DoctorFoye.com, and www.TailboneDoctor.com.
After fluid is removed from the olecranon bursa, an elastic, tubular compressive sleeve can be used to minimize reaccumulation of the fluid. Image courtesy of UMDNJ-New Jersey Medical School, www.DoctorFoye.com, and www.TailboneDoctor.com.
Gout. Radiograph of erosions with overhanging edges.
Gout. Polarizing microscopy revealing needles of urate.
Rheumatoid arthritis. Rheumatoid nodules at the elbow. Photograph by David Effron MD, FACEP
Olecranon fracture.
 
 
 
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