Olecranon Bursitis Treatment & Management
- Author: J Michael Wieting, DO, MEd, FAOCPMR, FAAPMR; Chief Editor: Stephen Kishner, MD, MHA more...
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.)
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.
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.
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.
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.
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. 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.
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.
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.
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.
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.
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.
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.
Snider RK. Olecranon bursitis. Snider RK, ed. Essentials of Musculoskeletal Care. 2nd ed. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1997. 156-9.
McGee DJ. Elbow joints. Orthopedic Physical Assessment. 2nd ed. Philadelphia, Pa: WB Saunders Co; 1992. 143-167.
Strakowski JA, Wiand JW, Johnson EW. Upper limb musculoskeletal pain syndromes. Braddom RL, ed. Physical Medicine and Rehabilitation. Philadelphia, Pa: WB Saunders Co; 1996. 756-82.
Morgan WJ. Elbow and forearm. Steinberg GG, Akins C, Baran D, eds. Orthopaedics in Primary Care. 3rd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 1998. 70-98.
Brinker MR, Miller MD. The adult elbow. Fundamentals of Orthopaedics. Philadelphia, Pa: WB Saunders Co; 1999. 153-64.
Wasserman AR, Melville LD, Birkhahn RH. Septic bursitis: a case report and primer for the emergency clinician. J Emerg Med. 2009 Oct. 37(3):269-72. [Medline].
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. 2006 Jan. 143(1):70-7. [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. 2008 Jul. 61(3):354-7. [Medline].
Turan H, Serefhanoglu K, Karadeli E, Timurkaynak F, Arslan H. A case of brucellosis with abscess of the iliacus muscle, olecranon bursitis, and sacroiliitis. Int J Infect Dis. 2009 Nov. 13(6):e485-7. [Medline].
Malkin J, Shrimpton A, Wiselka M, Barer MR, Duddridge M, Perera N. Olecranon bursitis secondary to Mycobacterium kansasii infection in a patient receiving infliximab for Behcet's disease. J Med Microbiol. 2009 Mar. 58:371-3. [Medline].
Gregory T, Mir O, Medioni J, Augereau B, Oudard S. Olecranon bursitis in patients treated with sunitinib for renal cell carcinoma. Med Oncol. 2010 Jun. 27(2):446-8. [Medline].
Larsen BT, Smith ML, Grys TE, Vikram HR, Colby TV. Histopathology of Disseminated Mycobacterium bovis Infection Complicating Intravesical BCG Immunotherapy for Urothelial Carcinoma. Int J Surg Pathol. 2015 May. 23 (3):189-95. [Medline].
Schumacher HR. Arthrocentesis, synovial fluid analysis, and synovial biopsy. Schumacher HR, ed. Primer on Rheumatic Diseases. 10th ed. Atlanta, Ga: Arthritis Foundation; 1993. 67-72.
Blankstein A, Ganel A, Givon U, Mirovski Y, Chechick A. Ultrasonographic findings in patients with olecranon bursitis. Ultraschall Med. 2006 Dec. 27(6):568-71. [Medline].
Olsen NK, Press JM, Young JL. Bursal injections. Lennard TA, ed. Physiatric Procedures in Clinical Practice. Philadelphia, Pa: Hanley & Belfus; 1995. 36-43.
Degreef I, De Smet L. Complications following resection of the olecranon bursa. Acta Orthop Belg. 2006 Aug. 72(4):400-3. [Medline].
Ogilvie-Harris DJ, Gilbart M. Endoscopic bursal resection: the olecranon bursa and prepatellar bursa. Arthroscopy. 2000 Apr. 16(3):249-53. [Medline].
Baumbach SF, Lobo CM, Badyine I, et al. Prepatellar and olecranon bursitis: literature review and development of a treatment algorithm. Arch Orthop Trauma Surg. 2014 Mar. 134(3):359-70. [Medline].
Rhyou I, Park K, Kim K, Lee J, S Kim. Endoscopic Olecranon Bursal Resection for Olecranon Bursitis. J Hand Surg Asian-Pac. 2016 Jun. 21:167-72.
Kim JY, Chung SW, Kim JH, et al. A Randomized Trial Among Compression Plus Nonsteroidal Antiinflammatory Drugs, Aspiration, and Aspiration With Steroid Injection for Nonseptic Olecranon Bursitis. Clin Orthop Relat Res. 2016 Mar. 474 (3):776-83. [Medline].
Green SM. Nonsteroidal anti-inflammatory drugs (NSAIDs). Tarascon Pocket Pharmacopoeia 2000. Loma Linda, Calif: Tarascon; 2000. 11-2.
Perez C, Huttner A, Assal M, Bernard L, Lew D, Hoffmeyer P, et al. Infectious olecranon and patellar bursitis: short-course adjuvant antibiotic therapy is not a risk factor for recurrence in adult hospitalized patients. J Antimicrob Chemother. 2010 May. 65(5):1008-14. [Medline]. [Full Text].
Lennard TA. Fundamentals of procedural care. Physiatric Procedures in Clinical Practice. Philadelphia, Pa: Hanley & Belfus; 1995. 1-13.
Wasserzug O, Balicer RD, Boxman J, Klement E, Ambar R, Zimhony O. A cluster of septic olecranon bursitis in association with infantry training. Mil Med. 2011 Jan. 176(1):122-4. [Medline].