Physical Medicine and Rehabilitation for Olecranon Bursitis Workup

• Usually, laboratory studies are necessary only if the clinician suspects that an underlying condition is present. It is necessary to check for infection (complete blood count [CBC], including a differential count of the white blood cells [WBCs]). Tests should also be run for rheumatoid factor, the erythrocyte sedimentation rate, and the C-reactive protein level, in order to assess for rheumatoid arthritis. The uric acid level should be checked in order to assess for gout.
• If infection is suggested due to fever, redness, previous puncture wounds, or cellulitis, the bursa should be aspirated and the fluid should be sent for immediate Gram stain for bacteria, as well as a cell count (WBCs, red blood cells [RBCs]).

  • The leukocyte count can help to determine whether the fluid is infectious or merely inflammatory.
  • Within synovial aspirates, WBC counts are assessed as follows:
    • A WBC count less than 200/µL is considered normal.
    • A WBC count is considered noninflammatory at 200-2000/µL.
    • A WBC count in the range of 2000-100,000/µL is considered to be an indication of inflammation.
    • A WBC count greater than 100,000/µL is considered to be an indication of a septic condition.
• Gram stain also is helpful to determine quickly whether bacterial infection appears to be present.
• If the Gram stain is positive, antibiotics should be started immediately and bursal corticosteroid injection should be avoided.
• Even if the Gram stain is negative or initially unavailable, antibiotics may seem indicated based on the mechanism of injury (eg, abrasion or puncture), physical examination findings suggestive of infection (eg, fever, significant local redness and warmth), or the gross appearance of the aspirate (eg, turbid, purulent).
• Gram stain can be followed by culture and sensitivity testing. The culture and sensitivity results should guide the use of antibiotics in cases of bacterial infection.
• Crystal analysis may reveal monosodium urate crystals in a patient with gout, calcium pyrophosphate crystals in a patient with pseudogout, or hydroxyapatite crystals.

• If there has been significant trauma, a radiograph of the elbow should be obtained to assess for possible fracture.
• The use of ultrasonography has been shown to be extremely effective in the diagnosis of olecranon bursitis and other soft-tissue lesions in the olecranon areas by rapidly demonstrating effusions, synovial proliferation, loose bodies, increased blood flow consistent with inflammation, tendonitis with calcifications, and other indications of bursitis.^[9]
• In rare cases, magnetic resonance imaging (MRI) may be indicated to exclude concomitant osteomyelitis or abscess formation.^{[10, 11]}

• Bursal aspiration still remains the criterion standard to differentiate septic and aseptic olecranon bursitis.^{[2, 3, 4]} (See following images.) Needle aspiration of olecranon bursitis. Image courtesy of UMDNJ-New Jersey Medical School, www.DoctorFoye.com, and www.TailboneDoctor.com. Olecranon bursitis aspiration of a hemorrhagic effusion. 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 repeat accumulation of the fluid. Image courtesy of UMDNJ-New Jersey Medical School, www.DoctorFoye.com, and www.TailboneDoctor.com.

  • The olecranon bursa can be aspirated using an 18-gauge needle inserted through the posterior-lateral approach, using a zigzag approach to minimize the risk of fistula formation.
  • Aspiration can be helpful diagnostically because any cloudy fluid should be sent for immediate Gram stain, leukocyte count, and culture, with tests for antibiotic sensitivity.
  • Aspiration can also be therapeutic, because it relieves the swelling.
  • If the clinician is confident that no infection is present, corticosteroid injection can be considered (for instance, immediately after aspiration of the fluid).^[12]

In cases of bacterial infection, synovial fluid analysis may reveal increased WBC counts.^[13]