Olecranon Bursitis

Updated: Oct 12, 2017
  • Author: J Michael Wieting, DO, MEd, FAOCPMR, FAAPMR; Chief Editor: Stephen Kishner, MD, MHA  more...
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Overview

Practice Essentials

Olecranon bursitis, a relatively common condition, is inflammation of the subcutaneous synovial-lined sac of the bursa overlying the olecranon process at the proximal aspect of the ulna (see the images below). [1] The bursa cushions the olecranon and reduces friction between it and the skin, especially during movement. The superficial location of the bursa, between the ulna and the skin at the posterior tip of the elbow, makes it susceptible to inflammation from acute or repetitive (cumulative) trauma. Less commonly, inflammation results from infection (septic bursitis). Many cases are idiopathic, however. (See Etiology, Workup, Treatment, and Medication.) [1, 2, 3, 4, 5, 6]

Olecranon bursitis, shown here with the elbow flex 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; t 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. I Olecranon bursitis seen with the elbow extended. Image courtesy of UMDNJ-New Jersey Medical School, www.DoctorFoye.com, and www.TailboneDoctor.com.

Workup

Usually, laboratory studies are necessary only if the clinician suspects that an underlying condition is present. If infection is suspected (due to the presence of fever, redness, previous puncture wounds, or cellulitis), the olecranon bursa should be aspirated and the fluid sent for culture, for a cell count (white blood cells [WBCs], red blood cells [RBCs]), and for immediate Gram staining for bacteria.

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. [7]

Plain radiographs of the elbow should be performed to assess for a possible olecranon fracture if significant trauma occurred or if an avulsed osteophyte is present at the triceps insertion into the olecranon, which is fairly common.

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 area by rapidly demonstrating the presence of effusions, synovial proliferation, loose bodies, increased blood flow consistent with inflammation, tendonitis with calcifications, and other indications of bursitis. [8]

In atypical cases, a magnetic resonance imaging (MRI) study may be indicated to help exclude concomitant pathology, such as a stress fracture, triceps tendinopathy or tear, or the rare case of osteomyelitis/abscess or tumor. [9]

Management

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.

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.

Oral nonsteroidal anti-inflammatory drugs (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. [10]

Usually, no surgical intervention is required in cases of olecranon bursitis. [11] If the patient's condition becomes severe and does not respond to conservative treatment, however, bursectomy may be indicated.

If surgical intervention is required, 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. [12]

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Etiology

The bursa allows the skin to glide freely over the olecranon process, thereby preventing tissue tears. As previously stated, the superficial location of the olecranon bursa makes it susceptible to inflammation from acute or repetitive trauma.

Acute injuries during sports activities can include any action that involves direct or repetitive minor trauma to the posterior elbow (eg, landing on the olecranon process during a fall onto a hard floor or an artificial-turf playing field).

Common causes of olecranon bursal inflammation that are unrelated to sports activities include repetitive microtrauma (eg, the elbow constantly rubbing against a table during writing).

Bursal infection, a less common cause of olecranon bursitis, can result from abrasion or laceration at the affected site or from seeding from hematogenous spread via bacteremia. Inflammation can also be cause by a systemic inflammatory process (eg, rheumatoid arthritis) or a crystal-deposition disease (eg, gout, pseudogout). Patients are also at increased risk if they have diabetes mellitus, uremia, a history of intravenous drug abuse, alcohol abuse, or long-term use of steroids. [13, 14, 15, 16, 17, 18]

In patients on long-term hemodialysis treatment, uremia or a mechanical insult (such as resting the posterior elbow during hemodialysis treatment) is thought possibly to cause bursitis. [19] Inflammation of the bursa can also be an adverse effect of the drug sunitinib, which is used to treat patients with renal cell carcinoma. [20]

Larsen et al reported a case of bacillus Calmette-Guérin (BCG) olecranon bursitis developing from disseminated BCG infection, the result of BCG treatment for superficial bladder cancer. [21]

A retrospective study by Schermann et al of olecranon bursitis in the Israel Defense Forces found the condition to be more prevalent in combat units than in noncombat units, with most of the diagnoses being made during those periods of the year, summer and autumn, when training is particularly intensive. The investigators stated that the relatively high number of olecranon bursitis cases diagnosed during those months is probably related to outdoor training that requires crawling and suggested that the use of protective gear could alleviate the problem. [22]

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Prognosis

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. Some patients may experience recurrence of olecranon bursitis, in which even a relatively minor bump causes a significant effusion to return at this site.

Complications

Complications of olecranon bursitis include progressive or persistent pain with associated difficulty in using the affected upper extremity. Potential complications of aspiration/injection include the following:

  • Bleeding
  • Bruising
  • Allergic reaction (to the corticosteroid)
  • 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 - The clinician should use appropriate techniques, including aseptic techniques, to minimize the chance of iatrogenic infection
  • Persistent drainage through the injection tract
  • Ulnar nerve injury - This theoretically may occur if a medial approach is used for the aspiration/injection
  • Transient elevation of blood glucose levels - This may occur after corticosteroid injection in a diabetic patient
  • Cardiac arrhythmia - This potentially can result from intravascular injection, due to the local anesthetic component
  • Peripheral nerve dysfunction - This is possible if the injection is administered near or within a major nerve
  • Compromised wound healing
  • Gastric, hepatic, and renal adverse effects from NSAIDs and narcotic analgesics
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Patient Education

The patient should be educated regarding olecranon bursitis’s diagnosis, causative factors, and treatment plan. The most important aspect of patient education is ensuring that the patient knows to immediately report any signs or symptoms of persistent drainage or infection, particularly if a corticosteroid injection has been given. Diabetic patients should be told that they may experience a transient increase in blood glucose levels.

Patients should be informed that a corticosteroid usually does not begin to provide symptomatic improvement until a few days after the injection. Patients should also understand that they may experience a mild, transient increase in symptoms during the window of time when the local anesthetic has worn off but the steroids have not begun to have a therapeutic effect. For patient education information, see the Arthritis Center, as well as Bursitis.

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