Approach Considerations
The patient’s history and physical examination should be considered when administering treatment for olecranon bursitis, as in the following cases:
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Pregnant patient - Aspiration of the bursa and corticosteroid injection can be performed during pregnancy; oral nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided
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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
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Patient with diabetes - Some patients with diabetes may experience a transient elevation in blood glucose levels after corticosteroid injections
In general, physical and occupational therapy are not needed in the treatment of olecranon bursitis. In some cases of aseptic bursitis, however, the physician may recommend a course of physical or occupational therapy to speed recovery time. Additionally, in cases of aseptic bursitis without concern for secondary trauma such as an acute fracture, therapeutic manipulation should be considered, since soft tissue and joint mobilization can assist in edema control. Physicians should, however, have a low threshold for consideration of an infectious etiology in the patient’s bursitis, as at least 20% of cases of acute olecranon bursitis have a primary or secondary septic cause. [1]
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. 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. [29, 25]
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. [12]
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. [30, 31]
A study by Meric et al also reported good results from endoscopic bursectomy, for either prepatellar or olecranon bursitis. The 49 patients in the study, including 30 with olecranon bursitis and 19 with prepatellar bursitis, were treated endoscopically (25 patients) or with open bursectomy (24 patients). At follow-up, the endoscopic group scored 8.5 on a patient satisfaction questionnaire, compared with 5.3 by the open surgery group. [32]
A novel approach by Kettering et al using an olecranon bursectomy with deepithelialized advancement flap reconstruction was introduced with successful results; however, the investigators reported on only two patients. [33]
The underlying etiology of a patient’s olecranon bursitis must be considered when pursuing surgical interventions. For example, Stewart et al found that only 40% of individuals (2 of 5) with rheumatoid arthritis who underwent surgery experienced complete and long-term relief, compared with 94% of patients (15 of 16) without rheumatoid arthritis. [34]
A study by Uçkay et al suggested that for adult patients with moderate to severe septic olecranon bursitis, the rate of wound dehiscence is lower with one-stage bursectomy than with a two-stage approach to the procedure. The investigators found that 1 out of 66 patients in the one-stage group experienced wound dehiscence, compared with 9 out of 64 in the two-stage group. [35]
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 2-7 days after the initial encounter, depending upon the severity of presentation. At that time, an assessment should be made regarding the reaccumulation of fluid, persistent drainage, and signs of infection. These assessments should be derived by clearly demarcating the bursa distention at the initial encounter; in that way, an assessment can be made in subsequent encounters regarding the progression/resolution, or lack thereof, of the patient’s olecranon bursitis.
Activity
The athlete with olecranon bursitis may be expected to return to play without restrictions after he/she has demonstrated resolution of symptoms, is devoid 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.
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. [36] 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 aseptic 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. [37]
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. [10]
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 septic 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. [38]
A retrospective study by Deal et al suggested that patients with uncomplicated septic olecranon bursitis can effectively be treated with empiric antibiotic therapy without aspiration. Among 11 patients who underwent traditional bursal aspiration, only one culture resulted in an alteration of antibiotic management. Moreover, despite the information derived from the cultures, five patients still had incomplete resolution with antibiotic therapy, requiring a second course of antibiotics, while eight patients subsequently needed a bursectomy. Among the 19 patients who underwent empiric antibiotic therapy without aspiration, only three individuals needed a second antibiotic course. Symptom recurrence occurred in one of the empiric therapy patients 2 months after the bursitis had resolved with a single antibiotic course, with a second course resolving the problem. None of the empiric therapy patients required bursectomy. [39]
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. [10, 36]
Corticosteroids should never be injected into a site that appears to be infected or through skin that appears to be infected.
Physical Therapy
As previously mentioned, although physical and occupational therapy are generally not needed for olecranon bursitis, in some aseptic cases the physician may recommend a course of physical or occupational therapy to speed recovery time.
Individuals who exhibit olecranon bursitis 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. [40]
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.
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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Olecranon bursitis, shown here with the elbow flexed. Image courtesy of UMDNJ-New Jersey Medical School, www.DoctorFoye.com, and www.TailboneDoctor.com.
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Olecranon bursitis seen with the elbow extended. Focal swelling at the olecranon is more visible with the elbow extended than in the flexed position. Image courtesy of UMDNJ-New Jersey Medical School, www.DoctorFoye.com, and www.TailboneDoctor.com.
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Olecranon bursitis seen with the elbow extended. Image courtesy of UMDNJ-New Jersey Medical School, www.DoctorFoye.com, and www.TailboneDoctor.com.
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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.
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Needle aspiration in olecranon bursitis. Image courtesy of UMDNJ-New Jersey Medical School, www.DoctorFoye.com, and www.TailboneDoctor.com.
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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.
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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.
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Gout. Radiograph of erosions with overhanging edges.
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Gout. Polarizing microscopy revealing needles of urate.
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Rheumatoid arthritis. Rheumatoid nodules at the elbow. Photograph by David Effron MD, FACEP
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Olecranon fracture.
