Olecranon Bursitis

Disease/Disorder

Definition

The olecranon bursa is a thin fluid-filled synovial sac that lies superficial to the olecranon process and acts to reduce friction between the cutaneous and osseous surfaces during elbow motion.^1,2 Olecranon bursitis refers to inflammation of the olecranon bursa.

Etiology

Olecranon bursitis is most commonly due to either chronic microtrauma in the setting of repetitive overuse, or direct trauma.^1,3 Less frequently, it is seen in crystalline diseases and systemic inflammatory conditions such as gout and rheumatoid arthritis.² Septic olecranon bursitis can arise from transcutaneous spread or via inoculation from direct trauma.^1,3

Epidemiology including risk factors and primary prevention

The incidence of aseptic olecranon bursitis is estimated to be 29 per 100,000 person-years⁴ and septic olecranon bursitis to be 10 per 100,000 persons annually.⁵ However, this is a likely underestimate given the benign nature of milder cases that do not seek medical attention. It occurs more frequently in men between the ages of 30-60 years old.¹

Risk factors include:

• Trauma with or without skin lesions
• Chronic microtrauma from compression through olecranon process
• Olecranon bone spur
• Crystal arthropathies: Gout, Pseudogout
• Inflammatory conditions: Rheumatoid Arthritis, Systemic Lupus Erythematosus, Psoriasis
• Conditions or treatments that lead to immunosuppression
• Adjacent cellulitis

Primary prevention measures involve avoidance of activities that place direct pressure or shear forces on the olecranon process and prevention of modifiable risk factors.^1,3

Patho-anatomy/physiology

The synovial lining of the olecranon bursa is poorly vascularized and has a low friction coefficient to allow for the olecranon to glide under the skin during flexion and extension. This superficial position and limited vascularity increases the bursa’s vulnerability to trauma, inflammation, and infection via transcutaneous route.⁶ Accordingly, the most common infectious organisms are skin flora, including Staphylococcus aureus and Staphylococcus epidermidis.¹ Conditions that either promote local microtrauma or weaken the immune system further predispose for olecranon bursitis to develop.³

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time):

New onset/acute

Swelling and pain may develop over the tip of the olecranon with or without acute trauma, with symptoms lasting from hours to days. Erythema is seen more commonly with septic olecranon bursitis but can be present in aseptic olecranon bursitis as well.

Subacute

Aseptic olecranon bursitis is usually self-limiting and resolves with conservative measures over weeks to months.⁷ Recurrence can occur after resolution of the acute period with even minimal trauma.

Chronic/stable

Fibrotic changes may occur in response to chronic inflammation, forming palpable nodules on the olecranon. These nodules may contain fluid, especially with repeated trauma to the bursa. As the chronicity advances, the consistency of the bursa increases.⁷

Pre-terminal

Persistent cases after conservative management may preclude the need for bursectomy or olecranon spur resection.¹

Specific secondary or associated conditions and complications

Commonly associated conditions include olecranon spur, immunosuppression, and crystalline diseases. Rarely, there can be concurrent septic arthritis in addition to septic olecranon bursitis.² Secondary complications usually occur after invasive treatments and include chronic sinus tract formation after needle aspiration, skin atrophy and septic olecranon bursitis after bursal corticosteroid injection.⁴

Essentials of Assessment

History

Patients may present with acute onset of swelling over the olecranon process after direct trauma onto elbow or after repeated compression of the olecranon process. In septic olecranon bursitis, there is more commonly associated erythema and pain⁶ and fever can be present in 20% – 70% of cases.^2,5,8 Patients may also report pain with elbow movement or direct pressure while others experience painless swelling. 

Physical examination

Examination of the elbow will include inspection for skin changes and swelling, palpation for pain, tenderness, mobility, and texture of any swelling or mass, and assessment of passive and active range of motion. Evaluation of the elbow with olecranon bursitis will reveal an erythematous, tender, fluctuant prominence over the olecranon. In the acute phase, olecranon bursitis does not limit elbow range of motion, distinguishing it from elbow effusion. On the other hand, chronic cases of olecranon bursitis may limit elbow range of motion.⁸

Clinical functional assessment: mobility, self-care, cognition/behavior/affective state

A thorough history of prior trauma, occupational and repetitive tasks should be performed. Since there is a high correlation between elbow injuries and the throwing athlete, it may be helpful to assess throwing biomechanics.⁶

Laboratory studies

Bursal aspiration with fluid analysis is the gold standard to diagnose septic olecranon bursitis. Bursal fluid should be sent for cell count, Gram stain, culture and sensitivity tests, and crystal exam. Crystal exam can indicate underlying gout or pseudogout.^2,8

Imaging

Olecranon bursitis is a clinical diagnosis, however imaging studies may be utilized in less straightforward cases. Elbow radiographs can demonstrate an olecranon spur as well as rule out fracture and joint effusion after trauma. Ultrasound can localize the swelling and characterize the collection. MRI demonstrates soft tissue edema, and contrast enhancement of the bursal margins in 76% of cases, regardless of cause although absence of enhancement is indicative of aseptic olecranon bursitis.⁹ MRI can also rule out muscle tear, tendinopathy, abscess and osteomyelitis.

Supplemental assessment tools

Other supplemental laboratory studies include complete blood count with differential, C-reactive protein, erythrocyte sedimentation rate, uric acid, and glucose.^2,6

Early prediction of outcomes

Early recognition and accurate diagnosis with prompt management can hasten recovery as prevention of recurrence is the best treatment. Once an episode has occurred, recurrence can become more frequent and require less trauma to trigger.¹⁰ Poorer prognosis is seen in patients with multiple co-morbidities and delay in seeking medical care.² Premature return to activity without proper management, or without addressing risk factors, can lead to chronic olecranon bursitis.

Environmental

Ergonomic evaluation is key to help prevent recurrences of injuries in occupations that require repeated compression or weight bearing through the olecranon process. Patients may need ergonomic modification to relieve pressure on olecranon bursa. It is important to also evaluate for proper technique in cases where sports may contribute to the injury.

Social role and social support system

Overuse athletic or occupational injuries may lead to mood disturbance, which can exacerbate mental health. It is important to assess the social support and how they may support the recovery of the patient. 

Professional issues

Fluid aspiration may alleviate pain and improve range of motion, but patients may also request aspiration cosmetic reasons. Olecranon bursitis however is often self-limiting, fluid can reoccur after aspiration and fluid aspiration increases risk for septic olecranon bursitis. Patients should therefore be thoroughly informed of risks and benefits of aspiration.

Rehabilitation Management and Treatments

Available or current treatment guidelines

Aseptic olecranon bursitis secondary to acute trauma or chronic microtrauma often responds to conservative measures: rest, ice, compression, padding the olecranon, avoidance of aggravating factors, and anti-inflammatory medications. Fluid aspiration and corticosteroid injection may be attempted; however, this increases risk for septic olecranon bursitis by 10% and re-accumulation is seen in 25% of cases.^1,6,11,12 In cases complicated by infection or refractory to conservative treatment consideration of bursectomy is appropriate.⁶ Septic olecranon bursitis requires aspiration and antibiotic treatment to cover causative microbes including Staphylococcus and Streptococcus.⁶ While systemic complications are rare due to avascularity of the region, those with systemic symptoms should be hospitalized for IV antibiotics.

At different disease stages.

• new onset/acute
  • includes potential curative interventions
  • includes symptom relief
  • includes rehabilitation strategies that intend to stabilize or optimize function or prepare for further interventions at later disease stages
• Aseptic olecranon bursitis should be treated conservatively with rest, ice, activity modification, avoidance of trauma and pressure to the olecranon, compression, padding, and anti-inflammatory medications.⁶
• Septic olecranon bursitis requires treatment with antibiotics and, in some cases, bursectomy or incision and drainage.¹³ Patients with systemic symptoms should be admitted to the hospital for IV antibiotic administration. Recommendations are to treat with at least 10 days of antibiotics for mild cases.¹⁴
• Olecranon bursitis secondary to inflammatory conditions (e.g., gout, rheumatoid arthritis) should be treated by addressing the underlying condition.¹⁵ No studies have been performed on the role of aspiration or corticosteroid injections in this population.
• subacute
  • includes secondary prevention and disease management strategies
  • includes symptom relief
  • includes rehabilitation strategies that intend to optimize function
• The role of aspiration and corticosteroid injection in treatment of aseptic olecranon bursitis is controversial. Some studies have demonstrated benefit with reduced symptom duration, however there were also higher rates of complications related to the procedure including infection and skin atrophy.^11,12 Some sources suggest aspiration if there is restriction of elbow range of motion.⁶
• There have been no studies performed on appropriate and effective physical or occupational therapy regimens.
• chronic/stable
  • includes secondary prevention and disease management strategies
  • includes palliative strategies
  • includes symptom relief
  • includes rehabilitation strategies that intend to optimize function
• In treatment of refractory olecranon bursitis surgical consultation is appropriate. Surgeons may consider open or endoscopic bursectomy or resection of an olecranon osteophyte if present.^16,17
• pre-terminal or end of life care
  • includes symptom relief

Pre-terminal or end of life care does not apply to olecranon bursitis

Coordination of care

Special attention should be given to ensuring close follow up with a medical provider in the days to weeks following initial diagnosis. Coordination between the diagnosing provider and a surgical provider may be necessary if symptoms do not improve.

Patient & family education

Patients and family members should be educated on their condition including diagnosis, treatment, and prognosis. Initial treatment should be primarily focused on behavioral modifications to decrease risk for reoccurrence including offloading the olecranon, avoidance of aggravating activities, and use of padding over the olecranon.

Measurement of treatment outcomes including those that are impairment-based, activity participation-based and environmentally-based

The are no studied outcome measures in relation to olecranon bursitis, however common upper extremity measures such as the Disability of the Arm, Shoulder and Hand (DASH) may be useful.

Translation into Practice:  practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

Most cases of aseptic olecranon bursitis will improve with time and conservative management.⁶ Use of corticosteroid injections in aseptic olecranon bursitis is controversial and not widely recommended due increased risk of iatrogenic septic olecranon bursitis, skin atrophy, and skin depigmentation.^6,11,12,18 There is no clear evidence to support aspiration alone. In presentations concerning for septic olecranon bursitis or in patients with significant comorbidities, aspiration should be performed for fluid analysis. Culture positive olecranon bursitis should be treated with a course of antibiotics.

Cutting Edge/ Emerging and Unique Concepts and Practice

In patients with olecranon bursitis refractory to non-operative treatment, surgical resection may be indicated. Arthroscopic bursectomy has been shown to reduce rates of surgical wound complications and fistula formation, reduced rates of recurrence, and improved patient satisfaction in preliminary studies when compared to open bursectomy.¹

A unique method of skin surface temperature measurement has been proposed to distinguish between septic and aseptic olecranon bursitis. Smith et al demonstrated that a difference in olecranon surface temperature of at least 2.2 degrees Celsius or higher compared to the contralateral limb was 100% sensitive and 94% specific for septic olecranon bursitis.¹⁹

Gaps in the Evidence-Based Knowledge

The use of olecranon bursa corticosteroid injection has been recommended to shorten symptom duration. However, their use is controversial due to risk of recurrence, skin atrophy, progression to septic olecranon bursitis, and triceps tendon rupture.^1,3,6 Moreover, needle aspiration for can lead to sinus tract formation.^1,3,20 To avoid this, recent studies have suggested use of empiric antibiotics for suspected septic olecranon bursitis on initial presentation. However, this is still controversial and further studies are needed to define antibiotic treatment algorithm and duration.²⁰

References

1. Nchinda NN, Wolf JM. Clinical Management of Olecranon Bursitis: A Review. J Hand Surg Am. 2021;46(6):501-506. doi:10.1016/j.jhsa.2021.02.006
2. Reilly D, Kamineni S. Olecranon bursitis. J Shoulder Elbow Surg. 2016;25(1):158-167. doi:10.1016/j.jse.2015.08.032
3. Deal JB Jr, Vaslow AS, Bickley RJ, Verwiebe EG, Ryan PM. Empirical Treatment of Uncomplicated Septic Olecranon Bursitis Without Aspiration. J Hand Surg Am. 2020;45(1):20-25. doi:10.1016/j.jhsa.2019.06.012
4. Schermann H, Karakis I, Dolkart O, Maman E, Kadar A, Chechik O. Olecranon Bursitis in a Military Population: Epidemiology and Evidence for Prolonged Morbidity in Combat Recruits. Mil Med. 2017;182(9):e1976-e1980. doi:10.7205/MILMED-D-16-00402
5. Laupland KB, Davies HD; Calgary Home Parenteral Therapy Program Study Group. Olecranon septic bursitis managed in an ambulatory setting. The Calgary Home Parenteral Therapy Program Study Group. Clin Invest Med. 2001;24(4):171-178.
6. Blackwell JR, Hay BA, Bolt AM, Hay SM. Olecranon bursitis: a systematic overview. Shoulder Elbow. 2014;6(3):182-190. doi:10.1177/1758573214532787
7. Del Buono A, Franceschi F, Palumbo A, Denaro V, Maffulli N. Diagnosis and management of olecranon bursitis. Surgeon. 2012;10(5):297-300. doi:10.1016/j.surge.2012.02.002
8. Pangia J, Rizvi TJ. Olecranon Bursitis. In: StatPearls. Treasure Island (FL): StatPearls Publishing; July 27, 2021.
9. Floemer F, Morrison WB, Bongartz G, Ledermann HP. MRI characteristics of olecranon bursitis. AJR Am J Roentgenol. 2004;183(1):29-34. doi:10.2214/ajr.183.1.1830029
10. Larson RL, Osternig LR. Traumatic bursitis and artificial turf. J Sports Med. 1974;2(4):183-188. doi:10.1177/036354657400200401
11. Weinstein PS, Canoso JJ, Wohlgethan JR. Long-term follow-up of corticosteroid injection for traumatic olecranon bursitis. Ann Rheum Dis. 1984;43(1):44-46. doi:10.1136/ard.43.1.44
12. Smith DL, McAfee JH, Lucas LM, Kumar KL, Romney DM. Treatment of nonseptic olecranon bursitis. A controlled, blinded prospective trial. Arch Intern Med. 1989;149(11):2527-2530.
13. Baumbach SF, Lobo CM, Badyine I, Mutschler W, Kanz KG. Prepatellar and olecranon bursitis: literature review and development of a treatment algorithm. Arch Orthop Trauma Surg. 2014;134(3):359-370. doi:10.1007/s00402-013-1882-7
14. Truong J, Mabrouk A, Ashurst JV. Septic Bursitis. [Updated 2022 Feb 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470331/
15. Khodaee M. Common Superficial Bursitis. Am Fam Physician. 2017;95(4):224-231.
16. Quayle JB, Robinson MP. A useful procedure in the treatment of chronic olecranon bursitis. Injury. 1978;9(4):299-302. doi:10.1016/s0020-1383(77)80050-8
17. Tu CG, McGuire DT, Morse LP, Bain GI. Olecranon extrabursal endoscopic bursectomy. Tech Hand Up Extrem Surg. 2013;17(3):173-175. doi:10.1097/BTH.0b013e31829c0535
18. Sayegh ET, Strauch RJ. Treatment of olecranon bursitis: a systematic review. Arch Orthop Trauma Surg. 2014;134(11):1517-1536. doi:10.1007/s00402-014-2088-3
19. Smith DL, McAfee JH, Lucas LM, Kumar KL, Romney DM. Septic and nonseptic olecranon bursitis. Utility of the surface temperature probe in the early differentiation of septic and nonseptic cases. Arch Intern Med. 1989;149(7):1581-1585. doi:10.1001/archinte.149.7.1581
20. Beyde A, Thomas AL, Colbenson KM, et al. Efficacy of empiric antibiotic management of septic olecranon bursitis without bursal aspiration in emergency department patients. Acad Emerg Med. 2022;29(1):6-14. doi:10.1111/acem.14406

Author Disclosures

Daniela Mehech, MD
Nothing to Disclose

Erin Barnes, MD
Nothing to Disclose

Sharnee Mead, DO
Nothing to Disclose

Colin Kammeraad, MD
Nothing to Disclose

Steven Kim, MD
Nothing to Disclose