AUTHOR AND EDITOR INFORMATION

Section 1 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• ACKNOWLEDGMENTS
• Multimedia
• References

INTRODUCTION

Section 2 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• ACKNOWLEDGMENTS
• Multimedia
• References

Background

Olecranon bursitis is condition in which there is inflammation of the bursa that overlies the olecranon process at the proximal aspect of the ulna. The bursa is located between the ulna and the skin at the posterior tip of the elbow; because of its superficial location, the olecranon bursa is susceptible to inflammation from a variety of mechanisms, primarily either acute or repetitive (cumulative) trauma. Less commonly, the inflammation may be due to infection (septic bursitis).

Frequency

United States

Olecranon bursitis is a relatively common condition.

Functional Anatomy

Based on its location between the ulna and the skin at the posterior tip of the elbow, the olecranon bursa functions to provide a mechanism for the skin to glide freely over the olecranon process, thereby preventing tissue tears.

Sport-Specific Biomechanics

Bursal inflammation may be caused by a variety of mechanisms. Due to the superficial location of the olecranon bursa, it is susceptible to inflammation that is caused by acute or repetitive trauma. Acute injuries during sports activities can include any action that involves direct trauma to the posterior elbow (eg, falls). 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). Less commonly, the inflammation may be due to infection (septic bursitis).

CLINICAL

Section 3 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• ACKNOWLEDGMENTS
• Multimedia
• References

History

• Patients usually notice focal swelling at the posterior elbow.
• Pain at the affected site is usually reported; however, the swelling is sometimes painless.
• Pain is often exacerbated by pressure (eg, leaning on the elbow, rubbing against a table when writing with the ipsilateral hand).
• Chronic recurrent swelling is usually not tender.
• Frequent bumping of the swollen elbow occurs because it protrudes further than it normally would.
• A history of isolated trauma (eg, contusion) or repetitive microtrauma may be present.
• The onset of bursal inflammation may be sudden if it is secondary to infection or acute trauma.
• The onset of bursal inflammation may be gradual if it is secondary to chronic irritation.

Physical

• The most classic finding of bursal inflammation is posterior elbow swelling, which is clearly demarcated by its appearance as a goose egg over the olecranon process.
• Tenderness to palpation is noted at the affected site.
• The affected area may be warm and red, particularly in cases in which infection is present.
• Skin inspection may reveal abrasion or contusion if there was recent trauma.
• The patient's vital signs may reveal fever, but fever generally occurs only with advanced infection.
• The affected elbow's range of motion (ROM) is usually normal, but occasionally the end-range of elbow flexion may be slightly limited due to pain.
• Patients with systemic inflammatory processes (eg, rheumatoid arthritis) or crystal-deposition disease (eg, gout, pseudogout) may reveal evidence of focal inflammation at other sites. Rheumatoid nodules can be present on inspection of the elbow in rheumatoid arthritis.
• Elbow pain during active or passive ROM may increase the clinical suspicion of an olecranon process fracture if a history of trauma exists.

Causes

Bursal inflammation may be caused by a variety of mechanisms. Due to the superficial location of the olecranon bursa, it is susceptible to inflammation caused by acute or repetitive trauma, and less commonly, infection.

• Acute trauma (eg, falling onto a hard floor or an artificial-turf playing field and then landing on the olecranon process)
• Minor cumulative trauma (eg, repetitively rubbing the olecranon region against a desktop during writing)
• Infection caused by abrasion or laceration at the affected site or by seeding from hematogenous spread via bacteremia
• Inflammation as part of systemic inflammatory process (eg, rheumatoid arthritis) or crystal-deposition disease (eg, gout, pseudogout)

DIFFERENTIALS

Section 4 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• ACKNOWLEDGMENTS
• Multimedia
• References

Other Problems to Be Considered

Fracture of the olecranon process of the ulna
Rheumatoid arthritis
Synovial cyst of the elbow joint
Presence of infection (the most important consideration)
Triceps tendinitis/tear
Olecranon traction osteophyte (with or without avulsion)

WORKUP

Section 5 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• ACKNOWLEDGMENTS
• Multimedia
• References

Lab Studies

• Serum studies are usually only necessary if the clinician suspects an underlying condition, which includes the following: 
• • Infection (complete blood cell count [CBC], including the differential count of white blood cells [WBCs], C-reactive protein [CRP], erythrocyte sedimentation rate [ESR])
  • Rheumatoid arthritis (rheumatoid factor, ESR, CRP)
  • Gout (check uric acid level)
• If infection is suspected (due to fever, redness, previous puncture wounds, or cellulitis), the bursa should be aspirated and the fluid sent for immediate Gram staining for bacteria and cell count (WBCs, red blood cells), as well as cultures. 
• • An immediate Gram stain for bacteria is helpful to quickly determine if bacterial infection is present. If the Gram stain is positive for bacteria, antibiotics should be started immediately and no corticosteroids should be injected into the bursa.
  • Even if the Gram stain is negative or initially unavailable, there are situations where it may be prudent to avoid local corticosteroid injection, and instead, start antibiotics immediately after the culture is obtained, to prevent worsening of the infection.¹ For example, antibiotics may seem to be indicated based on the mechanism of injury (eg, abrasion or puncture), on the physical examination findings that are suggestive of infection (eg, fever, significant local redness and warmth), or on the gross appearance of the aspirated fluid (eg, turbid, purulent).
  • The leukocyte count can help determine if the fluid is infectious or merely inflammatory. Within synovial aspirates, WBC counts are classified as follows:
  • • Normal – Less than 200 WBCs/µL
    • Noninflammatory – 200-2000 WBCs/µL
    • Inflammatory – 2000-100,000 WBCs/µL
    • Septic – More than 100,000 WBCs/µL
• Bacterial culture and sensitivity testing of the aspirate can then be performed to ensure the relevant bacteria are sensitive to the chosen antibiotic. These results can guide the modification of antibiotics in cases of bacterial infection.
• After an acute injury, blood may be found within the aspirate, indicating a hemorrhagic bursitis.
• Analysis for crystals may reveal monosodium urate crystals in patients with gout, calcium pyrophosphate crystals in pseudogout, or hydroxyapatite crystals.

Imaging Studies

• 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.
• In atypical cases, a magnetic resonance imaging 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.²

Procedures

• Bursal aspiration remains the criterion standard to differentiate between septic and aseptic olecranon bursitis.
• The olecranon bursa can be aspirated using an 18-gauge needle that is inserted through a posterolateral approach, via an oblique needle angle or zigzag approach. As opposed to a direct, perpendicular approach that is used for most joint aspirations, this technique creates a longer needle tract through the skin and subcutaneous layers, thus minimizing the risk of fistula formation.
• • Aspiration can be helpful diagnostically; any cloudy fluid should be sent for an immediate Gram stain and leukocyte count, as well as a culture, with tests for antibiotic sensitivity. No corticosteroids should be given until these tests prove negative.
  • Aspiration can also be therapeutic because it relieves the swelling.
  • If the clinician is confident that no infection is present, a corticosteroid injection can be considered (eg, immediately after aspiration of the fluid).
• The injection should be on the lateral side of the elbow to avoid the ulnar nerve. The target injection site is the soft-tissue center of the triangle that is 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.³

TREATMENT

Section 6 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• ACKNOWLEDGMENTS
• Multimedia
• References

Acute Phase

Rehabilitation Program

Physical Therapy

In general, physical and occupational therapy are not needed for this condition. In some cases of nonseptic bursitis, however, the physician may recommend a course of physical or occupational therapy to speed the patient's recovery time. Individuals who exhibit olecranon bursitis are often advised to apply the RICE (ie, rest, ice, compression, elevation) method of treatment. Physical therapy modalities (eg, phonophoresis, electrical stimulation) may also be helpful to further reduce pain and inflammation, although these modalities are not necessary for most patients with this condition. The therapist can also educate the patient and present compensatory strategies for resting the involved upper extremity while healing is occurring. If the patient's condition becomes severe and does not respond to conservative treatment, surgery may be indicated. For patients who undergo bursectomy (bursal excision), postoperative physical therapy may be recommended for regaining or maintaining ROM and strength of the elbow.

Medical Issues/Complications

• Complications of the disease process include persistent pain and an associated decreased functional use of the affected upper extremity.

• Potential complications of aspiration/injection include the following:

• Swelling: This may recur, particularly if the patient does not maintain adequate pressure or icing at the site or if 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 causing iatrogenic infection.

• Persistent drainage

Surgical Intervention

Usually, no surgical intervention is required in cases of olecranon bursitis; however, very severe cases may require bursectomy.

Consultations

• Consultation with a physiatrist (physical medicine and rehabilitation physician) or with an orthopedic surgeon may be considered by physicians without the training, comfort, or procedural office supplies that are 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 septic bursitis is present for which incision and drainage is required.

Other Treatment

• Oral nonsteroidal anti-inflammatory drugs (NSAIDs) are used in the treatment of olecranon bursal inflammation.
• Glucocorticoid injection can be used to treat this condition (see Procedures). A retrospective study by Weinstein et al showed that in 47 patients with traumatic olecranon bursitis, almost all cases resolved via aspiration with or without an intrabursal glucocorticoid injection.¹ The 25 patients who received a glucocorticoid injection (20 mg of triamcinolone) in addition to the bursal aspiration had resolution of their olecranon bursitis condition much more rapidly, usually within 1 week. However, glucocorticoid injection seemed to be more highly associated with complications, such as infection and skin atrophy.¹
• The posterior elbow should be iced 15-20 minutes at a time, several times per day, during the acute inflammatory period of 2-5 days.
• A compressive wrap using an elastic wrap or an elastic sleeve should be applied, but the application of excessive pressure over the elbow should be avoided.
• Avoiding further trauma to the bursa is the key to recovery and preventing recurrence. Consider use of elbow pads to cushion the elbow.

Recovery Phase

Medical Issues/Complications

Medical issues and complications during the recovery phase are the same as those listed for the acute phase (see Acute Phase, Medical Issues/Complications).

Other Treatment (Injection, manipulation, etc.)

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.

MEDICATION

Section 7 of 12  

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• Introduction
• Clinical
• Differentials
• Workup
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• Medication
• Follow-up
• Miscellaneous
• ACKNOWLEDGMENTS
• Multimedia
• References

Oral NSAIDs can be helpful 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 where the history, physical examination, and joint aspiration do not raise a significant suspicion for infection. Various oral NSAIDs can be used, but none holds a clear distinction as the drug of choice (DOC).

Empiric antibiotic selection is based upon the suspected source of the microorganisms (skin flora with local invasion via puncture or abrasion vs hematogenous spread from a primary infection at another body site). Antibiotic selection is further modified by the results of the culture and sensitivity. Initial antibiotic selection would also be directed by the result of the Gram stain of the aspirate. Antibiotic treatment may start with a broad-spectrum antibiotic; then when the culture results are available, the antibiotic regimen may be modified as appropriate.

Drug Category: Nonsteroidal anti-inflammatory drugs (NSAIDs)

NSAIDs can help decrease pain and inflammation. Various oral NSAIDs can be used, but none holds a clear distinction as the DOC. Choice of NSAID is largely a matter of convenience (eg, how frequently doses must be taken to achieve adequate analgesic and anti-inflammatory effects) and cost.

Drug Name	Ketoprofen (Actron, Orudis, Oruvail)
Description	For relief of mild to moderate pain and inflammation. Small dosages are initially indicated in small and elderly patients and in those with renal or liver disease. Doses over 75 mg do not increase therapeutic effects. Administer high doses with caution, and closely observe patient for response.
Adult Dose	25-50 mg PO q6-8h prn; not to exceed 300 mg/d
Pediatric Dose	<3 months: Not established 3 months to 12 years: 0.1-1 mg/kg PO q6-8h >12 years: Administer as in adults
Contraindications	Documented hypersensitivity; aspirin/NSAID-induced asthma; caution in elderly patients or patients with a history of GI bleed, hypertension, or CHF
Interactions	Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and β-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently.
Pregnancy	B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions	Category D in third trimester of pregnancy; caution in patients with CHF, hypertension, and decreased renal and hepatic function; caution in patients with anticoagulation abnormalities or during anticoagulant therapy

Drug Category: Corticosteroid preparation for focal injection

In contrast to the widespread systemic distribution of an oral anti-inflammatory drug, a local corticosteroid injection can achieve focal placement of a potent anti-inflammatory agent at the site of maximal tenderness or inflammation.

When corticosteroid injections are used, a variety of corticosteroid preparations are available to choose from. Commonly, the corticosteroid is mixed with a local anesthetic agent before the injection. Again, there are various local anesthetic agents to choose from.

FOLLOW-UP

Section 8 of 12  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• ACKNOWLEDGMENTS
• Multimedia
• References

Return to Play

The athlete may be expected to return to play without restrictions when he/she has demonstrated resolution of symptoms and any positive physical examination findings (eg, swelling, tenderness to palpation), as well as shown adequate performance in sports-specific practice drills without recurrence of symptoms or physical examination findings.

Complications

Complications include progressive or persistent pain with associated difficulty in using the affected upper extremity. Potential complications due to focal corticosteroid injection include bleeding, bruising, infection, and allergic reactions. Transient elevation of blood glucose levels may occur after corticosteroid injection in a diabetic patient. Intravascular injection could potentially cause cardiac arrhythmia due to the local anesthetic component. Peripheral nerve dysfunction is possible if the injection is administered near or within a major nerve.

Prevention

Avoid excessive pressure over the elbow. Avoid further trauma, if preventable. If an athlete plays contact sports, there may be no way to guarantee avoidance of further trauma to the site. Consider the use of elbow pads to cushion the region from further trauma.

Prognosis

In the absence of infection, most patients respond very well to a series of 1-2 joint aspirations (with or without corticosteroid injection) combined with the nonsurgical treatments outlined above (see 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.

Education

The patient should be educated regarding the nature of the diagnosis, causative factors, and treatment plan for olecranon bursitis. 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 instructed that they may experience a transient increase in blood glucose levels. Patients should be informed that symptomatic improvement from the corticosteroid usually does not begin to take effect until a few days after the injection. Patients should also understand that they may experience a transient mild increase in symptoms during the window of time when the local anesthetic has worn off but when the steroids have not begun to have a therapeutic effect.

For excellent patient education resources, visit eMedicine's Arthritis Center. Also, see eMedicine's patient education article Bursitis.

MISCELLANEOUS

Section 9 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• ACKNOWLEDGMENTS
• Multimedia
• References

Medical/Legal Pitfalls

• Never inject corticosteroids into a site or through skin that appears infected.
• In the presence of significant trauma, always check radiographs for the presence of fractures before proceeding with treatment.
• In the absence of trauma, have the aspirated fluid analyzed for infection and crystals.
• Avoid using the medial approach to the olecranon bursa because a misdirected needle could damage the ulnar nerve.
• When aspiration/injection is performed, the clinician should use aseptic techniques to minimize the chance of causing iatrogenic infection of the bursa. Septic olecranon bursitis due to Mycobacterium smegmatis has been reported after intrabursal steroid treatment.⁴

Special Concerns

• Pregnancy: Both aspiration of the bursa and corticosteroid injection can be performed during pregnancy. Oral NSAIDs, however, should be avoided, especially in the last trimester.
• Pediatric population: Obtain written informed consent from the patient's parent or legal guardian before proceeding with any aspiration or injection.
• Geriatric population: Be cautious with the use of NSAIDs in elderly patients.
• Patients with diabetes: Some diabetic patients may experience a transient elevation in blood glucose levels after corticosteroid injection.

ACKNOWLEDGMENTS

Section 10 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• ACKNOWLEDGMENTS
• Multimedia
• References

Greg Gazzillo, 4th year medical student, New Jersey Medical School–UMDNJ, Class of 2007, assisted with the 2006 revision of this manuscript.

Debra Ibrahim, 4th year medical student, New York College of Osteopathic Medicine, Class of 2008, assisted with the 2007 revision of this manuscript.

MULTIMEDIA

Section 11 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• ACKNOWLEDGMENTS
• Multimedia
• References

Media file 1:  Olecranon bursitis is shown in a patient with the elbow flexed. Image © 2007 by Patrick Foye, MD, UMDNJ New Jersey Medical School.
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Media file 2:  Olecranon bursitis is shown in a patient with the elbow extended. Image © 2007 by Patrick Foye, MD, UMDNJ New Jersey Medical School.
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Media file 3:  Olecranon bursitis is shown close up in a patient, with the elbow extended. Image © 2007 by Patrick Foye, MD, UMDNJ New Jersey Medical School.
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Media file 4:  Needle aspiration of olecranon bursitis. Image ©2007, by Patrick M. Foye, MD, UMDNJ New Jersey Medical School.
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Media file 5:  Olecranon bursitis aspiration of a hemorrhagic effusion. Image ©2007, by Patrick M. Foye, MD, UMDNJ New Jersey Medical School.
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Media file 6:  After fluid is removed from the olecranon bursa, an elastic, tubular, compressive sleeve can be used to minimize reaccumulation of the fluid. Image ©2007, by Patrick Foye, MD, UMDNJ New Jersey Medical School.
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Media type:  Photo

REFERENCES

Section 12 of 12

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• ACKNOWLEDGMENTS
• Multimedia
• References

1. Weinstein PS, Canoso JJ, Wohlgethan JR. Long-term follow-up of corticosteroid injection for traumatic olecranon bursitis. Ann Rheum Dis. Feb 1984;43(1):44-6. [Medline]. [Full Text].
2. Floemer F, Morrison WB, Bongartz G, Ledermann HP. MRI characteristics of olecranon bursitis. AJR Am J Roentgenol. Jul 2004;183(1):29-34. [Medline]. [Full Text].
3. Cardone DA, Tallia AF. Diagnostic and therapeutic injection of the elbow region. Am Fam Physician. Dec 1 2002;66(11):2097-100. [Medline]. [Full Text].
4. Friedman ND, Sexton DJ. Bursitis due to Mycobacterium goodii, a recently described, rapidly growing mycobacterium. J Clin Microbiol. Jan 2001;39(1):404-5. [Medline].
5. Avram MM, Wolf RE, Gan A, et al. Uremic hypoglycemia. A preventable life-threatening complication. N Y State J Med. Dec 1984;84(12):593-6. [Medline].
6. Barham GS, Hargreaves DG. Mycobacterium kansasii olecranon bursitis. J Med Microbiol. Dec 2006;55(Pt 12):1745-6. [Medline].
7. Blankstein A, Ganel A, Givon U, Mirovski Y, Chechick A. Ultrasonographic findings in patients with olecranon bursitis. Ultraschall Med. Dec 2006;27(6):568-71. Epub 2006 Feb 22. [Medline].
8. Brinker MR, Miller MD. The adult elbow. Fundamentals of Orthopaedics. Philadelphia, Pa: WB Saunders Co; 1999:153-64.
9. Degreef I, De Smet L. Complications following resection of the olecranon bursa. Acta Orthop Belg. Aug 2006;72(4):400-3. [Medline].
10. Green SM, ed. Nonsteroidal anti-inflammatories. Tarascon Pocket Pharmacopoeia. Loma Linda, Calif: Tarascon Publishing; 2000:11-12.
11. Jin W, Lee JH, Yang DM, et al. Olecranon bursitis communicating with an olecranon cyst in rheumatoid arthritis. J Ultrasound Med. Jun 2007;26(6):857-61. [Medline].
12. Lennard TA. Fundamentals of procedural care. Physiatric Procedures in Clinical Practice. Philadelphia, Pa: Hanley & Belfus; 1995:1-13.
13. McGee DJ. Elbow joints. Orthopedic Physical Assessment. 2^nd ed. Philadelphia, Pa: WB Saunders Co; 1992:143-167.
14. Morgan WJ. Elbow and forearm. In: Steinberg GG, Akins C, Baran D, eds. Orthopaedics in Primary Care. 3^rd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 1998:70-98.
15. Olsen NK, Press JM, Young JL. Bursal injections. Physiatric Procedures in Clinical Practice. Philadelphia, Pa: Hanley & Belfus; 1995:36-43.
16. Schumacher HR. Arthrocentesis, synovial fluid analysis, and synovial biopsy. In: Schumacher HR, Klippel JH, Koopman WJ, eds. Primer on the Rheumatic Diseases. 10^th ed. Richmond, Va: Arthritis Foundation; 1993:67-72.
17. Snider RK. Olecranon bursitis. Essentials of Musculoskeletal Care. 2^nd ed. Rosemont, Ill: American Academy Orthopedic Surgeons; 1997:156-9.
18. Strakowski JA, Wiand JW, Johnson EW. Upper limb musculoskeletal pain syndromes. In: Braddom RL, ed. Physical Medicine and Rehabilitation. Philadelphia, Pa: WB Saunders Co; 1996:756-82.

Article Last Updated: Oct 9, 2007