Olecranon Bursitis

History: visible swelling over the posterior olecranon is often the primary presenting complaint. The swelling may be painless (chronic friction) or painful (acute traumatic, septic, or crystal). Ask about preceding trauma, occupational or hobby pressure on the elbow, skin breaks, insect bites, systemic features, gout history, immunosuppression, and diabetes. Septic bursitis typically presents with pain, warmth, redness, and feeling unwell, often over 1-3 days.

Examination:

• •Visible fluctuant swelling over the olecranon - the hallmark finding. Posterior and superficial, distinct from an intra-articular effusion
• •Elbow ROM: usually preserved or only mildly limited. Marked passive ROM restriction should raise concern for intra-articular pathology
• •Inspect the overlying skin for breaks, abrasions, cellulitis, and puncture wounds

Distinguishing septic from aseptic clinically: erythema extending beyond the bursal margins, warmth (compare with the contralateral side), marked tenderness, fever or systemic illness (BUT 30% afebrile), and any overlying skin break all raise the suspicion of infection. However, the distinction cannot be made reliably on clinical grounds alone. If there is any doubt, aspirate.

Crystal bursitis: look for tophi (ear helix, first MTP, finger IP joints) and ask about gout history.

Rheumatoid nodules: firm, non-tender, non-fluctuant nodules in a known RA patient.

Differentials:

• •Septic arthritis of the elbow: restricted passive ROM in all planes, systemically unwell. The bursa does NOT communicate with the joint, so the two are clinically distinct
• •Gout or pseudogout of the elbow joint: acutely painful, restricted ROM, crystal-positive joint aspirate
• •Rheumatoid nodule: firm, non-fluctuant, non-tender in a known RA patient
• •Elbow joint effusion: deeper swelling, lateral or medial, with loss of ROM
• •Triceps tendinopathy: pain on resisted extension without fluctuant collection
• •Olecranon fracture: trauma, bony tenderness, inability to extend against gravity

• •Bursal aspiration: the single most important investigation when septic bursitis or crystal disease is suspected. Send for Gram stain and culture, AND crystal analysis under polarised light microscopy (MSU = negatively birefringent needles = gout; CPP = weakly positively birefringent rhomboids = pseudogout). In clearly aseptic cases, routine aspiration should usually be AVOIDED - it carries the risk of introducing bacteria or creating a chronic draining sinus
• •Bloods: FBC and CRP if infection is suspected. Serum urate if gout is suspected (may be normal during an acute flare)
• •Plain radiographs: not routinely required. Reserve for suspected fracture, osteophytes, loose bodies, or calcified tophi
• •Ultrasound: not routinely required. Can confirm bursal distension and guide aspiration if difficult
• •MRI: rarely needed. For suspected deep infection or mass lesion
• •Blood cultures: if the patient is systemically unwell or febrile with confirmed septic bursitis

Aseptic (non-septic) olecranon bursitis:

• •Activity modification and protection: stop leaning on the elbow, use elbow padding. Often sufficient for chronic friction bursitis
• •Compression and ice: compressive bandaging and ice may reduce swelling
• •Analgesia: paracetamol and/or topical or oral NSAIDs
• •Aspiration: should NOT be performed routinely for clearly aseptic cases (risk of introducing infection). May be performed for significant symptomatic tension or diagnostic uncertainty under strict aseptic technique
• •Corticosteroid injection: not first-line. May be considered selectively for persistent recurrent aseptic bursitis ONLY after infection has been excluded by aspirate. Counsel patients about skin atrophy, depigmentation, and skin breakdown. Evidence is limited and recurrence is common
• •Most aseptic cases resolve with activity modification, padding, and time

Septic olecranon bursitis:

• •Aspiration: if feasible, aspirate BEFORE starting antibiotics and send for Gram stain, culture, sensitivity, and crystal analysis. Do not delay antibiotics if the patient is systemically unwell
• •Antibiotics: empirical cover for S. aureus per NICE CKS. First-line: flucloxacillin 500 mg-1 g QDS oral. Penicillin allergy: clarithromycin or doxycycline. Oral antibiotics are often sufficient for mild septic bursitis without systemic illness; IV if systemically unwell, immunosuppressed, or failing oral treatment
• •Duration: typically 14 days, guided by clinical response
• •Repeated aspiration if the bursa re-accumulates
• •Urgent referral: severe infection, systemic toxicity, abscess, extensive cellulitis, or failure to respond to antibiotics
• •Do NOT inject corticosteroid into a septic bursa

Crystal bursitis:

• •Manage the acute flare per NICE NG219: offer an NSAID, colchicine, or short course of oral corticosteroid
• •Aspiration is both diagnostic and therapeutic
• •If gout is confirmed, consider long-term urate-lowering therapy once the acute flare has settled

Referral:

• •Urgent: septic bursitis not responding to treatment, abscess, extensive cellulitis, systemic toxicity, or suspected septic arthritis
• •Routine: recurrent aseptic bursitis despite conservative management for bursectomy consideration

Surgical options (awareness): bursectomy - excision of the olecranon bursa. Reserved for chronic recurrent bursitis failing conservative management or refractory septic bursitis.

Rehabilitation needs are usually minimal. The main interventions are protection, pressure avoidance, compression, and padding.

Elbow padding: neoprene elbow pads or foam padding. Important for occupational bursitis.

ROM exercises: usually not needed. If stiffness develops, gentle active ROM is sufficient. Formal physiotherapy is generally not required.

Post-bursectomy: wound care, progressive ROM, avoid direct pressure for 4-6 weeks. Return to full activity typically at 6-8 weeks.

Occupational health review: consider for workers with significant occupational exposure (desk-based, plumbing, carpet-laying, students).

• •NICE CKS Bursitis - The primary care framework: aseptic bursitis managed with activity modification and analgesia; routine aspiration of a clearly aseptic bursa is avoided. Flucloxacillin first-line for septic bursitis; clarithromycin or doxycycline in penicillin allergy.
• •NICE NG219 Gout - Governs acute flare management (NSAID, colchicine, short course oral corticosteroid) and long-term urate-lowering therapy following a confirmed flare.
• •Crystal analysis under polarised light - The classic exam-tested distinction: MSU (gout) = negatively birefringent needles; CPP (pseudogout) = weakly positively birefringent rhomboids.
• •S. aureus dominance - Approximately 80% of septic olecranon bursitis is caused by S. aureus. Empirical flucloxacillin coverage is therefore appropriate.
• •Tophaceous gout sites - The olecranon bursa, ear helix, first MTP, and finger IP joints are recognised sites for tophi; finding a tophus elsewhere on examination supports a gout-related cause.

• •The key clinical decision is septic vs aseptic. Cannot be reliably distinguished on clinical grounds alone. If any doubt, aspirate.
• •Approximately 30% of patients with septic bursitis are afebrile. Do NOT use absence of fever to exclude infection.
• •S. aureus accounts for approximately 80% of septic olecranon bursitis. Flucloxacillin is first-line; clarithromycin or doxycycline in penicillin allergy (per NICE CKS). Standard duration 14 days.
• •The olecranon bursa does NOT communicate with the elbow joint - ROM is typically preserved. Marked passive ROM restriction should redirect you to intra-articular pathology (septic arthritis, fracture, OA), not bursitis.
• •ALWAYS send aspirate for crystal analysis AND culture - gout and septic bursitis can coexist. The most commonly tested management principle.
• •Do NOT aspirate a clearly aseptic bursa routinely (risk of introducing infection); do NOT inject corticosteroid until infection has been excluded.