Treatment of Chronic Elbow Bursitis

Swelling or a boggy lump around the point of the elbow is often caused by a condition known as chronic olecranon bursitis. The swelling might increase and decrease but it never goes away fully. Some people have elbow pain or tenderness (especially if there is an infection) but many do not. Elbow range-of-motion may be limited but full motion is often present.

How can this be treated when there is no infection? That's the question answered in this review of chronic olecranon bursitis. A bursa is a sac made of thin, slippery tissue. Bursae occur in the body wherever skin, muscles, or tendons need to slide over bone. Bursae are lubricated with a small amount of fluid inside that helps reduce friction from the sliding parts.

The olecranon bursa is located between the tip, or point, of the elbow (called the olecranon) and the overlying skin. This bursa allows the elbow to bend and straighten freely underneath the skin. Treatment may depend on what is causing the bursitis.

In some cases, a direct blow or a fall onto the elbow can damage the bursa. This usually causes bleeding into the bursa sac, because the blood vessels in the tissues that make up the bursa are damaged and torn. In the skin this would simply form a bruise, but in a bursa blood may actually fill the bursa sac. This causes the bursa to swell up like a rubber balloon filled with water.

The blood in the bursa is thought to cause an inflammatory reaction. The walls of the bursa may thicken and remain thickened and tender even after the blood has been absorbed by the body. This thickening and swelling of the bursa is referred to as (acute) olecranon bursitis.

Chronic olecranon bursitis can also occur over a longer period of time. People who constantly put their elbows on a hard surface as part of their activities or job can repeatedly injure the bursa.

This repeated injury can lead to irritation and thickening of the bursa over time. The chronic irritation leads to the same condition in the end: olecranon bursitis but there may no longer be an active inflammatory process going on.

Other causes of chronic olecranon bursitis include gout, rheumatoid arthritis, lupus, or other systemic diseases. In some cases, the cause simply can't be identified. We call this idiopathic chronic olecranon bursitis.

Treatment for idiopathic bursitis may be slightly different than the type caused by another condition. Treating the arthritis, gout, or lupus may help resolve the elbow problem. But with idiopathic bursitis, there's no known cause to address. Instead, conservative (nonoperative) care is the first step in treatment.

The surgeon may advise patients with this problem how to treat just the symptoms. If it is painful or tender, use cold. If it is actively swelling, apply a compressive wrap. If work or daily activities require pressure on the elbow, then a protective pad can be applied over the tip of the elbow.

Surgeons don't rush in to more aggressive treatment with steroid injections or surgery. The risk of infection, skin problems, or creating a chronic draining opening outweighs the benefit of the treatment. Instead, patients are given advice about how to manage the problem with these conservative measures.

If nonoperative care doesn't work and the symptoms are interfering with daily function, then the surgeon might consider aspirating (withdrawing fluid from) the joint. Aspiration reduces the swelling and improves motion and function. But the fluid may build up again, so it's often a temporary solution.

Surgery is an option when conservative care has been applied diligently and the symptoms (especially swelling) are still present three (or more) months later. Any more specific recommendations for treatment beyond this are not possible. The lack of evidence supporting (or disproving) treatments and combinations of treatments just isn't available.

The authors strongly suggest there is a need for more research in this area. It would be good to know how many adults are bothered by this problem. It's likely there are more than we think because many people don't seek care for it.

Surgeons need more information on what happens if the condition is not treated -- this is called the natural history of a problem. And different trials of various treatments and treatment combinations are needed to find out what works best and when to use it. The true role of modification of activity, use of nonsteroidal antiinflammatory drugs (NSAIDs), compression wrap, no treatment, and steroid injections must be studied further.

Reference: Fernando A. Herrera, MD, and Roy A. Meals, MD. Chronic Olecranon Bursitis. In The Journal of Hand Surgery. April 2011. Vol. 36A. No. 4. Pp. 708-710.

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