Olecranon Bursitis

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Definition/Description

Olecranon bursitis is a condition in which there is an inflammation of the bursa. The bursa is overlying the olecranon process at the proximal aspect of the ulna. The superficial location of the bursa, namely between the ulna and the skin is susceptible to inflammation from a variety of mechanisms, primarily either acute or repetitive trauma. It is also possible that the inflammation is due to infection, called septic bursitis. Two-thirds of the cases are bursitis without an infection or nonseptic bursitis. Nevertheless this type of bursitis is less common. However the olecranon bursa normally provides a mechanism with which the skin can glide freely over the olecranon process, consequently the bursa prevents tissue tears.

Epidemiology/Etiology

Olecranon bursitis is a condition which is relatively common. There is no mortality associated with this condition. It is possible that the pain at the posterior elbow may cause morbidity, with limitation of some functional activities (e.g. writing). Although the overall incidence is not known, it typically affects men between the ages of 30 and 60 years. Two-thirds of cases are nonseptic (ie, without infection) and usually occur when trauma or repeated small injuries lead to bleeding into the bursa or release of inflammatory mediators.There is no predisposition for race or sex. Olecranon bursitis occurs with children and adults. Long-term hemodialysis treatment , uremia or a mechanical factor (like resting the posterior elbow during a hemodialysis treatment) can be a cause of inflammation. This condition can be caused by acute injuries (trauma) during sports activities because they can include any action that involves direct trauma to the posterior elbow. For example falling onto a hard floor et cet. Other common causes of olecranon bursitis, which are not related to sports activities, include repetitive microtrauma, like rubbing constantly the elbow against a table during writing. Such a trauma or those repeated small injuries lead to bleeding into the bursa or the release of inflammatory mediators. The inflammation can also be caused by an infection, but this is less common. People in certain occupations are especially vulnerable, particularly plumbers or heating and air conditioning technicians who have to crawl on their knees in tight spaces and lean on their elbows.Finally inflammation may be due to a systematic inflammatory process, like rheumatoid arthritis, or a crysal deposition disease, like gout and pseudogout. This condition can also be a side-effect of sunitinib, which is used to treat patients with renal cell carcinoma..

History

Patients usually remark a focal swelling at the posterior elbow. Pain is often reported at the affected site. On the other hand, the swelling is sometimes painless. Pressure, like leaning on the elbow or rubbing against a table while writing with the ipsilateral hand, are factors which can often exacerbate the pain. Chronic recurrent swelling is usually not tender. A typical symptom of olecranon bursitis is the frequent bumping of the swollen elbow, because it protrudes further than it usually would. It is possible that the patient reports a history of isolated trauma or repetitive microtrauma. The start may be sudden, when it is secondary to infection or acute trauma. When olecranon bursitis is secondary to chronic irritation, the onset will be more gradual.

Clinically Relevant Anatomy

A bursa is a part of your anatomy that allows two other parts to move smoothly together (outside of a joint). It’s a sac made of thin, slippery tissue. Bursae occur in the body wherever skin, muscles, or tendons need to slide over bone and 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, but when the bursa gets irritated, the sac fills up with fluid which leads to swelling of the elbow tip.

Mechanism of Injury / Pathological Process

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Clinical Presentation

Bursal inflammation’s most classic finding is a swelling, at the posterior elbow. This swelling is clearly marked off by its appearance as a goose egg over the olecranon process. There may be a tenderness for palpation at the affected site. Cases in which infection is present may show a warm and red affected area. When the trauma recently occurred, the inspection of the skin may reveal abrasion or contusion. Generally a patient with advanced infection, can have fever. The Range of motion (ROM) of the affected elbow is usually normal but now and then it is possible that the end-range of elbow flexion is slightly limited due to pain. Patients suffering from systematic inflammatory processes (like rheumatoid arthritis) or crystal – deposition disease (like gout or pseudogout) may reveal evidence of focal inflammation at other sites. When you exam a patient who has rheumatoid arthritis, it is possible that you can see rheumatoid nodules during inspection of the elbow. If the patient reports elbow pain during active or passive ROM and if a history of trauma exists, this may increase the clinical suspicion of an olecranon process fracture.

Diagnostic Procedures

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Outcome Measures

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Management / Interventions

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Differential Diagnosis

Rheumatoid arthritis
Elbow and forearm overuse injuries
Gout
Gout and pseudogout
Olecranon fractures
Triceps tendon avulsion

Physical therapy management

Level of evidence D :

Most of the time physical and occupational therapy are not necessary, but are often indicated to reduce recovery time. Patients who have often olecranon bursitis are recommend to apply the RICE method of treatment. Rice stands for Rest, Ice, Compression and Elevation. There are also other physical therapy modalities that could be helpful for reducing pain and inflammation. For example phonophoresis, electrical stimulation. However, most patients with olecranon bursitis don’t necessary need those modalities. The physical therapist can also take care of the patient education and present compensatory strategies for resting the involved upper extremity while healing takes place. When the patient shows no response to conservative treatment and his condition deteriorates, then surgery may be indicated. When a patient undergoes a bursal excision (bursectomy), there might be a recommendation for physical therapy after the operation for regaining or maintaining the ROM and strength of the elbow.

Key Evidence

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Resources

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Case Studies

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References

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