Olecranon and Prepatellar Bursitis
Treating Acute, Chronic, and Inflamed
Edward G. McFarland, MD; Pomthep Mamanee, MD; William S. Queale, MD; Andrew J. Cosgarea, MD
THE PHYSICIAN AND SPORTSMEDICINE - VOL 28 - NO. 3 - MARCH 2021
In Brief: Elbow and knee bursitis is common in both athletes and nonathletes and has three basic presentations: acute, chronic nonseptic, and chronic infected. Most acute swellings occur after trauma and can be treated with early aspiration, compression, and padding. Chronic, nonseptic bursitis can usually be treated with conservative therapy and, occasionally, aspiration or corticosteroid injection. Inflamed bursae should be aggressively evaluated and treated. Some may require aspiration and decompression, and oral or intravenous antibiotics should be started to prevent septicemia. Incision and drainage is rarely needed but may be indicated for injuries that do not respond. Surgical excision of the bursa is recommended only for recalcitrant cases.
Inflammation and swelling of the bursae at the tip of the olecranon and over the patella are very common in athletes and nonathletes. The cause is typically trauma, either due to repetitive extremity movement or to acute trauma to the olecranon or patella. In active persons, bursitis can be induced by work activity, as seen in coal miners, carpet layers, gardeners, and roofers (1-4). In athletes, olecranon and patellar bursitis have been reported in football players, wrestlers, basketball players, and dart throwers (5-7). Direct injury to the bursa comes from repetitive contact with the artificial turf, wrestling mat, hardwood floor, or exercise mat.
The exact incidence of bursitis in athletes and in nonathletes is not known because there are no published epidemiologic studies. Treatment depends on many factors, but the most important consideration is whether or not the bursa is infected.
Anatomy, Pathophysiology, and Differential
The body's more than 150 bursae allow skin, tendons, and ligaments to glide smoothly over one another. Most bursae are closed and sac-like, and neither the olecranon bursa (figure 1) nor prepatellar bursa (figure 2) communicates with the adjacent joint.
Bursae are typically only a few cell layers thick, but, when irritated, the cells multiply and collagen production increases. Chronic inflammation leads to production of fluid (8), and increased capillary permeability allows fluid and proteinaceous exudates to flow into the bursa. Over time the bursal wall thickens and may have irregular areas of scar tissue that feel like loose joint cartilage (joint mice). Calcium deposition can occur in some joints, such as in the shoulder, but is less common in the knee or elbow (8). In an acutely injured extremity, blood may fill the bursa, and, in some patients, the bursa can become quite large.
Only a few entities can be confused with olecranon or prepatellar bursitis. Synovial or ganglion cysts around the knee can resemble an enlarged bursa; however, synovial cysts in the knee typically are not anterior, and such cysts are very uncommon around the elbow. Other disorders include relatively rare tumors such as pigmented villonodular synovitis and xanthomas. Bursal swelling may also occur due to rheumatoid nodules or deposition of amyloid, uric acid crystals, or calcium pyrophosphate crystals (2,4).
Three different presentations of prepatellar or olecranon bursitis occur. The least common occurs after an acute blow to an already irritated bursa (6).
Diagnosis. Swelling occurs rapidly over several hours, and the bursa may become quite large, covering the knee or elbow (figure 3). The swelling is usually tender and may be slightly warm but is usually not severe enough to suggest sepsis. When aspirated, the bursal fluid may be bloody or dark. Because swelling occurs so rapidly, radiographs are recommended to rule out fracture. In the knee it is important not to confuse the dark bursal fluid with an intra-articular hemarthrosis, and a thorough knee examination is recommended (9,10).
Treatment. The recommended treatment is compression with an elastic bandage, frequent application of ice, nonsteroidal anti-inflammatory drugs (NSAIDs), and relative rest of the extremity (table 1). Splinting may decrease further inflammation caused by joint motion, but it should be used only for limited periods. Based on their experience with acute traumatic bursitis in wrestlers, Mysnyk et al (6) recommend immediate aspiration followed by the measures in table 1. They recommend immobilization for 1 week to prevent recurrence and progression to chronic bursitis but acknowledge that immobilization often has poor compliance. Although documentation of efficacy is anecdotal, NSAIDs may help decrease pain and allow earlier range of motion.
The need for aspiration depends on the degree of the swelling and the duration of symptoms. When aspiration is indicated, we recommend use of a local anesthetic before the larger needle is inserted. Strict adherence to sterile technique is mandatory during aspiration since infection can be a complication. Prepatellar bursa aspiration is best accomplished while the patient is supine with the knee fully extended. Aspiration of the olecranon bursa can be done with the patient either prone or supine. Injection of steroids into acute, traumatic bursitis is not recommended: Mysnyk et al (6) found no benefit.
Chronic Nonseptic Bursitis
Diagnosis. In this presentation, bursitis produces chronic swelling, but the joint is usually not inflamed or painful (figure 4). In many instances, the patient seeks treatment because of the swelling; the bursa is not red or hot, and it does not restrict movement or activities.
Treatment. Treatment typically involves an elbow or knee pad, frequent ice application, NSAIDs, and avoidance of the precipitating activity (table 2).
Aspiration and corticosteroids. Aspiration of fluid and injection of corticosteroids for this type of bursitis is controversial, primarily because of the paucity of controlled studies comparing treatment efficacy. Weinstein et al (11) evaluated 47 patients who had nonseptic bursitis of the olecranon. Twenty-two were treated with aspiration alone, while the remaining 25 patients had both aspiration and corticosteroid injection. The latter group had more rapid symptom resolution, usually within 2 weeks, whereas the aspiration-only group required more than 16 weeks to recover. Documented complications in the injection group included 3 infections, 5 instances of skin atrophy, and 7 cases of chronic pain. The investigators concluded that because the condition is self-limiting, aspiration alone was adequate and avoided some complications seen with corticosteroid injection.
In another controlled, prospective study of 42 patients with nonseptic olecranon bursitis, Smith et al (12) randomized patients into four groups: (1) steroid injection and naproxen sodium for 10 days, (2) steroid injection and placebo for 10 days, (3) oral naproxen for 10 days, and (4) oral placebo for 10 days. All patients used a compressive bandage for 10 days. At reexamination 1 week after the end of treatment, patients injected with steroids had significantly less swelling than those who were not given steroids. Also, patients who were not injected had symptoms longer and required more reaspirations during the 6-week study. No complications were associated with any regimen, and the authors concluded that injection of corticosteroids hastened recovery.
Padding, immobilization, ice, and NSAIDs. Despite these findings, most physicians recommend a very conservative approach to nonseptic olecranon or prepatellar bursitis (2,4,7,11,13). We recommend initial treatment with padding, immobilization, ice application, and NSAIDs. Corticosteroid injections are best reserved for patients in whom conservative treatment has failed or in athletes who desire a more rapid resolution of swelling. Injections are not recommended for any bursa that is inflamed or possibly infected. Patients should be warned that injection carries a slight risk of infection.
Surgery. Surgery is reserved for the most recalcitrant cases. At the Mayo Clinic, only 21 cases of aseptic olecranon bursitis in 10 years required excision (14). In the patients who eventually had surgery, symptoms were present for an average of 3 years and 10 months. Surgery was successful in 15 of 16 patients without rheumatoid arthritis, but in only 3 of 5 with the disease. In another study, Kerr (15) reported the outcomes of arthroscopic excision of the prepatellar bursa in 7 patients and of the olecranon bursa in 5 patients. All were maintained in a compressive dressing postoperatively for 3 weeks. Most did well; only one elbow became infected, and prepatellar bursitis recurred when one athlete returned to wrestling.
Inflamed or Septic Bursitis
Diagnosis. The inflamed bursa presents a greater diagnostic and therapeutic dilemma. It is critical to establish whether or not the bursa is infected, but because considerable overlap exists between the symptoms of infected and aseptic bursitis, distinguishing them may be difficult on clinical grounds alone (3,4,12,16,17). For example, Smith et al (12) found that 50% of the nonseptic patients in their series had increased bursal warmth, and Ho et al (3) reported that 45% of aseptic patients have tenderness. On the other hand, not all patients with septic bursitis have an elevated temperature; the percentage varies from 15% to 86% (18,19). Similarly, peripheral leukocytosis varies in patients with infected bursae, and one study (20) reported that white blood cell counts in infected olecranon bursae, ranged from 7,900/mm3 to 17,900/mm3.
Bursal aspiration can help distinguish septic from aseptic bursitis; tests on fluid should include white blood cell count, Gram stain, and culture. The most common organisms found in septic olecranon or prepatellar bursitis are staphylococci (90%; primarily S aureus), and streptococci species (9%; most commonly ß-hemolytic streptococci). Unfortunately, nondiagnostic aspiration missed the infection in about 37% of patients in one study: Smith et al (21) calculated the sensitivity and specificity of bursal fluid analysis based on a cohort of patients, 11 with septic and 35 with aseptic olecranon bursitis. Their analysis suggested that use of a surface temperature probe could help distinguish between types, but the probe has not been widely used or studied systematically. Nonetheless, aspiration with Gram stain, culture, and sensitivities are recommended for patients who may have underlying bursal infection (2,3,4,13).
Treatment. Treatment of the inflamed bursa includes rest of the extremity, padding, ice packs, NSAIDs, and antibiotics (either oral or intravenous) (table 3). If the bursa is not septic, the patient does not have leukocytosis or fever, and symptoms are mild to moderate, oral antibiotics can be instituted on an outpatient basis. We recommend a cephalosporin such as cephalexin, 500 mg every 8 hours, as initial treatment. If the infection has concomitant cellulitis or lymphangitis, intravenous antibiotics may be required. Intravenous therapy is 2 g of a penicillinase-resistant antibiotic every 4 hours. Patients taking oral or intravenous antibiotics should have frequent, and maybe daily, examinations. Also, the patient should be educated about the signs of worsening infection. In some patients, immobilization of the extremity may be warranted to prevent further aggravation of the bursa.
In patients with inflammation and a potential for bursal infection, a cephalosporin may be initiated, but the bursa must be carefully monitored for response to the antibiotics. In most cases, a penicillinase-resistant semisynthetic antibiotic is recommended as first-line therapy until cultures and sensitivity results are known (3,4,16,17,19). These antibiotics have good penetration of the bursa: Clearance of microbes from bursal aspirates may be seen as early as 4 days after therapy begins (22). Because septic bursitis can be caused by diverse organisms including Neisseria, Haemophilus, Mycobacteria, and Cryptococcus species, close monitoring of the patient's response to antibiotics and follow-up of culture results are imperative. Injection of antibiotics into the bursa has not demonstrated any benefit over oral or intravenous therapy (4).
Repeated aspiration may benefit patients who have reaccumulation of fluid and continued infection. Lavage of the bursa with angiocatheters has been described but may not be practical in most offices or in the training room (23). Most patients respond after 2 to 3 weeks of antibiotic therapy, but the response varies depending on the time before implementation of treatment and the severity of infection (23). Hospitalization and intravenous antibiotics may be necessary in patients who have severe infection, immunosuppression, or other medical conditions such as diabetes mellitus or rheumatoid arthritis, but in our experience such measures are rarely required.
Surgery. Surgical intervention is rarely indicated for septic bursitis but when done usually consists of a simple incision and drainage. The procedure should be done under sterile conditions, preferably in the operating room, because patients requiring incision and drainage usually have an infection that warrants hospitalization. Bursal lavage can be done at the same time, and drains can be placed if required. The extremity should be immobilized if incision and drainage are necessary. Excision of the bursa is not recommended in the presence of inflamed, infected tissues and should be done later only if symptoms persist after the infection is under control (2,3,13,14).
Olecranon and prepatellar bursitis in active patients has three common presentations, and treatment is dictated by the type, the patient's activity or sport, and the desired timing of return to activity. Acute, hemorrhagic bursitis is best treated by aspiration, compression, and rest of the extremity. Nonseptic bursitis typically responds to nonoperative measures and rarely needs to be excised; however, early excision is recommended for athletes who have multiple recurrences and participate in high-risk sports such as wrestling. Inflamed bursae should be treated aggressively with early antibiotic therapy. Oral or intravenous antibiotics usually suffice, but the patient should be carefully monitored. Occasionally, repeated aspirations or incision and drainage may be necessary.
Dr McFarland is director and Dr Mamanee is a research fellow in the Division of Sports Medicine and Shoulder Surgery in the Department of Orthopaedic Surgery, Dr Queale is senior clinical fellow in Primary Care Sports Medicine in the Department of Medicine, and Dr Cosgarea is assistant director in the Division of Sports Medicine and Shoulder Surgery in the Department of Orthopaedic Surgery, all at The Johns Hopkins University in Baltimore. Address correspondence to Edward G. McFarland, MD, 10753 Falls Rd, Suite 215, Lutherville, MD 21093; e-mail to [email protected].