The olecranon bursa is susceptible to repeated trauma and infection because of its superficial location and limited blood supply. Olecranon bursitis (OB) is characterized by inflammation and fluid collection in the bursal cavity. It is a commonly seen condition in outpatient settings and the majority of cases are of aseptic bursitis.1 It is usually self-limited because of the intrinsic healing abilities of the bursa. Etiologies can vary; repeated trauma, structural bony abnormalities, long-term hemodialysis, rheumatoid arthritis, and crystal arthropathies can predispose patients to OB. Clinical presentation may range from painless swelling to serious infections. Management of aseptic OB is derived from a limited evidence base. The data is heterogeneous regarding a stepwise and standardized approach to treatment, the efficacy of intra-bursal corticosteroid injections (CSI), and management largely depends on the clinician's preferences. Initial conservative treatment includes avoidance of pressure to the area, application of ice, compression bandaging, orthosis, or oral NSAIDs. Invasive methods including bursal needle aspiration with or without intra-bursal CSI have shown efficacy in resolving symptoms. Surgery including endoscopic or open bursectomy, osseous resection with or without bursectomy, and/or percutaneous suction-drainage are opted for when conservative methods fail. To our knowledge, there is only one systematic review performed by Sayegh et al. in 2014 reporting the treatment outcomes for septic and aseptic bursitis.2 The purpose of our review is to systematically evaluate the comparative non-surgical management approaches toward aseptic OB.

This systematic review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) recommendations.3

A trained medical librarian conducted searches in Embase, Cochrane Database of Systematic Reviews, ACP Journal Club, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects (all via the Ovid interface), Medline, CINAHL, and Google Scholar. The search terms included MeSH and keywords of the following: bursitis, elbow, and olecranon. The searches were run on March 12, 2021. Initially, the search was limited to English literature, however, an additional search for non-English citations was completed on May 27, 2021. The bibliography of identified studies was manually scanned to identify further studies. A sample search strategy is available in Appendix 1.

We included randomized clinical trials (RCTs) and cohort studies evaluating non-surgical treatment methods in adult patients with aseptic olecranon bursitis. Outcomes accessed were clinical resolution of aseptic olecranon bursitis and complications following each treatment. We excluded duplicate studies, case reports, reviews, meta-analyses, case series, commentary, animal studies, and cadaver studies. In addition, the studies assessing treatment outcomes without a control arm, studies not describing treatment protocol or clinical outcomes, and the studies only describing septic bursitis outcomes, or describing an aggregate treatment outcome for different types of bursitis were excluded. In multiple studies with similar patients, studies not meeting the other inclusion criteria were excluded. From the studies reporting other types of bursitis, outcomes of only olecranon bursitis were included in the review.

Data were extracted on the excel sheet and verified by another author. Parameters extracted were study characteristics, patient characteristics, treatment protocol, complications, and clinical resolution of aseptic OB following non-surgical treatment. Study characteristics included the study design, type and location of bursitis, sample size, and follow-up interval. Patient characteristics included age, gender distribution, comorbid condition, and symptom duration. Interest complications included persistent swelling or tenderness, persistent drainage, bursal infection, scar-related complications, and skin atrophy. A descriptive analysis was performed for the clinical outcomes. Patients who failed to respond by the last follow-up in a particular study were considered treatment failures.

The methodological quality for RCTs was assessed using the Revised Cochrane risk-of-bias tool for RCTs and the Newcastle-Ottawa Scale (NOS) for cohort studies.4,5 For the NOS, a score of ≥6 was suggestive of higher study quality and study credibility.

This systematic review evaluated the non-surgical management of aseptic bursitis by analyzing 2 RCTs and 2 observational studies with a comparative arm of different approaches. Both the RCTs failed to demonstrate a statistically significant difference in terms of the resolution of OB and bursal tenderness among various invasive (aspiration±CSI) and non-invasive (NSAIDS, compression) non-surgical treatment options. It is noteworthy that both RCTs had high ROB and the study by Kim et al. was powered to detect only a 30% difference in the treatment efficacy among groups.6,7 The corticosteroid injection was associated with a significant decline in the duration of symptoms and a reduction in the mean number of re-aspirations in the RCTs. Similarly, Weinstein et al. observed a marked and abrupt reduction in the percentage of patients with effusion in the first week with CSI as compared to bursal aspiration alone.8 It is evident that co-morbidities including diabetes mellitus, hypertension, bone spur, and immunosuppressant therapy were associated with impaired healing. Interestingly, only one study reviewed that diabetes and hypertension were not associated with treatment failure.6 Rather, a longer duration of symptoms before the treatment initiation was significantly associated with a failed clinical resolution by 4 weeks. The effect of co-morbidities on bursitis resolution and complications needs to be explored in future studies. Among all the studies, Weinstein et al. followed the treated patients for a longer duration and reported that CSI was associated with a higher number of complications including bursal infection (3 cases), chronic local pain (7 cases), and skin atrophy (5 cases) which is previously reported in the literature.10 Skin atrophy and bursal infection were not reported in patients treated by Kim et al. and Smith et al.6,7 Protocolized procedures to maintain an optimal aseptic practice and using a compression dressing after injection might be potential explanations. A lateral olecranon entry might have the advantage of avoiding infiltration of the steroid preparation into subcutaneous tissue surrounding the posterior tip of the olecranon bony process, a common site for irritation or pressure from arm resting. It is noteworthy that the duration of follow-up to evaluate the safety outcomes related to treatment was shorter in studies by Kim et al. (mean 12 weeks) and Smith et al. (6 months) compared to Weinstein et al. (mean 31 months).6–8 Further evidence and high-quality studies with a large sample size are needed to address the long-term safety profile of CSI in OB. Based on this review, it appears that the clinical resolution of aseptic bursitis can occur with conservative methods if implemented earlier in the disease course. Although corticosteroid injections are more effective than other treatment modalities, they possess a risk of secondary bursal infection and should be used with caution.

This systematic review has several limitations. A meta-analysis couldn’t be performed due to inconsistency in the various study outcomes. Inadequate reporting leads to a difficult assessment of some study findings e.g., pain VAS and repeated procedures before final resolution. The statistical significance of resolved cases among different treatment groups was not reported by observational studies making the implications of results challenging. Response to different therapeutic measures can differ by the etiology of OB and traumatic versus inflammatory OB (such as due to gout or rheumatoid arthritis) can have different responses to different therapeutic measures. Jaffe et al. did not mention comorbidities, and patients with inflammatory etiology of OB were excluded by Kim et al. and Weinstein et al., and only 1 patient in the study by Smith et al. had monosodium urate-induced bursitis, therefore, further studies are needed to delineate responses to different therapeutic measures based on etiology of OB.6–9

In summary, this systematic review suggests that conservative methods are a safe option for aseptic bursitis treatment due to a similar rate of clinical resolution and a lower risk of complications than invasive management options. CSI should be reserved for refractory cases where bursitis does not subside with conservative management.

The authors declare they have no conflict of interest.