Olecranon Bursitis
What is olecranon bursitis?
Olecranon bursitis is a condition characterized by tissue damage and inflammation of the olecranon bursa (a small fluid filled sac located at the back of the elbow) causing pain in the back of the elbow.
The elbow is formed primarily from the union of the humerus (upper arm bone) and the ulna (forearm bone). The ulna has a bony process situated at the back of the elbow known as the olecranon (figure 1). This bony prominence is a point of attachment of several muscles including the triceps (figure 2) and forms the outer most point of the back of the elbow. Between the olecranon and overlying skin lies a bursa known as the olecranon bursa (figure 1). A bursa is a small sac filled with lubricating fluid and is designed to reduce friction between adjacent soft tissue layers.
The triceps muscle is primarily responsible for straightening the elbow and is particularly active during pushing activities. During contraction of the triceps, friction is placed on the olecranon bursa. Pressure may also be placed on the olecranon bursa following a direct impact. When these forces are excessive due to too much repetition or high force, irritation and inflammation of the bursa may occur. This condition is known as olecranon bursitis.
Causes of olecranon bursitis
Olecranon bursitis most commonly occurs due to repetitive or prolonged activities placing strain on the olecranon bursa. This typically occurs due to prolonged pressure on the bursa (such as repetitive falls on the elbow or prolonged resting of the elbow on hard surfaces) or due to repetitive pushing activities or straightening the elbow against resistance (placing strain on the bursa via the triceps tendon). Occasionally, the condition may occur suddenly due a direct blow to the elbow (such as a fall onto a hard surface).
Signs and symptoms of olecranon bursitis
Patients with olecranon bursitis typically experience pain and swelling in the back of the elbow. Pain typically increases when leaning on the affected elbow or when bending and straightening the elbow. In less severe cases, patients may only experience an ache or stiffness in the elbow that increases with rest following activities placing strain on the bursa. These activities typically include resting or falling on the elbow (particularly on hard surfaces), pushing activities, repetitive use of a hammer or straightening the elbow against resistance. The pain associated with this condition may also warm up with activity in the initial stages of injury.
As the condition progresses, patients may experience symptoms that increase during sport or activity. Patients may notice marked swelling and an appearance of a large bulge over the point of the elbow. Most patients with olecranon bursitis experience pain on firmly touching the olecranon bursa (figure 1). Occasionally small lumps may be felt over the point of the elbow. Patients may also experience weakness in the elbow particularly when attempting to straighten the elbow against resistance.
Diagnosis of olecranon bursitis
A thorough subjective and objective examination from a physiotherapist may be sufficient to diagnose olecranon bursitis. Further investigations such as an Ultrasound, X-ray, CT or MRI scan are often required to assist with diagnosis and assess the severity of the condition.
Prognosis of olecranon bursitis
Most patients with this condition heal well with appropriate physiotherapy and return to normal function in a number of weeks. Occasionally, rehabilitation can take significantly longer and may take many months in those who have had their condition for a long period of time. Early physiotherapy treatment is vital to hasten recovery in all patients with olecranon bursitis.
Treatment for olecranon bursitis
The success rate of treatment for this condition is largely dictated by patient compliance. One of the key components of treatment is that the patient rests from ANY activity that increases their pain until they are symptom free. This allows the body to begin the healing process in the absence of further tissue damage. Once the patient can perform these activities pain free, a gradual return to these activities is indicated provided there is no increase in symptoms.
Ignoring symptoms or adopting a 'no pain, no gain' attitude is likely to lead to the condition becoming chronic. Immediate, appropriate treatment in patients with olecranon bursitis is essential to ensure a speedy recovery. Once the bursitis is chronic, healing slows significantly resulting in markedly increased recovery times and an increased likelihood of future recurrence.
Patients with this condition should follow the R.I.C.E. Regime in the initial phase of injury. The R.I.C.E regime is beneficial in the first 72 hours following injury onset or when inflammatory signs are present (i.e. morning pain or pain with rest). The R.I.C.E. regime involves resting from aggravating activities, regular icing, the use of a compression bandage and keeping the affected arm elevated. Anti-inflammatory medication may also significantly hasten the healing process by reducing the pain and swelling associated with inflammation.
Patients should also undergo a graduated flexibility and strengthening program of the surrounding muscles to ensure an optimal outcome. The treating physiotherapist can advise which exercises are most appropriate for the patient and when they should be commenced.
Contributing factors to the development of olecranon bursitis
There are several factors which can predispose patients to developing this condition. These need to be assessed and corrected with direction from a physiotherapist. Some of these factors include:
- joint stiffness (particularly the elbow)
- muscle tightness (particularly the triceps)
- inappropriate or excessive training
- inadequate rehabilitation following a previous elbow injury
Physiotherapy for olecranon bursitis
Physiotherapy treatment is vital to hasten the healing process, ensure an optimal outcome and reduce the likelihood of recurrence. Treatment may comprise:
- soft tissue massage
- electrotherapy (e.g. ultrasound)
- stretches
- joint mobilization
- ice or heat treatment
- exercises to improve strength and flexibility
- education
- anti-inflammatory advice
- activity modification advice
- a gradual return to activity program
Other intervention for olecranon bursitis
Despite appropriate physiotherapy management, some patients with this condition do not improve adequately. When this occurs the treating physiotherapist or doctor will advise on the best course of management. This may include further investigations such as X-rays, ultrasound, MRI or CT scan, pharmaceutical intervention, corticosteroid injection, drainage of the bursa or referral to appropriate medical authorities who will advise on any interventions that may be appropriate to improve the condition. In rare and recurrent cases of this condition surgical removal of the bursa may be indicated.
Exercises for olecranon bursitis
The following exercise is commonly prescribed to patients with olecranon bursitis. You should discuss the suitability of this exercise with your physiotherapist prior to beginning it. Generally, it should be performed 1 - 3 times daily and only provided it does not cause or increase symptoms.
Triceps Stretch
Begin this exercise by standing tall with your back and neck straight (figure 3). Place one hand behind your lower neck and your other hand on your elbow. Gently push your elbow backwards so your hand moves further down your spine until you feel a mild to moderate stretch pain-free. Hold for 15 seconds and repeat 4 times.
Figure 1 – Triceps Stretch (right side)
