Elbow bursitis: signs of infection, what helps, and protecting your elbow

What it is

The olecranon bursa is a thin, fluid-filled sac between the bony point of the elbow and the skin. It normally lies flat and lets the skin glide over the bone. In bursitis it fills with fluid and swells, often like 'a small soft ball, a bit like a cyst', as an NHS leaflet puts it. It can ache, feel tender or warm, and hurt more when you press on it or bend the elbow.

The elbow joint underneath isn't affected, so the elbow usually still bends and straightens. Old names for it include student's elbow and plumber's elbow.

Sources 1, 2, 3, 4, 5, 6

Why it happens, and who gets itEmerging evidence

There are four routes, often overlapping: pressure or friction, such as leaning on a desk, a car armrest or a hard floor, usually over months; a knock or fall onto the point of the elbow; infection through a cut, graze, insect bite or puncture, sometimes through a break too small to notice; and gout or rheumatoid arthritis. US orthopaedic surgeons name plumbers and heating engineers who crawl and lean on their elbows, and long plank holds; NHS Lothian names plumbers, mechanics and electricians.

A reference text puts it at 10 to 29 people per 100,000 a year, more in people who press on their elbows. In the Israeli army it was 29 per 100,000 soldiers a year overall and 97 in combat units, whose recruits crawl in field training. In 10,301 patients compared with 44,608 others, men, people with raised cholesterol and smokers were more likely to have it, and the risk rose with age and weight; diabetes wasn't linked. In the UK, bursitis at the elbow from severe or prolonged pressure in manual work is a prescribed industrial disease.

Sources 1, 5, 4, 3, 2, 7, 8, 9

Infected or not: what the signs do and don't tell youEmerging evidence

How often elbow bursitis is infected depends on who is studied: in 2,692 soldiers, 24% of cases were infected, rising to 32% in combat units. The germ is usually Staphylococcus aureus, more than 90% of infections according to one review.

The signs overlap. In a review that pooled studies of elbow bursitis, tenderness was found in 88% of infected and 36% of non-infected cases, redness in 83% against 27%, warmth in 84% against 56%, an injury or skin wound in 50% against 25%, and a fever in 38% against none; another review puts fever higher, at up to 77%. So a normal temperature doesn't rule infection out.

A sample of fluid drawn off with a needle and tested in the lab is what decides, and a GP or hospital takes one when infection or gout is suspected. People with diabetes, a weakened immune system or rheumatoid arthritis are more at risk of infection.

Sources 7, 6, 10, 3, 1, 11

How it usually goesMixed evidence

The NHS says bursitis should go away in a few weeks. An Essex NHS trust says most elbow cases settle within 2 months; NHS Lothian says it can take a year or two to settle completely, though a small leftover swelling rarely causes problems; NHS Ayrshire & Arran says a small painless thickening is common. In the soldiers, symptoms lasted 17.6 weeks on average. The estimates differ, so expect weeks to months.

In the only trial, 65% to 85% of non-infected cases had settled by 4 weeks, whatever the treatment, and a longer wait before treatment predicted failure; it can come back. Treated infected bursitis usually clears: treatment failed in 5.9% of 272 people with infected elbow or knee bursitis.

Sources 3, 12, 5, 4, 7, 13, 14

Look-alikes

A whole elbow that is swollen and hard to move points to the joint itself (an infection, gout or arthritis), not the bursa. Firm lumps at the elbow in people with gout or rheumatoid arthritis can be gout deposits or rheumatoid nodules. A review's warning signs for a growth mimicking bursitis are a lump that grows quickly, doesn't settle with treatment, or comes with weight loss or a past cancer, and the NHS asks you to see a GP for a lump that gets bigger, is hard and doesn't move, or grows back after removal. After a fall, an elbow you can't fully straighten needs checking for a fracture.

Sources 11, 15, 1, 5, 6, 16

Infected bursitis: antibiotics firstEmerging evidence

The NHS says antibiotics are usually taken for at least 7 days if bursitis is caused by an infection. In 272 French patients with infected elbow or knee bursitis, most settled without surgery; treatment failed in 5.9%, more often when antibiotics lasted under 14 days. In a US emergency department, 134 people sent home on antibiotics without the bursa being drained were followed up, and 88% settled without a later drainage, admission or operation. A French guideline from 2023 covers the tests, antibiotic choices and when to operate.

Surgery for infection is kept for severe, stubborn or recurring cases. In a trial in Geneva of 164 people admitted with infected bursitis (130 at the elbow), removing the bursa in one operation failed no more often than in two (10% against 16%), with fewer wound problems at the elbow. For skin infections, the NHS asks you to finish the course of antibiotics and to contact your GP if you don't start to feel better after 2 to 3 days.

Sources 3, 14, 17, 18, 19, 20, 21

Non-infected bursitis: pressure off, ice, painkillers and compressionEmerging evidence

The NHS advises resting it from pressure, an ice pack wrapped in a tea towel for around 10 minutes every few hours, paracetamol or ibuprofen, and extra cushions around the joint at night. An Essex NHS trust adds a tubular compression bandage and gentle supported bending and straightening of the elbow, little and often; NHS Lothian says avoid leaning on the elbow and keep it moving.

In the only randomised trial, 90 people with non-infected bursitis had an elastic bandage with mild compression plus a week of anti-inflammatory tablets, draining, or draining with a steroid injection, and all were told not to rub the elbow on hard surfaces. By 4 weeks it had settled (the fluid gone or clearly less) in 83%, 65% and 85%. The steroid worked fastest (2.3 weeks against about 3), but the trial was small and could only detect large differences, and its authors favoured compression and a short course of tablets as the best balance of safety and benefit. Anti-inflammatory tablets don't suit everyone, so check with a pharmacist.

US surgeons add elbow pads, avoiding pressure, and a splint that keeps the elbow straight so the skin doesn't tighten over the swelling; if it hasn't settled after 3 to 6 weeks, draining with a steroid injection may be offered.

Sources 3, 12, 5, 13, 1

Draining and steroid injections: more downsides than they lookMixed evidence

NHS Lothian doesn't routinely drain it, because the fluid comes back and the needle can rarely introduce infection, and NHS Ayrshire & Arran says the same. A GP may still take a sample to test for infection or gout, which can also ease it. A review of 29 studies found draining didn't raise the infection rate in non-infected bursitis, so the size of that risk is uncertain.

Steroid injections speed things up a little, but the same review (1,278 people) found steroid for non-infected bursitis linked with more complications, including infection and thinning of the skin, without a better outcome, and another review advised keeping it for bursitis that doesn't settle. One review's authors don't inject steroid at all. The NHS lists a steroid injection as an option, but not if bursitis is caused by an infection, and an Essex NHS trust considers it when the swelling is large, persistent and affecting daily life. An older review found only limited evidence, from one small trial, for any treatment.

Sources 5, 4, 3, 22, 23, 6, 12, 24

Surgery is rarely neededEmerging evidence

Across 29 studies, surgery resolved bursitis less often and caused more complications, persistent drainage and infection than non-surgical care. NHS Lothian performs it 'rarely, if ever': the scar can be sensitive and make leaning on the elbow painful, the swelling can come back, the wound can leak for weeks, and stiffness and pain can follow. In 191 patients, 11.5% needed a second operation, more often with rheumatoid arthritis, diabetes or previous bursitis.

In a small comparison of 49 people with knee or elbow bursitis, keyhole removal meant shorter hospital stays and higher satisfaction than open surgery. US surgeons say the skin usually heals within 12 to 16 days, full use of the elbow is often allowed after 3 to 4 weeks, and the elbow may need padding for several months.

Sources 22, 5, 4, 25, 26, 1, 3

Exercise doesn't treat the bursaEmerging evidence

No study has tested exercise for bursitis, and it isn't a treatment for it; a 2021 review calls bursitis often self-limiting. NHS services ask you to keep the elbow moving, because the joint itself isn't affected. The plan below is our suggestion: it keeps the elbow, wrist and shoulder moving, builds strength without pressure on the point of the elbow, and brings positions that rest on the elbows back on padding. US surgeons name long plank holds as a cause, so forearm planks wait.

Sources 3, 5, 12, 1, 27

Preventing itEmerging evidence

The NHS advises cleaning any cuts on the joints, using padding when you put a lot of pressure on them, taking regular breaks, not knocking them, and keeping a healthy weight. US surgeons recommend elbow pads. In the army study, combat units had more than three times the overall rate (97 against 29 per 100,000 a year), and the authors called protective gear the most promising prevention.

Sources 3, 1, 7

A compression bandage (written steps)

From the elbow trial and an Essex NHS leaflet; the steps marked are our suggestions.

• 1. Use a tubular compression bandage, or an elastic bandage about 10 cm (4 inches) wide with mild compression.
• 2. Cover from the upper forearm to above the elbow (our suggestion).
• 3. Check your hand: numbness, tingling, coldness or a change of colour means it's too tight, so loosen it (our suggestion).
• 4. In the trial it was worn with a week of anti-inflammatory tablets and advice not to rub the elbow on hard surfaces.
• 5. Don't put it on a hot, red swelling, or over broken skin, until it has been checked (our suggestion).

Sources 13, 12

Protecting the elbow (written steps)

Pads and fewer pressure points are the main prevention.

• 1. A pad or cushion on your desk, car door and chair arms (our suggestion).
• 2. Rest on your forearm, not the point of the elbow (our suggestion).
• 3. Elbow pads for work or sport that puts weight on your elbows, such as crawling in tight spaces or field training; mat sports such as wrestling are similar (our suggestion).
• 4. Clean and cover any cut, graze or bite over the elbow.
• 5. Take regular breaks if your work puts pressure on your elbows.

Sources 1, 3, 7

If it's infected

Take the antibiotics for as long as you're told, usually at least 7 days, and contact your GP if you don't start to feel better after 2 to 3 days. NHS Lothian notes the infection can be stubborn and may need more than one course. Rest the elbow from pressure, and start the stage 1 moves once the heat, redness and swelling are settling, as your clinician advises.

Sources 3, 21, 14, 5

After surgery to remove the bursa (as your team allows)

Your surgical team's instructions come first. US surgeons describe the usual recovery.

• 1. A splint may protect the skin for a short time; a cast or long immobilisation usually isn't needed.
• 2. Exercises to get the movement back usually start within a few days.
• 3. The skin is usually healed within 12 to 16 days, and full use of the elbow is often allowed after 3 to 4 weeks.
• 4. The elbow may need padding for several months. A wound that keeps leaking needs your team.
• 5. Then stages 2 and 3, as your team allows.

Sources 1, 5, 4