Elbow Pain Algorithm

Safety

Red Flags — Fracture, Septic Arthritis & Nerve Compromise

Done

Acute trauma + elbow swelling + loss of range Radial head, olecranon or distal humerus fracture → X-ray elbow (AP + lateral; additional views per local radiology protocol). Check radial pulse, capillary refill and median, ulnar and radial motor and sensory function, documented before and after splinting. Check wrist/distal radioulnar joint pain, forearm tenderness and pronation/supination (Essex–Lopresti injury). Fat pad sign with no visible fracture = evidence of elbow haemarthrosis — presume an occult intra-articular fracture until excluded. Dislocation, open injury or neurovascular compromise → immediate A&E (call 999 if the hand is pale, cold or pulseless). Displaced fracture → same-day orthopaedics. Otherwise local fracture pathway (BOAST: fracture clinic within 72 hours).

Child with an elbow injury — suspected supracondylar fracture Fall on an outstretched hand with elbow pain → same-day emergency/orthopaedic assessment, especially with deformity, marked swelling, inability to move the elbow, skin tenting or an open wound, an absent or reduced radial pulse or a cool pale hand, a nerve deficit, or compartment features (call 999 if the hand is pale, cold or pulseless). Immobilise comfortably, give analgesia and document the neurovascular status before transfer.

Child with sudden non-use of the arm — possible pulled elbow Usually under 5, sudden non-use after traction on the arm, no deformity or swelling. Exclude fracture and non-accidental injury and examine neurovascular status; a trained clinician may reduce it (hyperpronation or supination–flexion) per local practice. If reduction fails, the presentation is atypical or the child is still not using the arm → imaging and urgent paediatric assessment. Inconsistent history or a non-ambulant child → consider safeguarding. Source: local paediatric emergency/orthopaedic protocol — there is no single NICE guideline for children's elbow injuries.

Hot, swollen, painful elbow with restricted active and passive movement Treat as possible septic arthritis until excluded → same-day hospital assessment. Joint aspiration and blood cultures urgently, ideally before antibiotics if clinically stable; do not delay antibiotics in sepsis, haemodynamic instability or rapidly progressive infection. Fever may be absent; normal CRP, WCC or temperature does not exclude septic arthritis. Crystal arthritis can coexist with infection. Synovial fluid: microscopy and crystal analysis, Gram stain, culture and sensitivities, cell count if available. Orthopaedic emergency requiring hospital-led drainage and IV antibiotics — do not aspirate in general practice unless a trained clinician, aseptic equipment, a clear local pathway and timely laboratory processing are available.

Elbow pain + progressive hand weakness + wasting Ulnar nerve entrapment at cubital tunnel (cubital tunnel syndrome) progressing to intrinsic muscle wasting → urgent upper-limb/hand or orthopaedic referral per local pathway (objective weakness, intrinsic wasting, progressive sensory loss, clawing or functional deterioration); do not delay referral for nerve conduction studies. Persistent motor deficit may not fully recover.

Elbow pain + numbness in ring and little finger Cubital tunnel syndrome (ulnar neuropathy) — less urgent if purely sensory, but motor signs → urgent. Tinel's sign posterior to the medial epicondyle supports the diagnosis but is neither necessary nor diagnostic by itself.

Swollen warm elbow + immunocompromised Septic bursitis (olecranon bursa) vs septic arthritis — aspiration and culture where appropriate. Immunocompromise, diabetes, rheumatoid arthritis, prosthetic joint, spreading cellulitis, systemic illness, abscess or suspected joint involvement → lower threshold for same-day hospital/specialist assessment.

Persistent, progressive or unexplained focal bone pain Particularly pain at rest or at night, focal bony swelling, pathological fracture or a history of cancer → urgent assessment: plain X-ray of the affected area and appropriate blood tests (including FBC). X-ray suggests bone sarcoma → consider a suspected cancer pathway referral (NICE NG12). Child or young person: unexplained bone swelling or pain → consider a very urgent X-ray (within 48 hours); X-ray suggests bone sarcoma → consider a very urgent referral (within 48 hours). Suspected metastatic disease or myeloma → investigate and refer according to the likely primary and local pathway; aged ≥60 with persistent bone pain or unexplained fracture → myeloma investigations (NICE NG12). A normal X-ray does not exclude malignancy if pain persists or a mass is present — seek specialist advice or further imaging.

Open injury, rapidly increasing pain, cellulitis or major functional loss Suspected compartment syndrome (pain out of proportion or worsening tingling, especially in a cast) or open injury → immediate A&E; remove or split any cast or tight dressing. Rapidly progressive swelling or cellulitis, or acute tendon rupture with major functional loss → same-day hospital/specialist assessment.

The posterior fat pad sign on a lateral elbow X-ray is one of the most important radiological findings in trauma — it represents haemarthrosis displacing the fat pads from the olecranon and coronoid fossae, and is a marker of occult elbow fracture (fracture invisible on standard X-ray). In adults, a visible posterior fat pad with trauma is evidence of haemarthrosis — presume an occult intra-articular fracture until excluded. Management: analgesia, a sling for comfort and early gentle mobilisation as directed by the fracture service; refer via the local fracture pathway (BOAST: fracture-clinic assessment within 72 hours). Avoid unnecessary prolonged immobilisation, which commonly causes elbow stiffness. Failing to treat fat pad sign as an occult fracture is a well-recognised medicolegal issue. Cubital tunnel syndrome (ulnar nerve compression at the medial elbow) is the second most common peripheral nerve entrapment after carpal tunnel syndrome — it causes ring and little finger paraesthesia and, in advanced cases, weakness and wasting of the intrinsic hand muscles (hypothenar wasting, interossei wasting, claw hand).

Diagnose

History — Localise by Region

Done

Lateral elbow pain

Lateral epicondylalgia (lateral elbow tendinopathy; tennis elbow) — most common. Repetitive wrist extension activities: racquet sports, typing, screwdriving, painting. Pain on resisted wrist extension (Cozen's test). No joint swelling. Typically middle-aged. Gradual onset.

Medial elbow pain

Medial epicondylalgia (golfer's elbow) — less common. Repetitive wrist flexion activities: golf, throwing, hammering. Pain on resisted wrist flexion (reverse Cozen's). Associated with cubital tunnel syndrome (medial location — watch for ulnar nerve symptoms).

Posterior elbow swelling

Olecranon bursitis — large fluctuant posterior swelling, often painless, localised to bursa (joint movement usually preserved; septic arthritis gives more diffuse swelling and marked pain on active and passive movement — these may coexist). Traumatic (direct blow), repetitive (student's elbow, miner's elbow), inflammatory (gout, RA), septic (warm, red, tender, fever).

Anterior elbow pain

Bicipital tendinopathy or distal biceps tendon rupture (sudden pop + weakness of supination + Popeye deformity). Brachialis tendinopathy. Radial head fracture (lateral + anterior). Pronator teres syndrome (median nerve entrapment — anterior forearm radiation).

Referred pain

Cervical radiculopathy (C6/C7 — radiating from neck to lateral elbow, associated with neck movement/neurological symptoms) · Shoulder pathology (referred to elbow) · Cardiac ischaemia (left arm/elbow pain — if exertional or with chest pain, breathlessness, sweating or nausea, assess as possible acute coronary syndrome: 999 if pain is ongoing or in the last 12 hours, same-day assessment if 12–72 hours ago; NICE CG95). Always check neck and shoulder range of motion.

Key questions

Trauma and mechanism · onset and progression · fever, infection or skin breach · activity and occupational loading · night/rest pain · weight loss or history of malignancy · inflammatory symptoms · gout, RA or psoriasis · neurological symptoms · functional loss · anticoagulants and immunosuppression.

The anatomical localisation of elbow pain is highly diagnostically specific — the elbow has distinct compartments and structures, and pain in different regions points to different pathologies. Lateral epicondyle pain = extensor origin tendinopathy (tennis elbow). Medial epicondyle pain = flexor origin tendinopathy (golfer's elbow) ± cubital tunnel syndrome. Posterior swelling = olecranon bursa (separate from the joint). This anatomical precision means that a careful examination of exactly where the pain is, and what movements reproduce it, is the most important diagnostic tool — more informative than investigations in most cases. The key examination finding for tennis elbow (Cozen's test) takes 5 seconds: place two fingers on the lateral epicondyle and ask the patient to extend the wrist against resistance — reproduction of lateral elbow pain is a positive test. Special tests support a clinical diagnosis but do not exclude fracture, arthritis, radial tunnel syndrome, cervical radiculopathy or intra-articular pathology.

Diagnose

Differential Diagnosis

Done

Lateral epicondylalgia (tennis elbow)

Extensor carpi radialis brevis (ECRB) tendinopathy — not true inflammation but tendon degeneration (angiofibroblastic tendinosis). Lateral epicondyle tenderness + Cozen's test positive. No joint swelling. Usually a clinical diagnosis. Commonly self-limiting, although recovery may take several months and occasionally longer.

Medial epicondylalgia (golfer's elbow)

Flexor-pronator origin tendinopathy. Medial epicondyle tenderness + pain on resisted wrist flexion. Check ulnar nerve (ring/little finger numbness — cubital tunnel syndrome may coexist). Less common than tennis elbow. Similar natural history.

Olecranon bursitis

Posterior elbow swelling — fluctuant, transilluminates. Traumatic/pressure-related (many settle with conservative treatment, but recurrence is common if pressure continues). Septic (warm, red, tender ± fever — aspiration and culture where appropriate). Bursitis: focal posterior swelling, joint movement usually preserved; septic arthritis: diffuse swelling, pain on active and passive movement — may coexist or be hard to distinguish, so keep a low threshold for hospital assessment. Gouty (inspect for tophi, check urate). Rheumatoid (check for rheumatoid nodules, systemic features).

Cubital tunnel syndrome

Ulnar nerve at medial elbow. Numbness/tingling in ring and little fingers (especially at night, with elbow flexion). Tinel's sign at medial elbow (supportive, not diagnostic). Weak grip / intrinsic wasting in advanced cases. Primarily a clinical diagnosis; nerve conduction studies may help confirm, localise and assess severity where the diagnosis is uncertain, symptoms persist or surgery is considered.

Elbow OA

Older adults, previous fracture or loose bodies. Pain + stiffness + loss of extension. Crepitus on movement. X-ray: joint space narrowing, osteophytes, loose bodies (calcific or bony). Manage conservatively — surgery for severe cases (total elbow arthroplasty).

Radial head fracture

Post-fall/trauma. Lateral elbow pain + swelling + restricted pronation/supination. Fat pad sign on X-ray. Assess elbow movement, neurovascular status, wrist/forearm pain and possible Essex–Lopresti injury. Undisplaced, stable fractures: analgesia, sling for comfort and early gentle mobilisation as directed by the fracture service — avoid unnecessary prolonged immobilisation. Displaced or comminuted → orthopaedics (ORIF or radial head replacement).

Tennis elbow is not an inflammatory condition — histological studies consistently show angiofibroblastic tendinosis (degeneration and attempted disorganised repair) rather than inflammatory cells. This is why the terms lateral epicondylalgia or lateral elbow tendinopathy are preferred, and why management focuses on education, load modification and progressive strengthening rather than suppressing inflammation. Corticosteroid injection for tennis elbow provides rapid short-term pain relief (superior to physiotherapy at 6 weeks) but is associated with significantly worse outcomes at 1 year and higher recurrence rates than physiotherapy or watchful waiting. Do not routinely offer corticosteroid injection for lateral or medial epicondylalgia. Avoid repeated injections and do not inject directly into the tendon; if injection is considered, obtain informed consent and it should preferably be performed by a clinician with appropriate expertise. First line is education, load modification and individualised progressive strengthening (physiotherapy if persistent); massage or deep-friction massage is not a required first-line treatment. This represents a significant shift from historical practice.

Diagnose

Examination & Investigations

Done

Range of motion

Flexion approximately 0–145°, extension approximately 0°, pronation approximately 75–85°, supination approximately 80–90°. Normal values vary — compare with the other side rather than relying on a single measurement. Assess active and passive movement. Loss of full extension → joint pathology (fracture, OA, loose body, effusion). Restriction of pronation/supination → radial head pathology. Crepitus → OA, loose bodies.

Cozen's test (lateral epicondylalgia)

Stabilise elbow in 90° flexion, patient extends wrist against resistance — pain at lateral epicondyle = positive. Mill's test: extend elbow, pronate forearm, flex wrist — pain at lateral epicondyle = positive. These tests support a clinical diagnosis but do not exclude fracture, arthritis, radial tunnel syndrome, cervical radiculopathy or intra-articular pathology.

Tinel's sign (cubital tunnel)

Tap over ulnar nerve at medial elbow (cubital tunnel, posterior to medial epicondyle) — tingling in ring/little fingers = positive (Tinel's sign). Elbow flexion test (flex fully for 60 seconds) — if reproduces symptoms = cubital tunnel. A positive Tinel's is neither necessary nor diagnostic by itself. Also examine ulnar-distribution sensation, finger abduction/adduction, Froment's sign, grip strength, intrinsic muscle wasting, and the cervical spine (possible C8/T1 radiculopathy).

Olecranon bursa assessment

Fluctuant posterior swelling — transilluminate (fluid = cyst/bursitis). Temperature (warm = septic/inflammatory). Tender directly over bursa (not inside joint — elbow ROM should be preserved if truly bursal). If aspirated (not routine): straw-coloured (traumatic), turbid (septic), crystals (gout) — send for microscopy, crystals and culture.

Neurovascular examination

Every acute traumatic presentation: radial pulse and capillary refill; median, ulnar and radial nerve motor function; sensation in the relevant distributions. Document before and after splinting.

Investigations

Investigate selectively. X-ray elbow (AP + lateral; extra views per local protocol) — trauma with bony tenderness, significant swelling or loss of movement, focal radial-head/olecranon/distal-humeral tenderness, suspected fracture or dislocation, persistent unexplained focal bone pain, suspected OA with mechanical symptoms or diagnostic uncertainty. Aspiration + microscopy, crystals, Gram stain, culture (suspected septic arthritis or selected bursitis cases). USS (suspected distal biceps rupture, bursal fluid, tendon pathology, superficial mass, diagnostic uncertainty — not mandatory for tennis elbow). MRI (significant tendon rupture, persistent diagnostic uncertainty, intra-articular pathology, suspected tumour or osteomyelitis, failure of conservative treatment). NCS (persistent or progressive ulnar neuropathy, especially before surgery). Bloods — not routine for uncomplicated tendinopathy: FBC, CRP/ESR, renal function if infection or inflammatory arthritis suspected; urate if gout suspected (may be normal during an acute attack — NICE NG219); calcium, bone profile, myeloma screen if persistent bone pain or malignancy suspected; RF/anti-CCP only if inflammatory polyarthritis suggested, usually with rheumatology advice.

Most uncomplicated, clearly non-infected olecranon bursitis is managed conservatively — aspiration is not routinely required and may introduce infection or lead to recurrence. Consider aspiration when infection, crystal disease or another diagnosis is suspected, or when a large, painful collection requires specialist drainage; use an aseptic technique and send fluid for microscopy, crystals and culture (cell count if available). Staphylococcus aureus is the most common organism. Empirical oral treatment for a clinically stable, mild-to-moderate septic bursitis should cover staphylococci and streptococci and follow the local antimicrobial guideline and microbiology advice; do not use a specific MRSA regimen unless the local guideline or a microbiologist supports it.

Refer

Referral Pathways

Done

Same-day hospital / A&E

Suspected septic arthritis (hot, swollen, very painful elbow with restricted passive movement) · Suspected septic bursitis in a systemically unwell or immunocompromised patient · Dislocation, open injury, neurovascular compromise or suspected compartment syndrome (immediately — A&E) · Displaced fracture · Rapidly progressive swelling or cellulitis · Acute tendon rupture with major functional loss

Urgent referral

Progressive ulnar motor deficit or intrinsic wasting · Suspected distal biceps rupture (early surgical repair gives better outcomes) · Persistent focal bone pain or swelling · Abnormal X-ray suggesting tumour, pathological fracture or significant fracture displacement

Children

Suspected supracondylar fracture → same-day emergency/orthopaedic assessment (immobilise, analgesia, document neurovascular status) · Pulled elbow not reduced, atypical, or child still not using the arm → imaging and urgent paediatric assessment · Inconsistent history or non-ambulant child → consider safeguarding (local paediatric emergency/orthopaedic protocol; no single NICE guideline)

Orthopaedics / fracture clinic

Fat pad sign on X-ray (occult fracture) — fracture clinic via local fracture pathway (BOAST: within 72 hours) · Radial head fracture (assessment + follow-up) · Elbow OA with significant functional limitation · Cubital tunnel syndrome with motor deficit

Physiotherapy

Lateral or medial epicondylalgia that is persistent, severe or functionally limiting (education, load modification, individualised progressive strengthening) · Post-fracture rehabilitation · Elbow OA exercise programme

Upper-limb / hand or orthopaedics (local pathway)

Cubital tunnel syndrome — neurology is not necessarily the default destination. NCS where diagnosis uncertain, symptoms persist or surgery considered; do not delay urgent referral for NCS. Motor signs, wasting, clawing or progressive sensory loss → urgent. Purely sensory → conservative first, routine if persistent. Decompression surgery (simple decompression or anterior transposition) for persistent or progressive cases.

Rheumatology

Suspected RA or inflammatory arthritis (persistent synovitis, bilateral, prolonged morning stiffness, systemic features) — urgent, ideally within 3 working days, if small joints of the hands or feet or more than one joint are affected, or symptoms for 3 months or longer (NICE NG100) · Recurrent gouty bursitis + high urate · Psoriatic arthritis

Distal biceps tendon rupture requires early orthopaedic assessment — early surgical repair produces better long-term supination strength and functional outcomes than delayed repair or conservative management. With delay, tendon retraction and adhesion formation make surgical repair progressively more difficult. The clinical features are classic: sudden pop at the anterior elbow during forceful elbow flexion or supination (e.g., lifting a heavy box), followed by weakness of elbow flexion and supination and a visible deformity (Popeye sign — biceps muscle belly displaced proximally). The Hook test is specific: the examiner hooks a finger under the bicipital tendon at the elbow — if the tendon cannot be hooked, it has ruptured. Any patient with suspected distal biceps tendon rupture should be referred to orthopaedics urgently, not managed conservatively by default.

Treat

GP Treatment by Diagnosis

Done

Lateral / medial epicondylalgia

Education + load modification + progressive strengthening

Commonly self-limiting, although recovery may take several months and occasionally longer. Temporary reduction of aggravating gripping, lifting or repetitive wrist activity; progressive resistance exercise; stretching only where tolerated; ergonomic and occupational advice. Physiotherapy if persistent, severe or functionally limiting. Topical NSAID if suitable (follow SPC and local formulary). Do not routinely offer corticosteroid injection — short-term relief but poorer longer-term outcomes and recurrence. Counterforce strap or wrist support — optional short-term aid only.

Olecranon bursitis (non-septic)

Conservative: avoid pressure, protect, ice, simple analgesia

Small, minimally symptomatic, non-infected bursitis: avoid pressure, elbow pad/protection, activity modification, ice and simple analgesia if required; compression only if appropriately fitted. Aspiration and steroid injection are not routine — aspiration may introduce infection or lead to recurrence. Consider aspiration when infection, crystal disease or another diagnosis is suspected, or a large, painful collection needs specialist drainage; use an aseptic technique and send fluid for microscopy, crystals and culture. Many traumatic or pressure-related bursae settle with conservative treatment, but recurrence is common if pressure continues. Gouty: treat underlying gout (NICE NG219). RA: DMARD optimisation. Review if increasing warmth, redness, pain, fever or reduced joint movement.

Septic olecranon bursitis

Antibiotics per local guidance antimicrobial guideline

Arrange aspiration/culture where appropriate. Same-day hospital assessment if systemically unwell, immunocompromised or suspected septic arthritis; same-day specialist advice or assessment if significant comorbidity (e.g. diabetes, RA), spreading cellulitis, severe pain, large abscess or failure to improve. Clinically stable, mild-to-moderate: empirical oral treatment covering staphylococci and streptococci, following the local antimicrobial guideline and microbiology advice (check before prescribing; no fixed course length). Review at 36–48 hours and modify according to clinical response and culture results — not improving or re-accumulating → hospital (IV antibiotics, surgical drainage).

Tennis elbow — refractoryMSK specialist assessment. ESWT (NICE HTG201, formerly IPG313, 2009): should only be offered with special arrangements for clinical governance, consent and audit or research, because the evidence of efficacy is inconsistent. PRP (platelet-rich plasma) or other autologous blood injection (NICE HTG299, formerly IPG438): only with special arrangements for clinical governance, consent and audit or research, because the evidence of efficacy is inadequate — not routine and not a standard next step after physiotherapy. Surgical release (ECRB debridement) for persistent cases after specialist assessment. Avoid repeated steroid injections.

Cubital tunnel (mild/sensory)Avoid prolonged elbow flexion and leaning on the elbow. Night support or towel wrap to prevent sustained flexion. Modify aggravating activities; ergonomic keyboard adjustment. Review after approximately 6–8 weeks — if progressive (objective weakness, wasting, clawing, progressive sensory loss) → urgent upper-limb/hand or orthopaedic referral per local pathway (do not delay for NCS).

The evidence against corticosteroid injection for tennis elbow represents one of the most significant recent guideline shifts in MSK primary care. The landmark RCT by Coombes et al. (JAMA, 2013) demonstrated that corticosteroid injection produced significantly worse outcomes at 1 year compared to physiotherapy alone or placebo injection — patients who received steroid injection had higher recurrence rates, greater global deterioration, and worse functional outcomes at 52 weeks despite better short-term pain relief at 4 weeks. Current practice has therefore moved away from steroid injection as a routine treatment for tennis elbow. If injection is considered, obtain informed consent, avoid repeated injections and do not inject directly into the tendon. This requires active de-prescribing of an established GP practice — explaining to patients why the previously offered steroid injection is no longer recommended requires good communication skills. The SCA examination may specifically test this communication scenario.

Treat

Analgesia Principles & Elbow OA

Done

Analgesia principles

Use analgesia to support activity and rehabilitation. Consider a topical NSAID for a localised musculoskeletal condition if there are no contraindications (NICE NG226 supports topical NSAIDs for OA of joints other than the knee, but does not specifically establish them for tennis elbow). If ineffective or unsuitable, consider a short course of oral NSAID after assessing gastrointestinal, renal, cardiovascular, pregnancy and drug-interaction risks; use gastroprotection where indicated. Paracetamol is not automatic — consider liver disease, alcohol excess, low body weight and frailty. Follow the current product SPC and local formulary for preferences and cautions. Avoid opioids for chronic MSK pain (NICE NG226: do not offer strong opioids for OA; weak opioids only infrequently and short term).

Elbow OA management

Conservative: analgesia + physiotherapy + activity modification. Intra-articular corticosteroid injection (specialist — short-term benefit). Elbow arthroplasty (total elbow replacement) for end-stage OA with severe functional impairment. Less common than knee/hip arthroplasty — orthopaedic decision.

Occupational advice

Workplace ergonomics assessment (occupational health) for repetitive strain disorders. Keyboard height, mouse grip, tool handle diameter. Statutory sick note (Med3) if unable to work. Reasonable adjustments under Equality Act 2010 if permanent disability.

Next steps: see Tennis elbow · Osteoarthritis · Gout · Cellulitis and erysipelas

Topical NSAIDs (diclofenac gel) have equivalent efficacy to oral NSAIDs for peripheral MSK pain (epicondylalgia, OA of superficial joints) with dramatically lower systemic side effects — GI toxicity, renal impairment, and cardiovascular risk are all significantly reduced. NICE NG226 recommends a topical NSAID before an oral NSAID for knee OA (and to consider one for other affected joints); it is an osteoarthritis guideline and does not specifically establish topical NSAIDs for tennis elbow, bursitis or general elbow pain. Dose and frequency depend on the product — follow the current SPC and local formulary. Provide occupational advice for work-related epicondylalgia — returning a patient to the same job without addressing the causative ergonomic factor risks relapse.

Lifestyle

Activity Modification, Ergonomics & Prevention

Done

Tennis elbow — load management Identify and reduce the aggravating activity (repetitive wrist extension). Use two-handed technique for heavy lifting (reduces wrist extensor loading). Counterforce brace (tennis elbow strap) — optional short-term aid, worn just below the lateral epicondyle during activities. Reduce grip strength requirements (larger handle grips on tools and racquets).

Ergonomic assessment Keyboard users: raise keyboard (reduces wrist extension angle), vertical mouse (neutral forearm posture), regular micro-breaks. Manual workers: larger tool handles, reduced grip force, task rotation. Occupational health referral for complex cases. OHS referral for statutory assessment.

Exercise prescription Management of lateral and medial epicondylalgia focuses on progressive strengthening of the relevant muscle–tendon unit. Exercise selection and progression should be individualised, ideally with physiotherapy support if symptoms are persistent or functionally limiting. Stretching only where tolerated. The Tyler Twist (rubber bar wrist extension) is one option.

Olecranon bursitis prevention Avoid prolonged elbow resting on hard surfaces (desk, table). Use elbow padding (gel pad, foam) for occupations requiring elbow contact. Ice and simple analgesia if required; compression only if appropriately fitted. Avoid routine aspiration or steroid injection.

Nerve care (cubital tunnel) Avoid prolonged elbow flexion (phone holding, sleeping with arm under pillow, using elbow rest on car door). Night support or towel wrap (prevents sleeping with the elbow in sustained flexion). Computer posture: elbow at 90°, forearm supported. Refer ergonomics if desk-related.

Return to sport (tennis elbow) Grade return to racquet sport: begin with gentle groundstrokes (low load) progressing gradually to a full game as symptoms allow. Reduce string tension (reduces shock transmission). Larger sweet spot racquet. Proper backhand technique coaching (a two-handed backhand may reduce lateral elbow load).

The Tyler Twist exercise (using a rubber bar/Flexbar) is one way of loading the wrist extensors in a functionally relevant pattern; exercise selection and progression should be individualised. Instructions: hold the bar vertically in both hands, twist the bar with the affected hand (wrist extends eccentrically against the bar's resistance). This is available for patients to view via YouTube. Most physiotherapists include this as part of a broader programme. Technique coaching, including a two-handed backhand, may reduce loading of the extensor origin during tennis.

Safety

Follow-Up & Safety-Netting

Done

Epicondylalgia — 6–12 weeks

Review after 6–12 weeks depending on severity. Exercise programme established? Symptoms improving? Recovery may take several months. USS is not mandatory — consider it when the diagnosis is uncertain, symptoms are refractory or an alternative lesion is suspected. Persistent, severe or functionally limiting → physiotherapy and/or MSK specialist referral.

Bursitis — review

Septic bursitis: review at 36–48 hours; culture results back — modify antibiotics according to response and culture. Non-infected: settling with pressure avoidance? Increasing warmth, redness, pain, fever or reduced joint movement → reassess for infection. If re-accumulating after aspiration → repeat aspiration + culture. Failure of oral antibiotics for septic bursitis → hospital for IV antibiotics and possible surgical drainage.

Cubital tunnel — 6–8 weeks

Night support helping? Sensory symptoms improving? Any new motor signs (grip weakness, hand wasting, clawing)? Motor signs developing → urgent upper-limb/hand or orthopaedic referral per local pathway. NCS may help confirm, localise and assess severity, but should not delay urgent referral.

Post-fracture

Fracture clinic follow-up per their plan. Pain resolving? Full pronation/supination returning? Follow-up imaging depends on fracture type, stability, symptoms and the fracture-clinic plan — not routine for every uncomplicated radial head fracture. Physiotherapy for stiffness (common post-radial head fracture).

999 / A&E safety-net

Loss of pulse or change in hand colour; worsening pain, tingling or numbness in a cast or after an injury (possible compartment syndrome — the cast must be removed); hot, swollen, very painful elbow you cannot move (possible joint infection); rapidly spreading redness + feeling unwell (septic arthritis progressing); sudden pop + weakness at elbow (distal biceps rupture — early repair gives better outcomes)

Same-day GP

Septic bursitis not improving at 36–48 hrs on antibiotics, fever or systemic illness, increasing redness or warmth, rapidly enlarging swelling, new or worsening numbness, weakness, dropping objects or hand wasting, worsening pain despite treatment, new acute elbow swelling following any activity

Routine review

Night/rest pain or unexplained persistent pain · failure to improve within the agreed review period — reassess the diagnosis if symptoms are atypical, progressive or fail to improve

Compartment syndrome following elbow fracture or dislocation is a rare but devastating complication — the forearm is the second most common site for compartment syndrome (after the leg). It presents with the 5 P's: Pain (disproportionate, unrelieved by opioids), Paraesthesia (early — indicates ischaemic nerve), Pallor, Paralysis (late), Pulselessness (very late). Any patient in a cast who reports worsening pain + tingling must have the cast removed and be assessed for compartment syndrome immediately — do not give more analgesia and wait. This is a medicolegal emergency with a narrow window for limb salvage.