Reasoning GP · Algorithm · 1-page summary
Elbow pain in adults
For: adults with elbow pain or swelling, after an injury or without one, in primary care. Not for: children's injuries (local paediatric fracture pathway); arm pain with chest pain (chest pain algorithm).
Core rule: treat a hot, swollen elbow with restricted active and passive movement as septic arthritis, and a fat pad sign after trauma as an occult fracture, until excluded.
0Stop — call 999 now
- Pale, cold or pulseless hand → 999. Dislocation, open injury, neurovascular compromise → A&E now.
- Suspected compartment syndrome (pain out of proportion, worsening tingling, especially in a cast) → A&E now; split or remove the cast — not more analgesia.
- Arm pain with exertion, chest pain, breathlessness or sweating → possible ACS: 999 if ongoing or in the last 12 hours; Same-day if 12–72 hours ago.
1Triage — localise by region
| Region | Think |
|---|---|
| Lateral | Tennis elbow; radial head fracture after a fall |
| Medial | Golfer's elbow — check the ulnar nerve |
| Posterior | Olecranon bursitis (movement preserved) vs septic arthritis (diffuse, painful movement) — may coexist |
| Anterior | Distal biceps rupture (pop, weak supination, Popeye sign) |
| Referred | C6/C7 radiculopathy, shoulder, cardiac |
2Screen — serious causes
- Hot, swollen elbow, restricted active and passive movement → septic arthritis → Same-day hospital; do not delay antibiotics in sepsis.
- Septic bursitis + unwell or immunocompromised, spreading cellulitis, tendon rupture with major functional loss → Same-day hospital.
- Trauma + swelling or lost movement → X-ray. Displaced → Same-day orthopaedics; fat pad sign or other fracture → fracture clinic ≤72 h.
- Ulnar weakness, wasting or clawing → Urgent upper-limb/hand or orthopaedics; do not wait for nerve studies.
- Suspected distal biceps rupture → Urgent orthopaedics (early repair is better).
- Persistent focal bone pain, night pain, bony swelling, cancer history → Urgent X-ray + FBC; sarcoma on X-ray → consider suspected cancer pathway; ≥60 → myeloma tests.
3Assess
☐ Pulse, capillary refill, median/ulnar/radial nerves ☐ Active and passive range vs other side ☐ Resisted wrist extension/flexion ☐ Ulnar nerve, Froment's, wasting ☐ Neck and shoulder ☐ Infection suspected: FBC, CRP/ESR, renal function; urate (may be normal in a flare)
Do not aspirate a suspected septic joint. No routine bloods or USS for tennis elbow.
4Classify — only if blocks 0–2 are negative
- Lateral / medial epicondylalgia — epicondyle tenderness, pain on resisted wrist extension / flexion, no swelling.
- Olecranon bursitis — fluctuant, movement preserved; warm, red, tender ± fever → septic.
- Cubital tunnel — ring/little finger tingling, worse with elbow flexion.
- Radial head fracture — fall, lateral pain, restricted pronation/supination, fat pad sign.
- Elbow OA — older, previous fracture, lost extension, crepitus.
- Uncertain, atypical or not improving → reassess; X-ray, USS or MRI.
5Treat today — doses: NICE/SPC, BNF, local formulary
- Epicondylalgia: education, load modification, progressive strengthening; recovery may take months. Do not routinely offer steroid injection (worse long term, recurrence).
- Analgesia: consider a topical NSAID; short oral NSAID after GI, renal, CV, pregnancy and interaction checks. Avoid opioids for chronic MSK pain.
- Non-septic bursitis: avoid pressure, pad, ice, analgesia; no routine aspiration or steroid.
- Septic bursitis, stable, mild–moderate: oral antibiotic (staphylococci, streptococci) per local guidance guideline; culture where appropriate; review at 36–48 h — not improving → hospital.
6Refer routinely
- Physiotherapy: epicondylalgia persistent, severe or functionally limiting; post-fracture; elbow OA.
- MSK specialist: refractory tennis elbow (shockwave, PRP not routine).
- Upper-limb/hand or orthopaedics: sensory cubital tunnel persisting despite avoiding prolonged flexion and night support; OA limiting function.
- Rheumatology: suspected inflammatory arthritis — ≤3 working days if small joints, >1 joint or ≥3 months; recurrent gouty bursitis.
7Never reassure by
- Normal temperature, CRP or white cell count in a hot, swollen elbow.
- Crystals or known gout — infection can coexist.
- "No visible fracture" when there is a fat pad sign — presume an occult fracture.
- A normal X-ray when focal bone pain persists or a mass is present.
- Pending nerve conduction studies, or a negative Tinel's, when there is weakness or wasting.
- A positive Cozen's test — it does not exclude fracture, arthritis or radiculopathy.
8Safety-net — say it, then document it
999 / A&E “Call 999 or go to A&E now if your hand goes pale or changes colour, or pain, tingling or numbness gets worse in a cast or after an injury. Go to A&E for a hot, swollen, very painful elbow you cannot move, spreading redness with feeling unwell, or a sudden pop with weakness at the elbow.”
Same day: “Contact us the same day if an infected bursa is not better after 36–48 hours of antibiotics, or for fever, increasing redness, warmth or swelling, new numbness, weakness, dropping things or hand wasting. Come back if pain wakes you at night or is not improving at your review.”
✓Safe to leave primary care only if — all five, documented
No block 0–2 row applies
Neurovascular status recorded, before and after any splint
Active and passive range checked; septic joint excluded
Diagnosis named, or uncertainty → imaging or specialist
Review date and safety-net given and documented
Summary of the full Reasoning GP elbow pain algorithm, which holds the history, examination tests, investigations, rehabilitation and evidence. Sources: BOAST fracture-clinic standards, NICE NG12 (suspected cancer), NG226 (osteoarthritis), NG219 (gout), NG100 (rheumatoid arthritis), CG95 (chest pain), HTG201 and HTG299, local antimicrobial guideline and local formulary. Clinical reference — follow local pathways and check doses: NICE/SPC, BNF.