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Elbow red flags

What you cannot afford to miss in elbow pain, before any special test.

Most elbow pain is musculoskeletal. These are the conditions that are not, or that need referral before treatment, with the features that point to each. Every row carries its source, listed at the foot of the page.

Use with your local protocols. Referral pathways, and how urgently to act, differ between health services and countries: where your local protocol or current guideline differs, follow it. Never delay emergency care to check a protocol.

Can’t missWhat points to it
Arterial or nerve injury after dislocation or fracture1Absent or weak radial pulse, a pale or cool hand, or altered sensation after a dislocation or fracture. Send the patient to an emergency department now. Neurovascular status should be recorded before and after any reduction; reduction is a medical procedure, not a physiotherapy procedure.
Compartment syndrome2Pain out of proportion to the injury, increased by passive finger stretch, and a tense, swollen forearm. A palpable pulse does not exclude the condition. Send the patient to an emergency department now.
Child with a fall onto the arm3,4Deformity, swelling or refusal to move the arm should raise suspicion of a supracondylar fracture, the most common elbow fracture in children. Same-day X-ray and medical assessment are required, even if the hand is normal; this is not a physiotherapy work-up. The circulation and nerve function of the hand should be checked. Any abnormality is an emergency because of the risk of compartment syndrome and Volkmann's ischaemic contracture: send the child to an emergency department now.
Pulled elbow versus fracture5,6Pulled elbow presents in a young child who stops using the arm after being pulled or swung by the hand, with no swelling, bruising, deformity or bony tenderness. A fall or direct blow, swelling, bruising or point tenderness indicates a fracture instead, and the elbow should be imaged before any reduction is attempted.
Septic arthritis or septic bursitis7,8A hot, globally painful elbow that the patient will not move, or spreading redness over a swollen olecranon bursa, particularly in a patient who is unwell. Fever is often absent, so its absence does not exclude infection. Same-day medical assessment is required.
Mechanical block after injury9A true block to forearm rotation or elbow movement (not just pain), deformity, or a suspected dislocation. A displaced radial head fragment or loose body will not settle with rest or exercise. Prompt orthopaedic review is required.
Distal biceps rupture10,11A sudden pop at the front of the elbow as a loaded, flexed elbow was forced into extension, followed by bruising, an altered biceps contour or weak supination. Repair becomes more difficult with delay, so prompt orthopaedic review is required, within days rather than weeks.
Cardiac referred pain12New arm or elbow pain that is exertional, bilateral or migrating, accompanied by breathlessness, sweating, nausea, fatigue or chest tightness and without a mechanical trigger. This should be treated as a possible cardiac event rather than an elbow complaint: call an ambulance if symptoms are present now. If symptoms have settled, medical assessment should still be arranged the same day, and an ambulance called if there is any doubt; the examination should not be continued.
Mass or malignancy13,14A lump that is enlarging, deep, firm, larger than about 5 cm, or producing new nerve symptoms requires imaging and referral to a sarcoma service before any local treatment. A history of cancer or unexplained weight loss with non-mechanical pain warrants urgent medical review. Firm nodules over the back of the forearm with symmetrical small-joint arthritis suggest rheumatoid disease.
Osteochondritis dissecans of the capitellum15,16An adolescent throwing athlete (such as a baseball pitcher) or gymnast with lateral elbow pain, catching, locking or loss of extension. This is not simple overuse, and continued loading risks the development of a loose body. Referral for imaging is indicated.
Cervical spine disorder presenting as elbow pain17Arm pain that changes with neck movement, a dermatomal distribution, or a change in reflexes or strength.

A red flag raises suspicion; it does not make the diagnosis, and its absence does not rule the condition out. The table is not a complete list of every serious condition, and it is not a clinical protocol. When a red flag is present, act on the referral advice in the row, in line with your local protocols. This page is for registered health practitioners and students and is not clinical advice for patients; see the terms of use.

Last checked against the cited sources: 15 October 2026.

Then the tests: Elbow special tests, with sensitivity, specificity and likelihood ratios.

Get the book for deciding which elbows need an X-ray after a fall, and whether the distal biceps is torn

This table opens the chapter ‘The elbow’ in Rule It In, Rule It Out. The book then works through the questions that matter in this region, with the published figures for each test and how to read them.

Coming in late 2026 as a PDF and a paperback. Join the list to hear when it's out

Sources

  1. Ayel JE, Bonnevialle N, Lafosse JM, et al. Acute elbow dislocation with arterial rupture. Analysis of nine cases. Orthop Traumatol Surg Res. 2009;95(5):343–351. Link
  2. Jimenez A, Marappa-Ganeshan R. Forearm Compartment Syndrome. StatPearls Publishing; updated 2023. Link
  3. Hope N, Varacallo MA. Supracondylar Humerus Fractures. StatPearls Publishing; updated August 4, 2023. Link
  4. Mirza TM, Taqi M. Volkmann Contracture. StatPearls Publishing; updated 2023. Link
  5. Bexkens R, Washburn FJ, Eygendaal D, van den Bekerom MPJ, Oh LS. Effectiveness of reduction maneuvers in the treatment of nursemaid's elbow: a systematic review and meta-analysis. Am J Emerg Med. 2017;35(1):159–163. Link
  6. Krul M, van der Wouden JC, Kruithof EJ, van Suijlekom-Smit LWA, Koes BW. Manipulative interventions for reducing pulled elbow in young children. Cochrane Database Syst Rev. 2017;(7):CD007759. Link
  7. Mistry D, Khatri C, Bickley M, Shyamalan G, Malik S, Jordan R. Management of acute septic native elbow arthritis — a systematic review. Shoulder Elbow. 2026;18(1):118–128. Link
  8. Margaretten ME, Kohlwes J, Moore D, Bent S. Does this adult patient have septic arthritis? JAMA. 2007;297(13):1478–1488. Link
  9. Patiño JM, Saenz VP. Radial Head Fractures. StatPearls Publishing; updated June 26, 2023. Link
  10. Safran MR, Graham SM. Distal biceps tendon ruptures: incidence, demographics, and the effect of smoking. Clin Orthop Relat Res. 2002;(404):275–283. Link
  11. Giannicola G, Prigent S, Colozza A, Blonna D, Amura A, Sessa P. Treatment delay and type of retraction affect the surgical treatment of distal biceps tendon ruptures: a quantitative analysis of 123 patients. Healthcare. 2025;13(16):1977. Link
  12. Storari L, Barbari V, Brindisino F, Testa M, Maselli F. An unusual presentation of acute myocardial infarction in physiotherapy direct access: findings from a case report. Arch Physiother. 2021;11:5. Link
  13. Cordts S. Nontender Elbow Nodules. Am Fam Physician. 2016;94(5):375–376. Link
  14. Grimer RJ, Briggs TWR. Earlier diagnosis of bone and soft-tissue tumours. J Bone Joint Surg Br. 2010;92-B(11):1489–1492. Link
  15. Kida Y, Morihara T, Kotoura Y, et al. Prevalence and Clinical Characteristics of Osteochondritis Dissecans of the Humeral Capitellum Among Adolescent Baseball Players. Am J Sports Med. 2014;42(8):1963–1971. Link
  16. Churchill RW, Munoz J, Ahmad CS. Osteochondritis dissecans of the elbow. Curr Rev Musculoskelet Med. 2016;9(2):232–239. Link
  17. Wainner RS, Fritz JM, Irrgang JJ, Boninger ML, Delitto A, Allison S. Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy. Spine. 2003;28(1):52–62. Link

Red flags for other regions: Neck · Shoulder · Wrist and hand · Thoracic spine and chest wall · Low back and pelvis · Hip and groin · Knee · Ankle and foot

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