Red flags for elbows, wrists & hands

Prior to referral consider / screen to exclude:

Key Clinical Observations of concern

  • Hot / red / swollen joint with raised body temperature
  • Rapidly worsening deformity
  • Neuro-vascular compromise
Urgent elbow / wrist / hand referral

Patients with any of the following suspected should be sent to A&E:

  • Fracture or dislocation
  • Suspected infection
  • Recent tendon or ligament rupture

Urgent appointments can be made in elective Hand Clinics for patients with:

  • Rapidly worsening symptoms
  • Hand pain with confirmed presence of cancer on imaging.
  • Constant unrelenting hand or forearm pain / especially unrelenting night pain in presence of cancer
  • Progressive or significant neurological loss suggestive of acute peripheral nerve compression
GP / Primary Clinician
  • Consider Diagnosis (discuss within peer review).
  • Consider neural component/ referral from cervical spine.

Tennis Elbow (lateral epicondylagia):

  • Causes: Repeated gripping and twisting activities with arms outstretched.
  • Presentation:  Pain over lateral epicondyle.

Golfer’s Elbow  (medial epicondylagia):

  • Causes: Repeated activities requiring wrist flexion.
  • Presentation:  Pain medial side of elbow (rule out referred pain from cervical spine).


If serious pathology suspected refer directly to Surgeon.

If no serious pathology suspected:

  • Ice
  • NSAIDs
  • Advise purchase of epicondylar clasp
  • Consider self referral or refer on to Physiotherapy Service for diagnosis (if not already ascertained) and treatment

If no improvement after course of physiotherapy and steroid injection consider referral to interface team.


X-ray to rule out OA.

Physiotherapist or Occupational Therapist
  • Assessment / Diagnosis (consider neural component/ referral from cervical spine).
  • Detailed advice/ activity modification/ Self management.
  • Ice/ Graded exercise programme/ stretching.
  • Elbow Brace.

If non-resolving - consider referral to Interface Team.

Interface Team
  • Consider  previous assessment diagnosis and management.
  • Local steroid injection may be considered however there is conflicting evidence regarding the benefit and potential harm to soft tissues. Sometimes recommended by clinicians.
  • If no response to corticosteroid injection consider onward referral as surgical criteria below.
  • If patient does not wish to explore surgical option refer back to GP or Pain Consultant for advice regarding analgesia.
  • If patient fits the criteria below refer to Surgeon.


  • AP & Lateral X-ray to rule out OA or prior to surgical referral.
  • U/S to confirm diagnosis.
Surgical Criteria

Referral is appropriate if surgery is an option or for complex diagnosis.

  • 80-95% of patients recover without surgical intervention.
  • If patient remains symptomatic with limited activity and with no response to corticosteroid injections for 12-18, months consider surgery however prognosis is not always good.

Discuss the following:

  • willingness to undergo surgery
  • general health
  • understand recovery period post surgery

Surgical for interventions include:

  • Surgical release:  Often splint for one week post operatively then progress to a graded exercise programme. Return to sport/full function after 4-6 months.
  • Specific risk of surgery: loss of strength.