Rheumatoid arthritis is the most common cause of elbow instability, but other causes include other erosive arthritides and noninflammatory diseases. Surgical consultation should be obtained for refractory pain or disability, or when physical examination or imaging reveals instability, erosions, or impending pathologic fracture. Medical management for rheumatoid arthritis includes early treatment and combination therapy, including biologic response modifiers. Current recommendations for rheumatic medicines, including perioperative use, are discussed.