The Elk is formed by the confluence of Big Sugar Creek and Little Sugar Creek at Pineville, Missouri, and flows generally westward through McDonald County, Missouri, past the town of Noel, into Delaware County, Oklahoma, where it meets the Neosho River.

Most of the river's course in Oklahoma is part of the Grand Lake o' the Cherokees, an impoundment formed by Pensacola Dam on the Neosho.

[4][5] The portion of the river between the confluence of Big and Little Sugar Creeks and the dam at Noel, Missouri is a popular route for recreational canoeing, kayaking, rafting, and tubing.

However, it has also been reported that the name was originally Cowskin and was changed to Elk due to the influence of Steve Elkins, a local politician.

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