It follows a generally westward course across the unglaciated Allegheny Plateau, through Randolph, Webster, Braxton, Clay, and Kanawha Counties, past the towns of Webster Springs, Sutton, Gassaway, Clay, Clendenin, and Elkview before joining the Kanawha River at Charleston.

The upper portion of the river, above Sutton Lake, is a popular coldwater trout stream.

[8] [9] Below Sutton Lake, is a high-gradient warmwater fishery well known for its muskellunge, walleye and smallmouth bass fishing.

[11] According to the Geographic Names Information System, the Elk River has also been known historically as: In January 2014 a spill of the chemical 4-methylcyclohexane methanol, a foaming agent used as a wash component in the coal-preparation process, required West Virginia authorities to supply water to as many as 300,000 people in nine of the state's counties.

[13] Multiple West Virginia stage record fish were caught along the Elk River.