Management of Coccyx Pain After Fall with Suspected Fracture or Buckling
A patient with coccyx pain and suspected fracture after a fall should undergo radiographic imaging first, followed by an orthopedic evaluation if symptoms persist or if imaging shows a fracture.
Initial Evaluation and Imaging
First-Line Imaging
- Plain radiographs of the coccyx (anteroposterior and lateral views) are the recommended initial imaging study for suspected coccyx fracture 1
- These radiographs should include:
- AP view of the pelvis
- Lateral view of the coccyx
- This approach allows visualization of both the coccyx and surrounding pelvic structures that may be affected
When Initial Radiographs Are Negative
If initial radiographs are negative but clinical suspicion remains high due to persistent pain:
- MRI without IV contrast is the preferred next imaging study 1
- MRI is highly sensitive for detecting occult fractures not visible on plain radiographs
- Case evidence shows that fractures can be missed on initial radiographs but later detected on MRI 1
- CT without IV contrast is an acceptable alternative if MRI is contraindicated 1
Indications for Orthopedic Referral
Immediate Orthopedic Evaluation Needed
- Visible fracture or displacement on imaging
- Severe pain limiting activities of daily living
- Neurological symptoms (numbness, weakness, bowel/bladder dysfunction)
Delayed Orthopedic Evaluation Needed
- Persistent pain beyond 4-6 weeks despite conservative management
- Development of refractory coccydynia (persistent tailbone pain)
- Failed conservative treatment after 2 months 2, 3
Treatment Approach
Conservative Management (First-Line)
- Rest and activity modification
- NSAIDs for pain control
- Cushioned seating or donut pillows to reduce pressure on the coccyx
- Physical therapy in cases of persistent pain
When to Consider Advanced Interventions
If pain persists beyond 2 months despite conservative treatment:
- Orthopedic consultation for potential interventional treatments
- Possible interventions may include:
- Local injections
- Pulsed radiofrequency therapy 4
- In severe cases, surgical evaluation may be warranted
Important Considerations
- Coccyx fractures can be easily missed on initial radiographs, as demonstrated in case reports 1, 5
- Persistent pain beyond the expected healing time (6-8 weeks) warrants further investigation and specialist referral
- Different fracture types (flexion, compression, extension) have different healing potentials and may require different management approaches 3
- Untreated coccyx fractures can lead to chronic pain and significant impact on quality of life 6
Follow-up Recommendations
- Re-evaluation at 2-4 weeks if symptoms persist
- If pain continues beyond 6-8 weeks despite conservative management, advanced imaging and orthopedic referral are indicated
- Long-term follow-up may be necessary for patients with persistent symptoms
By following this algorithmic approach, clinicians can ensure appropriate diagnosis and management of coccyx injuries, minimizing the risk of chronic pain and disability.