What is the appropriate management for a 65-year-old patient with coccygeal (tailbone) pain after a fall?

Management of Coccygeal Pain in a 65-Year-Old After a Fall

Acetaminophen should be used as the first-line pharmacological treatment for coccygeal pain in this 65-year-old patient, administered on a scheduled basis rather than as needed, with appropriate non-pharmacological interventions including cushioning and early mobilization as tolerated. 1

Initial Assessment and Diagnosis

• Pain Assessment:

  • Use validated pain assessment tools such as Numerical Rating Scale (NRS) or Visual Analog Scale (VAS) 1
  • Evaluate for pain behaviors: facial expressions, vocalizations, body movements, changes in activity patterns 1

• Imaging:

  • Obtain lateral X-rays of the coccyx in both standing and sitting positions to assess for abnormal mobility, which is found in 70% of patients with coccygodynia 2
  • Consider MRI if suspecting more serious pathology such as fracture, tumor, or infection 3

Treatment Algorithm

First-Line Treatment

1. Non-pharmacological interventions:

   • Coccyx cushion with cutout to reduce pressure on tailbone 3
   • Application of ice for short-term relief and to reduce inflammation 1
   • Appropriate immobilization initially, followed by early mobilization as tolerated 1
   • Medium-firm mattress rather than firm mattress 1

2. Pharmacological management:

   • Acetaminophen: 1000mg every 6 hours (maximum 4000mg/day) scheduled, not as needed 1
   • Topical NSAIDs: Consider diclofenac gel for localized pain with fewer systemic effects 1

Second-Line Treatment (if inadequate response after 1-2 weeks)

1. Interventional approaches:

   • Local injection of anesthetic and corticosteroid into the painful segment 4, 5
   • Manual therapy including coccyx massage and stretching of the levator ani muscle 5

2. Escalation of pain management:

   • Tramadol: 50mg every 4-6 hours as needed (reduced dosing for elderly patients) if pain is moderate to severe and unresponsive to acetaminophen 1
   • Consider physical therapy with gentle stretching and progressive mobilization 1

Medications to Avoid

• Oral NSAIDs: High risk of adverse effects in elderly patients including exacerbation of heart failure, hypertension, kidney disease, and gastrointestinal bleeding 1
• Benzodiazepines: Associated with cognitive impairment, reduced mobility, and increased fall risk 1
• Muscle relaxants: Can cause CNS impairment, delirium, sedation, and falls 1
• Dexamethasone: May negatively affect recovery and function 1

Fall Prevention and Safety Considerations

• Implement fall prevention strategies in the environment:

  • Rubber or nonskid floor surfaces/mats
  • Even floor surfaces
  • Handrails on walls and hallways
  • Aisle lighting
  • Bedside commodes and grab bars in restrooms 6

• Consider home safety assessment for patients discharged from the ED 6

• Consider admission if patient safety cannot be ensured 6

Follow-up and Monitoring

• Regular reassessment of both pain and potential medication side effects 1
• Evaluate for improvement in mobility and function
• Consider referral to physical therapy for assessment and treatment 6
• If symptoms persist beyond 4-6 weeks despite conservative management, consider additional imaging and specialist referral

Special Considerations

• Coccygectomy should only be considered in rare cases when all non-surgical treatments have failed 4, 5
• Venous thromboembolism prophylaxis with LMWH or UFH should be considered if mobility is significantly reduced, based on renal function, weight, and bleeding risk 6
• Undertreatment of pain is common in elderly patients, with only 10% receiving adequate analgesia after falls 1

By following this structured approach, most patients with coccygeal pain after a fall will experience significant improvement with conservative management, avoiding the need for more invasive interventions.