What is the appropriate management for a 20-year-old male with a history of recent coccyx trauma, now presenting with thoracic spine pain aggravated by activity but not by sitting?

Thoracic Pain Aggravated by Activity Changes the Clinical Picture Significantly

Yes, thoracic spine pain aggravated by activity but not by sitting fundamentally changes the analysis from typical coccydynia and suggests a distinct thoracic pathology requiring different evaluation and management. 1, 2

Key Clinical Distinction

The pattern of pain aggravated by activity but relieved by sitting is opposite to classic coccydynia, which characteristically worsens with sitting and improves with standing. 3, 4 This activity-related thoracic pain pattern suggests:

• Mechanical thoracic spine pathology (facet joint pain, disc herniation, or muscular strain) rather than coccygeal injury 5
• Thoracic facet pain specifically presents with paravertebral pain aggravated by prolonged standing, hyperextension, or rotation 5
• The recent coccyx trauma may be coincidental or a red herring in this clinical scenario 2

Initial Management Approach

Conservative Management Without Imaging (First-Line)

For a 20-year-old without red flags, imaging is NOT indicated initially. 1, 2 The American College of Radiology explicitly states that imaging is not typically warranted for acute thoracic back pain without myelopathy, radiculopathy, or red flags. 1, 2

Initial conservative therapy should include:

• NSAIDs or acetaminophen for analgesia 2
• Activity modification (avoiding aggravating movements) 2
• Physical therapy focusing on thoracic spine mobilization and strengthening 2, 5
• Advice to remain active within pain tolerance 2
• Reassurance about the benign nature of most thoracic pain 2

Red Flag Assessment (Critical)

You must systematically exclude red flags before proceeding with conservative management: 2, 6

• Neurologic deficits: myelopathy signs (spasticity, hyperreflexia, Babinski sign), radiculopathy, or motor/sensory deficits 1, 6
• Constitutional symptoms: fever, night sweats, unexplained weight loss suggesting malignancy or infection 6
• Trauma history: significant high-energy mechanism beyond the reported coccyx injury 1
• Risk factors for fracture: chronic steroid use, known osteoporosis (less likely at age 20) 6
• Constant unremitting pain: suggesting possible tumor or infection 6

Imaging Considerations

When to Image

Imaging should only be considered after 4-6 weeks of conservative management if there is little or no improvement. 2 This waiting period is evidence-based and avoids unnecessary costs and incidental findings that complicate management. 2

Appropriate Initial Imaging Study

If imaging becomes necessary after failed conservative therapy:

• Plain radiography of the thoracic spine is the appropriate initial study for chronic thoracic back pain without red flags 2, 6
• MRI thoracic spine without IV contrast becomes indicated if: 1, 6
  • Myelopathy or radiculopathy develops during follow-up
  • Red flags emerge
  • Plain radiographs show concerning findings (fracture, bone destruction, deformity)

Clinical Pitfalls to Avoid

• Do not prematurely image in the absence of red flags—this increases costs without improving outcomes 2
• Do not assume the coccyx trauma is the source of thoracic pain when the pain pattern doesn't fit coccydynia 3, 4
• Reassess at 4-6 weeks and maintain vigilance for emerging red flags 2
• Do not overlook myelopathy development, which requires immediate MRI evaluation 1, 2

Differential Diagnosis for Activity-Related Thoracic Pain

In a 20-year-old with this presentation, consider: 6, 5

• Thoracic facet joint pain (most likely given activity aggravation pattern) 5
• Myofascial pain syndrome in thoracic paraspinous muscles 6
• Thoracic disc herniation (though more common in 30-50 year age group, can occur with trauma history) 1, 6
• Muscular strain from the initial trauma mechanism 6

Follow-Up Protocol

• Clinical reassessment at 4-6 weeks to evaluate response to conservative therapy 2
• Escalate to imaging only if no improvement or if red flags develop 2, 6
• Consider referral to pain management if symptoms persist beyond 8-12 weeks despite appropriate conservative management 5