{"id":91,"date":"2014-12-02T18:48:08","date_gmt":"2014-12-02T23:48:08","guid":{"rendered":"http:\/\/www.orthopaediclist.com\/blog\/?p=91"},"modified":"2014-12-02T18:48:08","modified_gmt":"2014-12-02T23:48:08","slug":"coccygodynia-whatever-happened-to-performing-a-physical-examination","status":"publish","type":"post","link":"https:\/\/www.orthopaediclist.com\/blog\/coccygodynia-whatever-happened-to-performing-a-physical-examination\/","title":{"rendered":"Coccygodynia: Whatever Happened to Performing a Physical Examination?"},"content":{"rendered":"

by James D. Hundley, MD<\/p>\n

\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 There are so many good things about Modern Medicine that I hate to be critical but the following story from one of my friends put a bee in my bonnet:<\/p>\n

Dr. X is a retired university Professor of Sociology who is in great health with no known history of cancer or other serious disorder.\u00a0 He reported that he fell onto his buttocks with a brief duration of tailbone pain several weeks before his office visit that was precipitated by having to sit in a confined space on an airplane for several hours during which he developed \u201ctailbone\u201d tenderness that occurred only when sitting.\u00a0 He denied pain on lying supine, night pain, back pain, neurologic symptoms, bowel difficulties, and blood in his stools.<\/p>\n

Because his tenderness persisted for a few weeks he made an appointment with a capable orthopaedic surgeon and was seen by the surgeon\u2019s PA.\u00a0 The PA took a history and then did a cursory examination reportedly checking the strength of the patient\u2019s toes and ankles.\u00a0 An x-ray was \u201cnormal\u201d.\u00a0 The PA ordered an MRI.<\/p>\n

Coincidentally, my friend and I were scheduled for a lunch meeting between the office visit and the MRI at which he asked if I thought he needed to have the MRI.\u00a0 After a discussion during which I did not feel that I could recommend against having the MRI he decided to proceed with it.\u00a0 Not surprisingly, the MRI was negative.<\/p>\n

Here\u2019s the rub.\u00a0 Why get an MRI before doing a thorough physical examination and using the history as a guide?\u00a0 With a history like this, what was the PA looking for?\u00a0 Cancer?\u00a0 On what basis?<\/p>\n

As for the physical exam, here\u2019s what I think should be done:<\/p>\n

    \n
  1. Examine the intergluteal crease over the sacrum and coccyx externally for visible skin changes and tenderness.\u00a0 Is the problem really his tailbone?\u00a0 What about a pilonidal abscess or cyst, for example?<\/li>\n
  2. Perform a rectal examination to check for masses and tenderness of the coccyx which is easy to palpate.\u00a0 Check the prostate and for occult blood.\u00a0 How about a thrombosed or abscessed hemorrhoid?<\/li>\n
  3. Do a back exam to see if this was referred pain.\u00a0 That would include back tenderness and range of motion, nerve root irritation tests, and a neurologic exam (some of which the PA to his credit reportedly performed).<\/li>\n
  4. Always remove shoes and stockings and check the ankles and feet for circulation and ulcerations, of course, not to diagnose tailbone tenderness but because you\u2019re a thorough clinician and the opportunity to so is before you.<\/li>\n<\/ol>\n

    Assuming the findings of the exam were negative, how about some conservative treatment such as allowing time to recover and advice on how to manage his symptoms.\u00a0 Since he only had pain on sitting, he didn\u2019t really need analgesics or anti-inflammatory medications.\u00a0 A simple pad with a cutout in the rear to unload the coccyx (not a \u201cdoughnut\u201d which unloads the wrong area) should be very helpful.\u00a0 Then check him back in a few weeks unless the symptoms have subsided spontaneously.<\/p>\n

    Interestingly, the patient reported that the tenderness subsided within a week or two after the MRI.\u00a0 Did the MRI cure the problem?\u00a0 Of course not.\u00a0 Did peace of mind have anything to do with it?\u00a0 Maybe, but he wasn\u2019t very nervous about his condition to begin with and after we discussed his problem before the MRI he said he was even less worried about the basis for his symptom.<\/p>\n

    If we\u2019re to do our share in reducing the cost of Medicine, we need to avoid unnecessary testing, especially those as expensive as MRI\u2019s.<\/p>\n

     <\/p>\n

    Dr. Hundley is a retired orthopaedic surgeon, a founder and currently the president of OrthopaedicLIST.com<\/a>, a free, open access, resource website for orthopaedic surgeons and related professionals.<\/i><\/p>\n","protected":false},"excerpt":{"rendered":"

    by James D. Hundley, MD \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 There are so many good things about Modern Medicine that I hate to be critical but the following story from one of my friends put a bee in my bonnet: Dr. X is a retired university Professor of Sociology who is in great health with no known history of […]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[5],"tags":[13,14],"yoast_head":"\nCoccygodynia: Whatever Happened to Performing a Physical Examination? - OrthopaedicLIST.com Blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.orthopaediclist.com\/blog\/coccygodynia-whatever-happened-to-performing-a-physical-examination\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Coccygodynia: Whatever Happened to Performing a Physical Examination? - OrthopaedicLIST.com Blog\" \/>\n<meta property=\"og:description\" content=\"by James D. Hundley, MD \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 There are so many good things about Modern Medicine that I hate to be critical but the following story from one of my friends put a bee in my bonnet: Dr. X is a retired university Professor of Sociology who is in great health with no known history of […]\" \/>\n<meta property=\"og:url\" content=\"https:\/\/www.orthopaediclist.com\/blog\/coccygodynia-whatever-happened-to-performing-a-physical-examination\/\" \/>\n<meta property=\"og:site_name\" content=\"OrthopaedicLIST.com Blog\" \/>\n<meta property=\"article:published_time\" content=\"2014-12-02T23:48:08+00:00\" \/>\n<meta name=\"author\" content=\"James Hundley, MD\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:label1\" content=\"Written by\" \/>\n\t<meta name=\"twitter:data1\" content=\"James Hundley, MD\" \/>\n\t<meta name=\"twitter:label2\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data2\" content=\"3 minutes\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\/\/schema.org\",\"@graph\":[{\"@type\":\"WebPage\",\"@id\":\"https:\/\/www.orthopaediclist.com\/blog\/coccygodynia-whatever-happened-to-performing-a-physical-examination\/\",\"url\":\"https:\/\/www.orthopaediclist.com\/blog\/coccygodynia-whatever-happened-to-performing-a-physical-examination\/\",\"name\":\"Coccygodynia: Whatever Happened to Performing a Physical Examination? - OrthopaedicLIST.com Blog\",\"isPartOf\":{\"@id\":\"https:\/\/www.orthopaediclist.com\/blog\/#website\"},\"datePublished\":\"2014-12-02T23:48:08+00:00\",\"dateModified\":\"2014-12-02T23:48:08+00:00\",\"author\":{\"@id\":\"https:\/\/www.orthopaediclist.com\/blog\/#\/schema\/person\/87a719b32f490b91a2f4a6a44d4d6752\"},\"breadcrumb\":{\"@id\":\"https:\/\/www.orthopaediclist.com\/blog\/coccygodynia-whatever-happened-to-performing-a-physical-examination\/#breadcrumb\"},\"inLanguage\":\"en-US\",\"potentialAction\":[{\"@type\":\"ReadAction\",\"target\":[\"https:\/\/www.orthopaediclist.com\/blog\/coccygodynia-whatever-happened-to-performing-a-physical-examination\/\"]}]},{\"@type\":\"BreadcrumbList\",\"@id\":\"https:\/\/www.orthopaediclist.com\/blog\/coccygodynia-whatever-happened-to-performing-a-physical-examination\/#breadcrumb\",\"itemListElement\":[{\"@type\":\"ListItem\",\"position\":1,\"name\":\"Home\",\"item\":\"https:\/\/www.orthopaediclist.com\/blog\/\"},{\"@type\":\"ListItem\",\"position\":2,\"name\":\"Coccygodynia: Whatever Happened to Performing a Physical Examination?\"}]},{\"@type\":\"WebSite\",\"@id\":\"https:\/\/www.orthopaediclist.com\/blog\/#website\",\"url\":\"https:\/\/www.orthopaediclist.com\/blog\/\",\"name\":\"OrthopaedicLIST.com Blog\",\"description\":\"News About Orthopaedic Surgery and Orthopaedic Products and Services\",\"potentialAction\":[{\"@type\":\"SearchAction\",\"target\":{\"@type\":\"EntryPoint\",\"urlTemplate\":\"https:\/\/www.orthopaediclist.com\/blog\/?s={search_term_string}\"},\"query-input\":{\"@type\":\"PropertyValueSpecification\",\"valueRequired\":true,\"valueName\":\"search_term_string\"}}],\"inLanguage\":\"en-US\"},{\"@type\":\"Person\",\"@id\":\"https:\/\/www.orthopaediclist.com\/blog\/#\/schema\/person\/87a719b32f490b91a2f4a6a44d4d6752\",\"name\":\"James Hundley, MD\",\"image\":{\"@type\":\"ImageObject\",\"inLanguage\":\"en-US\",\"@id\":\"https:\/\/www.orthopaediclist.com\/blog\/#\/schema\/person\/image\/\",\"url\":\"https:\/\/secure.gravatar.com\/avatar\/210425b5d38259409c4acb9bbb1e31bf?s=96&d=mm&r=g\",\"contentUrl\":\"https:\/\/secure.gravatar.com\/avatar\/210425b5d38259409c4acb9bbb1e31bf?s=96&d=mm&r=g\",\"caption\":\"James Hundley, MD\"},\"description\":\"Dr. Hundley is a retired orthopaedic surgeon and the originator and co-founder of OrthopaedicLIST.com, a resource website for orthopaedic surgeons and related professionals.\",\"sameAs\":[\"http:\/\/www.orthopaediclist.com\"],\"url\":\"https:\/\/www.orthopaediclist.com\/blog\/author\/hundleysr\/\"}]}<\/script>\n<!-- \/ Yoast SEO plugin. -->","yoast_head_json":{"title":"Coccygodynia: Whatever Happened to Performing a Physical Examination? - OrthopaedicLIST.com Blog","robots":{"index":"index","follow":"follow","max-snippet":"max-snippet:-1","max-image-preview":"max-image-preview:large","max-video-preview":"max-video-preview:-1"},"canonical":"https:\/\/www.orthopaediclist.com\/blog\/coccygodynia-whatever-happened-to-performing-a-physical-examination\/","og_locale":"en_US","og_type":"article","og_title":"Coccygodynia: Whatever Happened to Performing a Physical Examination? - OrthopaedicLIST.com Blog","og_description":"by James D. 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