Clinical decision making for the evaluation and management of coccydynia: 2 case reports.

STUDY DESIGN: Case report. BACKGROUND: Coccydynia is a painful condition of the sacrococcygeal region, with symptoms associated with sitting and rising from a seated position. There is no gold standard for diagnosis of this condition; however, coccyx mobility assessment, pain provocation testing, and imaging have been proposed as reasonable diagnostic approaches. Once correctly diagnosed, treatment options for coccydynia include conservative management and surgical excision. The purpose of this report is to describe the different but successful clinical management strategies of 2 patients with coccydynia. CASE DESCRIPTION: Two women, 26 and 31 years of age, presented to physical therapy with persistent coccygeal pain that increased with prolonged sitting and intensified when transitioning from sit to stand. One patient had a traumatic onset of symptoms, in contrast to the other patient, for whom prolonged sitting was the precipitating factor. Both individuals were considered to have hypomobility of the sacrococcygeal joint, as assessed through intrarectal mobility testing, which also reproduced their symptoms. In both patients, examination of the lumbar spine was negative for alleviation or reproduction of symptoms. The patient with a traumatic onset of symptoms was referred to physical therapy at the onset of her symptoms, whereas the patient with a nontraumatic onset of symptoms was initially treated with a cortisone injection and, when symptoms returned 1 year later, was referred to physical therapy. Both individuals underwent manual therapy to the sacrococcygeal joint over 3 treatment sessions. OUTCOMES: The patient with traumatic onset of symptoms had almost complete resolution of symptoms, whereas the patient with a nontraumatic onset only had temporary relief. This patient required further diagnostic examination and surgical excision. DISCUSSION: Although the mechanisms of injury were different, both patients presented with similar clinical symptoms, and both were considered to have coccydynia through coccyx mobility assessment and pain provocation testing. Successful clinical outcomes were achieved in both cases; however, the interventions were significantly different. Level of Evidence Therapy, level 4.

Skin conditions in the athlete.

Dermatologic conditions are a common presenting complaint in the athletic training room. There are many different causes for rashes, and treatment options vary depending on the condition and the severity. Bacterial infections of the skin have a variety of different appearances and can spread rapidly among individuals. Healthcare providers need to be aware of the increasing prevalence of methicillin-resistant Staphylococcus aureus when making the choice of antibiotics. Other infectious rashes, including tinea and herpes, are well-described conditions in wrestlers; however, these rashes can be seen in any athlete, especially those engaged in contact sports. Early recognition and appropriate treatment are important to clear the rash and reduce the spread to others. In addition to infectious rashes, athletes are prone to mechanical rashes and skin conditions due to friction and tight-fitting equipment. Sports medicine providers must not only diagnose and treat these conditions but also be aware of the return-to-play guidelines set forth by the governing bodies under which he or she operates.

Clavicle fractures.

Clavicle fractures are most common in children and young adults, typically occurring in persons younger than 25 years. Its superficial location, its thin midshaft, and the forces transmitted across it make the clavicle a common site for injury. The most common mechanism of injury is a forceful fall with the arm at the side, which commonly occurs during contact sports. Diagnosis can often be made by the history and physical examination, although appropriate radiography should be used to confirm the diagnosis and guide treatment options. Most clavicle fractures occur in the midshaft and can be treated nonoperatively. A prominent callus is common in children, and parents may require reassurance. If a child has no history of trauma, then malignancy, rickets, and physical abuse should be considered. Surgery is an option in fractures that have high potential for nonunion (e.g., displaced or communited fractures, fractures with more than 15 to 20 mm clavicle shortening). Distal fractures are classified based on the relationship to the coracoclavicular ligaments, which determines the likelihood of displacement. Most distal fractures can also be treated nonoperatively; however, certain factors must be considered in children.

The collapsed athlete.

Athletic collapse is rare, but personnel caring for athletes at sporting events must be prepared for it. Most cases are nonfatal and, with proper management, can have good outcomes. Medical personnel should expect the typical causes of athletic collapse that occur at the events they are covering, but rare causes should also be anticipated.