Coccygodynia (Coccydynia, Coccalgia, Tailbone Pain): Difference between revisions

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== Definition / Description  ==
== Definition   ==


Coccygodynia is considered a symptom not a diagnosis and is described as a disabling pain in and around the coccyx<ref name="Wray">Wray CC, Easom S, Hoskinson J. Coccydynia: aetiology and treatment. J Bone Joint Surg 1991;73(B):335-8.</ref><ref name="Kerr" />. The pain typically is triggered in a seat position and may intensify when the patient rises to a standing position.<ref name="Wray" /><ref name="Kerr" /> Coccygodynia may also be referred to as coccydynia or coccygeal neuralgia<ref name="Kerr">Kerr EE, Benson D, Schrot RJ. Coccygectomy for chronic refractory coccygodynia: clinical case series and literature review. J Neurosurg Spine 2011;14:654-663.</ref>. The pain caused by coccygodynia may have a significant impact on the patient's quality of life<ref name="Kerr" />. A patient may describe the pain as a pulling or lancinating sensation that may radiate to the sacrum, lumbar spine, buttocks, and occasionally into the thighs<ref name="Kerr" />.  
Coccygodynia, sometimes referred to as coccydynia, coccalgia, coccygeal neuralgia or tailbone pain, is the term used to describe the symptoms of pain that occur in the region of the coccyx.<ref name=":0">Patel R, Appannagari A, Whang PG. [https://link.springer.com/article/10.1007/s12178-008-9028-1 Coccydynia]. Current reviews in musculoskeletal medicine. 2008 Dec;1(3):223-6.</ref><ref name=":1">Fogel GR, Cunningham III PY, Esses SI. [https://journals.lww.com/jaaos/fulltext/2004/01000/coccygodynia__evaluation_and_management.7.aspx Coccygodynia: evaluation and management]. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 2004 Jan 1;12(1):49-54.
</ref><ref name=":2">Kerr EE, Benson D, Schrot RJ. [https://thejns.org/spine/view/journals/j-neurosurg-spine/14/5/article-p654.xml Coccygectomy for chronic refractory coccygodynia: clinical case series and literature review]. Journal of Neurosurgery: Spine. 2011 May 1;14(5):654-63.</ref><ref name=":3">Lirette LS, Chaiban G, Tolba R, Eissa H. [http://www.ochsnerjournal.org/content/14/1/84.abstract Coccydynia: an overview of the anatomy, etiology, and treatment of coccyx pain]. Ochsner Journal. 2014 Mar 20;14(1):84-7.</ref>  The pain is most commonly triggered in a sitting position, but may also occur when the individual changes from a sitting to standing position.<ref name=":2" /> Most cases will resolve within a few weeks to months, however for some patients the pain can become chronic, having negative impacts on quality of life.<ref name=":2" /><ref name=":3" /> For these individuals, management can be difficult due to the complex nature of coccygeal pain.<ref name=":3" />   


== Clinically Relevant Anatomy  ==
== Clinically Relevant Anatomy  ==


The coccyx is the most distal aspect of the vertebral column, and consists of three to five rudimentary vertebral units that are typically fused. The ventral part of the coccyx is concave, and the dorsal aspect is convex and features coccygeal articular processes<ref name="Patel">Patel R, Appanagari A, Whang PG. Coccydynia. Curr Rev Musculoskelet Med 2008;1:223-226.</ref>. The coccyx articulates with the sacral cornua of the inferior sacral apex at S5<ref name="Patel" />.  
The coccyx is a triangular bone that forms the most distal segment of the spine.<ref name=":0" /><ref name=":2" /> It is composed of 3 to 5 coccygeal segments.<ref name=":1" /> These segments fuse together to form a single bone, with the exception of the first coccygeal segment.<ref name=":1" /><ref name=":2" /> The first coccygeal segment might not fuse together with the second coccygeal segment.<ref name=":1" /><ref name=":2" />The ventral aspect of the coccyx is concave in shape, while the dorsal aspect of the coccyx is convex in shape.<ref name=":0" />The first coccygeal segment is composed of articular processes that form the coccygeal cornua.<ref name=":0" /><ref name=":1" /><ref name=":3" /> The coccygeal cornua articulates with the sacral cornua of the inferior sacral apex of S5.<ref name=":0" /><ref name=":1" /><ref name=":3" /> This articulation creates a symphysis or synovial joint, which forms one of the borders of the foramen for the dorsal branch of the fifth sacral nerve route (S5).<ref name=":0" /><ref name=":3" /> 


[[Image:Sacrum and Coccyx.jpg|center|500px]]  
[[Image:Sacrum and Coccyx.jpg|center|500px]]


The anterior aspect of the coccyx serves as the attachment site of ligaments and muscles important for many functions of the [[Pelvic Floor Anatomy|pelvic floor]]. The levator ani muscle includes the coccygeus, pubococcygeus, and iliococcygeus. The coccyx supports the position of the anus. Attached to the posterior side of the coccyx is gluteus maximus. Muscle weakness disturbed tonus or damage to muscles or ligaments can cause abnormal positions of the coccyx<ref name="Patel" />.
The coccyx serves as an attachment site for several muscles and ligaments.<ref name=":3" /> Anteriorly, the coccyx is bordered by the [https://www.physio-pedia.com/Pelvic_Floor_Anatomy levator ani] muscle and the [https://www.physio-pedia.com/Pelvic_Floor_Anatomy sacro-coccygeal ligament].<ref name=":3" /> In an anterior (front) to posterior (back) direction, the lateral border of the coccyx serves as an insertion point for the coccygeal muscles, the [https://www.physio-pedia.com/Pelvic_Floor_Anatomy sacrospinous ligament], the [https://www.physio-pedia.com/Pelvic_Floor_Anatomy sacrotuberous ligamen]t and the [https://physio-pedia.com/Gluteus_Maximus gluteus maximus].<ref name=":3" /> Inferiorly, the tendon of the [https://www.physio-pedia.com/Pelvic_Floor_Anatomy iliococcygeus] muscle inserts onto the tip of the coccyx.<ref name=":3" />Together, these ligaments and muscles contribute to voluntary bowel control, as well, provide support to the pelvic floor.<ref name=":3" />  


{| width="100%" cellspacing="1" cellpadding="1" border="0" align="center"
In addition to being an insertion site, the coccyx, in conjunction with the ischial tuberosities, provides weight-bearing support to an individual in a seated position.<ref name=":3" /> For this reason, increased stress and pressure can be placed on the coccyx while a person leans back in a seated position.<ref name=":3" /> The coccyx also functions in providing support to the anus.<ref name=":3" />
|-
| [[Image:Pelvic floor.png|left|300px]]
| [[Image:Pelvic floor.jpg|right|300px]]
|}


== Epidemiology / Etiology  ==
Postascchini and Massobrio (1983)<ref name=":4">Postacchini FR, Massobrio MA. Idiopathic coccygodynia. [https://europepmc.org/article/med/6226668 Analysis of fifty-one operative cases and a radiographic study of the normal coccyx]. The Journal of bone and joint surgery. American volume. 1983 Oct 1;65(8):1116-24.</ref> classified the variations in morphology of the coccyx into four different configurations:<ref name=":4" />
* '''Type I:''' The coccyx is slightly curved forward, with its apex positioned downward.<ref name=":4" />
* '''Type II:''' The forward curvature of the coccyx is more exaggerated, with the apex positioned in a straightforward direction.<ref name=":4" />
* '''Type III:''' Sharp angulation of the coccyx forward.<ref name=":4" />
* '''Type IV:''' Subluxation of the coccyx at the sacrococcygeal or intercoccygeal joint.<ref name=":4" />


The prevalence for coccygodynia is five times greater in women than in men<ref name="Patel" />. This may be related to increased pressure during pregnancy or delivery (post-partum coccygodynia)<ref name="Ombregt">Ombregt L, Bisschop P, ter Veer JH. A System of Orthopaedic Medicine. Elsevier Science Limited, 2003, p.968-969.</ref>. The pain in the coccyx can be caused by radiation from a lumbosacral segment, a direct trauma or an overcharge<ref name="Gregory">Gregory P. Grieve, De wervelkolom, veel voorkomende aandoeningen (The spine), 1984, p. 320-321.</ref>. Congenital deviations can also cause complaints during long sitting<ref name="Gregory" />. <br><br>Coccygodynia may be classified as posttraumatic or idiopathic. Posttraumatic coccygodynia may be due to a fall onto the buttocks, or due to difficult childbirth<ref name="Kerr" />. Some studies question the possibility that coccygodynia could be caused by direct trauma, because of protection by the ischiadic bones. <br><br>Often, a positional change of the coccyx is caused by overtension of the anal levator muscle<ref name="Maigne">Maigne R. Douleurs d’origine vertébrale et traitements par manipulations, medicine orthopédique des derangements intervertébraux mineurs, 2e editie, p. 473-476.</ref>. In more than one-third of cases, coccygodynia has an idiopathic cause<ref name="Kerr" />.<br>
== Epidemiology and Etiology ==


== Characteristics / Clinical Presentation ==
Currently, the incidence of coccygodynia is unknown.<ref name=":3" /> Certain factors can increase an individual's risk for developing coccygodynia, such as body mass, age, gender.<ref name=":0" /><ref name=":3" />  With obesity, the coccyx is more vulnerable to increases in intrapelvic pressure while sitting, increasing the risk of posterior subluxation (displacement backward) of the coccyx.<ref name=":0" /><ref name=":5">Maigne JY, Doursounian L, Chatellier G. [https://journals.lww.com/spinejournal/fulltext/2000/12010/causes_and_mechanisms_of_common_coccydynia__role.15.aspx Causes and mechanisms of common coccydynia: role of body mass index and coccygeal trauma]. Spine. 2000 Dec 1;25(23):3072-9.</ref> With rapid weight loss, the cushioning around the coccyx may be lost,<ref name=":3" /> and the coccyx is at an increased risk for anterior subluxation (displacement forward).<ref name=":0" /><ref name=":5" /> The risk of coccygodynia is 5 times higher in females than it is in males<ref name=":3" />, which may be a result of the increased pressure that occurs during pregnancy and delivery.<ref name=":6">Ombregt L, Bisschop P, ter Veer JH. A System of Orthopaedic Medicine. Elsevier Science Limited, 2003, p.968-969.</ref> Furthermore, adults and adolescents are more likely to present with coccygodynia than children.<ref name=":3" /><ref name=":5" /> 


The patient may complain of pain in the coccyx region during, going into, or coming out of a seated position - this is first indication of coccygodynia. Tenderness over the coccyx is likely present, and the location of tenderness may help to discern between different forms of coccygodynia<ref name="Ombregt" /><ref name="Gregory" />:  
Coccygodynia may be classified as post-traumatic, non-traumatic or idiopathic.<ref name=":2" /><ref name=":3" />  Post-traumatic coccygodynia is usually a result of internal or external trauma.<ref name=":3" />  For example, external trauma could result from a backwards fall that might dislocate or break the coccyx,<ref name=":3" /><ref>Schapiro S. [https://www.sciencedirect.com/science/article/pii/0002961050902029 Low back and rectal pain from an orthopedic and proctologic viewpoint with a review of 180 cases]. The American Journal of Surgery. 1950 Jan 1;79(1):117-28.</ref> and internal trauma could result from a difficult childbirth or a childbirth with an assistive delivery.<ref name=":3" /> Minor trauma, such as repetitive sitting on hard surfaces can also lead to coccygodynia.<ref name=":3" /><ref>Pennekamp PH, Kraft CN, Stütz A, Wallny T, Schmitt O, Diedrich O. [https://journals.lww.com/jtrauma/Fulltext/2005/12000/Coccygectomy_for_Coccygodynia__Does_Pathogenesis.18.aspx Coccygectomy for coccygodynia: does pathogenesis matter?]. Journal of Trauma and Acute Care Surgery. 2005 Dec 1;59(6):1414-9.</ref>  Non-traumatic coccygodynia can result from degenerative disc disease, hyper and/or hypo-mobility of the sacrococcygeal joint, infectious diseases and different variations in the configuration of the coccyx.<ref name=":3" /> Type II, III, and IV configurations typically cause more pain than type I configurations.<ref name=":0" /><ref name=":4" /> Postacchini and Massobrio (1983)<ref name=":4" /> stated that individuals with coccygodynia are more likely than the general population to have a configuration of Type II,III and IV.<ref name=":4" /> Idiopathic coccygodynia occurs in the absence of any pathology in the coccyx.<ref name=":0" /> This is typically a diagnosis of exclusion, and may result from spasticity or other abnormalities that affect the musculature of the pelvic floor.<ref name=":0" />  For example, over-extension of the levator ani muscle can shift the coccyx into an abnormal position.<ref>Maigne R. Douleurs d’origine vertébrale et traitements par manipulations, medicine orthopédique des derangements intervertébraux mineurs, 2e editie, p. 473-476.</ref>
* '''Referred or radiating pain''' is caused by a lumbar disc lesion, irritation of lower pelvic structures or deviations of the lower lumbar and/or sacroiliac joints<ref name="Ombregt" /><ref name="Gregory" />.
== Clinical Presentation  ==
The most common complaint of coccygodynia is pain in and around the coccyx without any reports of severe low back pain or radiating pain.<ref name=":0" /><ref name=":1" /> The pain is typically localised to the sacrococcygeal joint<ref name=":1" /> and is described as a “pulling” or “cutting” sensation.<ref name=":2" /> Individuals will commonly report tenderness on palpation of the coccyx.<ref name=":0" /><ref name=":1" />  


*'''Local pain or coccygodynia''' is usually caused by direct trauma to the coccyx bone, or may be idiopathic in nature: Factors contributing to idiopathic coccygodynia include anatomical variations of the coccyx or pregnancy/delivery.<ref name="Ombregt" /><ref name="Gregory" />. <br>
Patients will usually exhibit a guarding seated posture, whereby one buttock will be elevated to take weight off of the coccyx.<ref name=":2" /> Pain is usually exacerbated with repeated sitting or with transition from sitting to standing position.<ref name=":0" /><ref name=":1" /> Individuals will report that pain is alleviated with sitting on the legs or buttock.<ref name=":1" /> Patients may also report pain with defecation or the frequent need to defecate.<ref name=":0" /><ref name=":1" /> Other complaints may include pain with coughing or increased pain during menstruation in females.<ref name=":6" /><ref name="Gregory">Gregory P. Grieve, De wervelkolom, veel voorkomende aandoeningen (The spine), 1984, p. 320-321.</ref>


== Differential Diagnosis ==
Although not a hallmark sign of coccygodynia, low back pain may still arise in individuals with coccygodynia due to the morphological variations in the shape of the coccyx and it’s forward curvature.<ref name=":0" /><ref name=":1" /><ref name=":4" /> 
* Coccyx fracture
 
* Rectal tumour
== Diagnosis ==
* Perianal abscess
 
* Lumbar spondylosis/disk herniation
=== Physical Exam ===
* [[Chronic proctalgia|Chronic proctalgia]]
Palpation over the sacrococcygeal joint will display tenderness.<ref name=":0" /><ref name=":2" /><ref name=":3" /> The coccyx should also be palpated to detect the presence of swelling, bone spicules or fragments, and coccygeal masses.<ref name=":0" /><ref name=":1" /> The soft tissues around the coccyx should be examined for the presence of pilonidal cysts (in-grown hairs).<ref name=":0" /><ref name=":1" /> 
* [[Chronic Pelvic Pain|Chronic pelvic pain]] and pudendal neuralgia
 
* [[Piriformis Syndrome|Piriformis syndrome]]
Palpating the coccyx can be used to differentiate between true coccygodynia, which is localised pain over the area of the coccyx, and pseudo coccygodynia, which is characterised by pain that is referred to the coccygeal area from visceral organs, a peripheral nerve, nerve root or plexus.<ref name=":2" /> If referred pain is present, pain will radiate around the buttocks, thigh and back, and reports of pain will be present with lumbar movements.<ref name=":6" /><ref name="Gregory" /> Referred pain may also be indicative of psychogenic coccygodynia, in which pain will be more diffuse and pain will be experienced with lumbar and hip movements.<ref name=":6" /><ref name="Gregory" />
 
Increased pain may also be reported during a [https://physio-pedia.com/Straight_Leg_Raise_Test straight leg raise test].<ref name=":6" /><ref name="Gregory" />


== Diagnostic Procedures  ==
Upon rectal examination, pain will be present when the tip of the coccyx is manipulated.<ref name=":0" /><ref name=":1" />An internal mass, referred to as a chordoma, might also be present on the anterior surface of the sacrum.<ref name=":1" />


Local coccygodynia presents as pain felt in the coccyx during sitting, and does not spread in any direction. The pain can be relieved by sitting on a hard surface or with the buttocks over the border of the chair. Only pressure point pain is present. Depending on the exact location of the pain, walking, stair walking or getting up from sitting can be painful.  
=== Imaging ===
Although primarily a clinical diagnosis, dynamic radiographs can be used in diagnosis.<ref name=":0" /><ref name=":1" /> Dynamic radiographs taken in both sitting and standing positions can provide measurements of coccygeal displacement.<ref name=":1" /> Single-position radiographs are usually not used for diagnosis as they are unable to identify any morphological differences between individuals with and without coccygodynia.<ref name=":0" /><ref name=":1" /><ref name=":4" />  Radiographs are usually taken if the pain persists for a duration that is greater than 8 weeks.<ref name=":1" />


Other movements are painless and examination of the lumbar spine and sacroiliac joints and hips are normal. Trauma or overtension of the levator ani muscle can shift the coccyx into an abnormal position. These contributing factors can be distinguished based on the affected tissues<ref name="Ombregt" /><ref name="Gregory" />.<br><br>Psychogenic coccydynia features a less specific pain location and usually a vague and radiating pain in various directions. Lumbar and hip movements are painful<ref name="Ombregt" />.
=== Differential Diagnosis  ===
The following differential diagnoses should be ruled out:<ref name=":2" /><ref>Schrot RJ. Coccygodynia. Epocrates Online (<nowiki>https://online</nowiki>. epocrates. com/u/29411067/Coccygodynia)[Accessed December 15 2010] Search Google Scholar Export Citation. 2010.</ref>
* [[Coccyx Fractures|Coccyx fracture]]
* [[Lumbar Spondylosis|Lumbar spondylosis]] or [https://physio-pedia.com/Disc_Herniation disc herniation]
* [[Functional Anorectal Pain|Levator ani syndrome]]
* [https://physio-pedia.com/Piriformis_Syndrome Piriformis syndrome]
* Descending perineal syndrome
* Perianal abscess
* Rectal tumour or teratoma
* Aclock canal syndrome
* Proctalgia Fugax


== Outcome Measures  ==
=== Outcome Measures  ===


=== Pain Measures ===
==== Pain Measures ====
*[[4-Item Pain Intensity Measure (P4)]]  
*[[4-Item Pain Intensity Measure (P4)]]  
*[[Brief Pain Inventory - Short Form]]  
*[[Brief Pain Inventory - Short Form]]  
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*[[Visual Analogue Scale]]
*[[Visual Analogue Scale]]


=== Level of Function in Activities of Daily Living ===
==== Level of Function in Activities of Daily Living ====
* [[Oswestry Disability Index]]
* [[Oswestry Disability Index]]


=== Condition Specific ===
==== Condition Specific ====
*[[Pelvic Floor Distress Inventory (PFDI - 20)]]  
*[[Pelvic Floor Distress Inventory (PFDI - 20)]]  
*[[Pelvic Girdle Questionnaire (PGQ)]]
*[[Pelvic Girdle Questionnaire (PGQ)]]  
 
== Management ==
Conservative or non-surgical treatments are typically the gold standard when treating coccygodynia, being successful for 90% of cases.<ref name=":0" /><ref name=":1" /><ref name=":2" /><ref name=":3" /> Non-operative treatments may range from the recommendation of non-steroidal anti-inflammatory drugs (NSAIDs), activity modification, ergonomic adjustments, and physical therapy.<ref name=":0" /><ref name=":1" /><ref name=":2" /><ref name=":3" /> Surgery is usually only considered when patients continue to complain of coccygeal pain after the use of conservative treatments.<ref name=":0" /><ref name=":1" /><ref name=":2" /><ref name=":3" />A coccygectomy, which is the removal of a section or all of the coccyx, is the most common surgical treatment performed.<ref name=":0" /><ref name=":1" /><ref name=":2" /><ref name=":3" />
 
=== Physical Therapy Management  ===
 
==== Ergonomic Adjustments ====
The initial goal of treatment should be focused on providing postural education.<ref name=":7">Chiarioni G, Asteria C, Whitehead WE. [https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3218134/ Chronic proctalgia and chronic pelvic pain syndromes: new etiologic insights and treatment options]. World Journal of Gastroenterology: WJG. 2011 Oct 28;17(40):4447.</ref>  Individuals should be taught to correct their sitting posture by sitting more erectly on a firm chair.<ref name=":7" /><ref name=":8">Thiele GH. [https://link.springer.com/article/10.1007/BF02633479 Coccygodynia: cause and treatment]. Diseases of the Colon & Rectum. 1963 Nov;6(6):422-36.</ref> A proper sitting posture ensures weight is taken off the coccyx and is instead loaded onto the ischial tuberosities and the thighs.<ref name=":7" /><ref name=":8" /> Patients should be advised to avoid any positions or movements that might exacerbate their symptoms.<ref name=":7" />
 
Physiotherapists may also recommend the use of cushions. Modified wedge-shaped cushions (coccygeal cushions), which can be purchased over the counter, help to relieve the pressure placed on the coccyx during sitting.<ref name=":3" /> Donut shaped or circular cushions may also be used.<ref name=":2" /><ref name=":3" /><ref name=":7" /> Donut shaped cushions may actually increase pressure over the coccyx, but are more beneficial for rectal pain.<ref name=":3" />The use of cushions can be recommended over a 6-8 week period.<ref name=":7" /> Although commonly recommended, the therapeutic outcomes of these conservative recommendations have not been evaluated in the literature.<ref name=":7" />
 
==== Manual Therapy ====
The manual therapy techniques suggested in the literature range from massage, stretching, mobilisation and manipulation, and may either involve internal or external contact with the coccyx.<ref name=":1" /><ref name=":9">Maigne JY, Chatellier G. [https://journals.lww.com/spinejournal/Fulltext/2001/10150/Comparison_of_Three_Manual_Coccydynia_Treatments_.24.aspx Comparison of three manual coccydynia treatments: a pilot study]. Spine. 2001 Oct 15;26(20):E479-83. </ref>
 
Internal techniques may include massage of the levator ani muscle or the coccygeus muscle,<ref name=":9" /><ref name=":10">Thiele GH. [https://jamanetwork.com/journals/jama/article-abstract/278868 Coccygodynia and pain in the superior gluteal region: and down the back of the thigh: causation by tonic spasm of the levator ani, coccygeus and piriformis muscles and relief by massage of these muscles]. Journal of the American Medical Association. 1937 Oct 16;109(16):1271-5.</ref> joint mobilisation while the coccyx is hyperextended to stretch the levator ani,<ref name=":9" /><ref>Maigne R, Nieves WL. [https://www.taylorfrancis.com/books/diagnosis-treatment-pain-vertebral-origin-robert-maigne-walter-nieves/10.1201/b14257 Diagnosis and treatment of pain of vertebral origin]. CRC Press; 2005 Sep 1.</ref><ref name=":11">Maigne R. Les Manipulations Vertébrales. 3rd ed. Paris: Expansion Scientifique Française, 1961: 180.</ref> or repeated mobilisations while the coccyx is rotated.<ref name=":9" /><ref name=":12">Mennell JB. The science and Art of Joint Manipulation. London: Churchill, 1952.</ref>


== Examination  ==
External techniques may include manipulations of either the coccyx or sacroiliac joint,<ref name=":9" /><ref name=":13">Bergmann TF, Petersen DH, Lawrence DJ. Chiropractic Technique-Principals and Procedures. New York: Churchill Livingston Inc. 803p. ISBN 0-443-0872-0; 1993.</ref><ref>Polkinghorn BS, Colloca CJ. [https://www.sciencedirect.com/science/article/pii/S0161475499700874 Chiropractic treatment of coccygodynia via instrumental adjusting procedures using activator methods chiropractic technique]. Journal of manipulative and physiological therapeutics. 1999 Jul 1;22(6):411-6.</ref><ref>Plaugher G, editor. Textbook of clinical chiropractic: a specific biomechanical approach. Williams & Wilkins; 1993.</ref> mobilisations of the sacrococcygeal or intercoccygeal joints,<ref name=":12" /> posterior mobilisations to the thoracic spine,<ref name=":14" /> and stretching of the piriformis or iliopsoas.<ref name=":14">Mohanty PP, Pattnaik M. [https://www.sciencedirect.com/science/article/pii/S1360859217300499 Effect of stretching of piriformis and iliopsoas in coccydynia]. Journal of bodywork and movement therapies. 2017 Jul 1;21(3):743-6.</ref>Including thoracic spine mobilisations can help address compensatory patterns that affect the entire spine and pelvis, potentially influencing coccygeal pain. Additionally, mobilisations focusing on the lumbar spine are also beneficial as this area has a more direct relationship with pelvic tilt and alignment, impacting the position and stress on the coccyx.


Coccygodynia can be diagnosed during a physical examination. Patients may take a guarding seated position, in which one buttock is elevated to shift weight from the coccyx and to prevent and/or minimize discomfort and pain. With referred or radiated pain, the pain will also arise during lumbar movements. Coughing is painful. Physical examination will show increased pain during a [[Straight Leg Raise Test|straight leg raise test]]. There may be radiating pain around the buttocks and going to the back of the thighs. Women may have pain during menstruation<ref name="Ombregt" /><ref name="Gregory" />. Palpation at the sacrococcygeal junction will elicit a tender point and will be painful<ref name="Kerr" />.<br>  
The technique chosen will vary depending on what the originating cause of the coccygodynia is.<ref name=":9" /> For example, massage or stretching of the levator ani might be chosen if the underlying cause is due to spasm of the pelvic floor musculature.<ref name=":9" /><ref name=":10" /><ref name=":11" /> . Mobilisation techniques may be the preferred technique when the goal of treatment is to increase coccygeal mobility.<ref name=":9" /><ref name=":12" />Manipulation techniques are helpful when the goal of treatment is to improve extension of the coccyx.<ref name=":9" /><ref name=":13" />


{{#ev:youtube|KziCDXXfC-4|300}}<ref>CRTechnologies Straight Leg Raise Test (CR) Available from https://www.youtube.com/watch?time_continue=2&v=KziCDXXfC-4 accessed on 13/6/19</ref>
A study by Maigne and Chatellier (2001)<ref name=":9" />, who compared the effectiveness of various massage, mobilisation and manipulation techniques, reported that manual treatments were helpful for ~ 26% of cases with coccygodynia at 6 months and ~ 24% of the cases of coccygodynia at 2 years post treatment.<ref name=":9" /> The findings of this study also reported that massage and stretching techniques of the levator ani muscle were more effective than joint mobilisation techniques.<ref name=":9" />


== Physical Therapy Management ==
In support of manipulation, Maigne and colleagues (2006)<ref name=":15">Maigne JY, Chatellier G, Le Faou M, Archambeau M. [https://journals.lww.com/spinejournal/fulltext/2006/08150/the_treatment_of_chronic_coccydynia_with.26.aspx The treatment of chronic coccydynia with intrarectal manipulation: a randomized controlled study]. Spine. 2006 Aug 15;31(18):E621-7.</ref> reported mild effectiveness of intrarectal manipulation in managing chronic coccygodynia when compared to shortwave diathermy.<ref name=":15" /> Chakraborty (2012)<ref name=":16">Chakraborty S. [https://www.thespinejournalonline.com/article/S1529-9430(12)00763-2/abstract Nonoperative Management of Coccydynia: A Comparative Study Comparing Three Methods]. The Spine Journal. 2012 Sep 1;12(9):S69-70.</ref> reported that combined manipulation and corticosteroid injection was more effective in treating coccygodynia than either technique alone.<ref name=":16" />


Patients with coccygodynia are initially advised to '''avoid provocative factors'''. Initial treatment includes '''ergonomic adjustments''' such as using a donut-shaped pillow or gel cushion when sitting for a long period of time. This reduces local pressure and improves the patient's posture. There is however no significant evidence that these minor changes reduce the patient's complaints<ref name="Chiarioni">Chiarioni G, et al. Chronic proctalgia and chronic pelvic pain syndromes: New etiologic insights and treatment options. World J Gastroenterol 2011;17(40):4451-4455.</ref>.
Mohanty and Pattnaik (2017)<ref name=":14" /> reported that individuals with coccygodynia may benefit from stretching of the piriformis or iliopsoas muscles.<ref name=":14" /> In this study, piriformis and iliopsoas stretches, as well as Maitland’s mobilisation of hypomobile thoracic spine, had a beneficial effect in increasing pain free sitting duration and pressure pain threshold.<ref name=":14" /> Tightness of either the piriformis or iliopsoas can cause excessive anterior tilting of the pelvis and consequently place an excessive load on the coccyx.<ref name=":14" /> Stretching these muscles can help to correct the load that is placed on the coccyx.<ref name=":14" /> By increasing thoracic extension, thoracic mobilisations may also help to reduce the load on the coccyx.<ref name=":14" />In this study, stretching was performed for 2 minutes on each side of the hip, 5 times per week.<ref name=":14" />  


===  Mobilizations ===
Based on the work of Maigne and chatellier (2001)<ref name=":9" /> and Wray (1991),<ref name=":17">Wray CC, Easom S, Hoskinson J. [https://online.boneandjoint.org.uk/doi/abs/10.1302/0301-620X.73B2.2005168 Coccydynia. Aetiology and treatment]. The Journal of Bone and Joint Surgery. British volume. 1991 Mar;73(2):335-8.</ref>Fogel and Colleagues (2004)<ref name=":1" /> designed a treatment algorithm for coccygodynia. When a patient is presenting with acute coccygodynia (less than 2 months in duration), 8 weeks of rest and adjustable seating should be recommended in conjunction with stool softener and NSAIDs.<ref name=":1" /> When a patient  presents with chronic coccygodynia (greater than 2 months in duration), massage and stretching techniques should be initiated in conjunction with corticosteroid injections.<ref name=":1" />
Mobilizations can be used to help realign the position of the coccyx. The first choice for mobilization is postero-anterior central vertebral pressure (first gently oscillating). Given that there is tenderness to palpation, it might be best to start with rotation mobilization. It is advised to begin mobilizing only one side at one treatment<ref name="Maitland">Maitland GD, Brewerton DA. Vertebral manipulation. Butterworths, 1973, p.236-239.</ref>.<br><br>Another option for manual therapy is to apply '''[[Deep friction massage|Deep transverse frictions]] (DTF)''' to the affected ligaments. The patient lies in a prone position with a pillow under the pelvis and the legs in slight abduction and internal rotation. The therapist places his thumb on the affected spot, and, depending on the location of the lesion (direction DTF), the DTF is administered.  


=== Manipulation ===
==== Physical Modalities ====
Manipulation of the coccyx can be performed intrarectal with the patient in lateral position. With the index finger, the coccyx is repeatedly flexed and extended. This is performed for only one minute, to avoid damage or irritations of the rectal mucosa<ref name="Wray" />.
Lin and colleagues (2015)<ref name=":18">Lin SF, Chen YJ, Tu HP, Lee CL, Hsieh CL, Wu WL, Chen CH. [https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0142475 The effects of extracorporeal shock wave therapy in patients with coccydynia: a randomized controlled trial]. PloS one. 2015 Nov 10;10(11):e0142475.</ref>, who compared the benefits of [https://physio-pedia.com/Extracorporeal_shockwave_therapy_(ESWT) extracorporeal shockwave therapy (ESWT)] with other physical modalities, reported that ESWT was more effective in decreasing visual analogue scale pain scores than shortwave diathermy and [https://physio-pedia.com/Interferential_Therapy_/_Interferential_Current_(IFC) IFC].<ref name=":18" /> Patients who received ESWT reported greater subjective satisfaction scores following treatment, with ~ 70% reporting good to excellent satisfaction.<ref name=":18" /> In this study, 2000 shots of ESWT were applied to the coccyx area per session for 4 sessions at 5 Hz and a pressure of 3-4 bar.<ref name=":18" />The findings of this study can be supported by a case report by Marwan and colleagues (2014)<ref name=":19">Marwan Y, Husain W, Alhajii W, Mogawer M. [https://www.sciencedirect.com/science/article/pii/S1529943013013594 Extracorporeal shock wave therapy relieved pain in patients with coccydynia: a report of two cases]. The Spine Journal. 2014 Jan 1;14(1):e1-4.</ref>, who reported the effectiveness of ESWT to relieve pain over 3 sessions in 2 cases of coccygodynia.<ref name=":19" /> A quasi-experimental study by Haghighat and Mashayekhi (2016),<ref name=":20">Haghighat S, Asl MM. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5098426/ Effects of extracorporeal shock wave therapy on pain in patients with chronic refractory coccydynia: A quasi-experimental study]. Anesthesiology and pain medicine. 2016 Aug;6(4).</ref> involving 10 patients with cocycgodynia, stated that ESWT significantly decreased visual analogue scale pain scores at 4 weeks and 2 months post treatment.<ref name=":20" /> ESWT was delivered to the coccygeal area at 3000 shock waves per session, with a frequency of 21 Hz and pressure of 2 bar.<ref name=":20" />  


=== Massage ===
Although the mechanism is still being debated in the literature, it is proposed that ESWT decreases the inflammatory response and the expression of inflammatory mediators present in coccygodynia through the induction of neovascularisation.<ref name=":18" /><ref name=":20" />  
Massage of the levator ani muscle and coccygeus muscles has also been found to relieve pain<ref name="Thiele">Thiele GH. Coccygodynia: cause and treatment. Diseases of the Colon and Rectum, 1963, p.422-436.</ref><ref name="Wu">Wu C, et al. The application of infrared thermography in the assessment of patients with coccygodynia before and after manual therapy combined with diathermy. J Manipulative Physiol Ther 2009:287-293.</ref>. To exclude the possibility of muscles pulling on the os coccyx, relaxation of the pelvic floor muscles can be integrated by using '''biofeedback'''<ref name="Physiotherapist">Physiotherapist UZ Brussels, internal physiotherapy and gynaecology.</ref>.


== Evidence of Physical Therapy Treatments ==
When considering the effects of other modalities, Lin and Colleagues (2015)<ref name=":18" /> reported that IFC and shortwave diathermy were able to decrease pain scores but not to the same extent as ESWT.<ref name=":18" /> Wray and colleagues (1991)<ref name=":17" /> reported minimal benefits with a combined treatment of [https://physio-pedia.com/Therapeutic_Ultrasound ultrasound] and shortwave diathermy. After receiving 2 weeks of ultrasound and 2 weeks of shortwave diathermy, only 16% of patients in the study report relief in their symptoms.<ref name=":17" /> Given these discrepancies, more evidence regarding which modalities provide the greatest benefit to patients with coccygodynia. 
* Stretching of piriformis and iliopsoas muscles and Maitland's rhythmic oscillatory thoracic mobilization for 3 weeks, 5 sessions per week showed significant improvement in pain pressure threshold.<ref>Mohanty PP, Pattnaik M. Effect of stretching of piriformis and iliopsoas in coccydynia. Journal of bodywork and movement therapies. 2017 Jul 1;21(3):743-6.</ref>
* Extracorporeal shortwave therapy was more effective and satisfactory in reducing discomfort and disability caused by coccydynia than the use of physical modalities. Thus, it was recommended as an alternative treatment option for patients with coccydynia.<ref>Lin SF, Chen YJ, Tu HP, Lee CL, Hsieh CL, Wu WL, Chen CH. The effects of extracorporeal shock wave therapy in patients with coccydynia: a randomized controlled trial. PloS one. 2015 Nov 10;10(11):e0142475.</ref>
* Combined manipulation and corticosteroid injection were more effective in the treatment of Coccydynia as compared to manipulation or corticosteroid injection alone. Patients following the treatment were completely pain free at the end of the year.<ref>Chakraborty S. Nonoperative Management of Coccydynia: A Comparative Study Comparing Three Methods. The Spine Journal. 2012 Sep 1;12(9):S69-70.</ref>
* In 16% of the patients (Wray et al) daily '''ultrasound''' followed by two weeks of short-wave diathermy (no settings were given) was found beneficial.<ref name="Wray" /><ref name="Wu" />
== References  ==
== References  ==


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Latest revision as of 17:33, 11 March 2024

Original Editor - Maxime Tuerlinckx as part of the Vrije Universiteit Brussel's Evidence-based Practice project
Top Contributors - Victoria Geropoulos, Nicole Hills, Maxime Tuerlinckx, Evan Thomas, Kim Jackson, Vidya Acharya, Redisha Jakibanjar, Admin, Daphne Jackson, Aminat Abolade, Rosie Swift, Pacifique Dusabeyezu, Laura Ritchie and WikiSysop

Definition[edit | edit source]

Coccygodynia, sometimes referred to as coccydynia, coccalgia, coccygeal neuralgia or tailbone pain, is the term used to describe the symptoms of pain that occur in the region of the coccyx.[1][2][3][4] The pain is most commonly triggered in a sitting position, but may also occur when the individual changes from a sitting to standing position.[3] Most cases will resolve within a few weeks to months, however for some patients the pain can become chronic, having negative impacts on quality of life.[3][4] For these individuals, management can be difficult due to the complex nature of coccygeal pain.[4]

Clinically Relevant Anatomy[edit | edit source]

The coccyx is a triangular bone that forms the most distal segment of the spine.[1][3] It is composed of 3 to 5 coccygeal segments.[2] These segments fuse together to form a single bone, with the exception of the first coccygeal segment.[2][3] The first coccygeal segment might not fuse together with the second coccygeal segment.[2][3]The ventral aspect of the coccyx is concave in shape, while the dorsal aspect of the coccyx is convex in shape.[1]The first coccygeal segment is composed of articular processes that form the coccygeal cornua.[1][2][4] The coccygeal cornua articulates with the sacral cornua of the inferior sacral apex of S5.[1][2][4] This articulation creates a symphysis or synovial joint, which forms one of the borders of the foramen for the dorsal branch of the fifth sacral nerve route (S5).[1][4]

Sacrum and Coccyx.jpg

The coccyx serves as an attachment site for several muscles and ligaments.[4] Anteriorly, the coccyx is bordered by the levator ani muscle and the sacro-coccygeal ligament.[4] In an anterior (front) to posterior (back) direction, the lateral border of the coccyx serves as an insertion point for the coccygeal muscles, the sacrospinous ligament, the sacrotuberous ligament and the gluteus maximus.[4] Inferiorly, the tendon of the iliococcygeus muscle inserts onto the tip of the coccyx.[4]Together, these ligaments and muscles contribute to voluntary bowel control, as well, provide support to the pelvic floor.[4]

In addition to being an insertion site, the coccyx, in conjunction with the ischial tuberosities, provides weight-bearing support to an individual in a seated position.[4] For this reason, increased stress and pressure can be placed on the coccyx while a person leans back in a seated position.[4] The coccyx also functions in providing support to the anus.[4]

Postascchini and Massobrio (1983)[5] classified the variations in morphology of the coccyx into four different configurations:[5]

  • Type I: The coccyx is slightly curved forward, with its apex positioned downward.[5]
  • Type II: The forward curvature of the coccyx is more exaggerated, with the apex positioned in a straightforward direction.[5]
  • Type III: Sharp angulation of the coccyx forward.[5]
  • Type IV: Subluxation of the coccyx at the sacrococcygeal or intercoccygeal joint.[5]

Epidemiology and Etiology[edit | edit source]

Currently, the incidence of coccygodynia is unknown.[4] Certain factors can increase an individual's risk for developing coccygodynia, such as body mass, age, gender.[1][4] With obesity, the coccyx is more vulnerable to increases in intrapelvic pressure while sitting, increasing the risk of posterior subluxation (displacement backward) of the coccyx.[1][6] With rapid weight loss, the cushioning around the coccyx may be lost,[4] and the coccyx is at an increased risk for anterior subluxation (displacement forward).[1][6] The risk of coccygodynia is 5 times higher in females than it is in males[4], which may be a result of the increased pressure that occurs during pregnancy and delivery.[7] Furthermore, adults and adolescents are more likely to present with coccygodynia than children.[4][6]

Coccygodynia may be classified as post-traumatic, non-traumatic or idiopathic.[3][4] Post-traumatic coccygodynia is usually a result of internal or external trauma.[4]  For example, external trauma could result from a backwards fall that might dislocate or break the coccyx,[4][8] and internal trauma could result from a difficult childbirth or a childbirth with an assistive delivery.[4] Minor trauma, such as repetitive sitting on hard surfaces can also lead to coccygodynia.[4][9] Non-traumatic coccygodynia can result from degenerative disc disease, hyper and/or hypo-mobility of the sacrococcygeal joint, infectious diseases and different variations in the configuration of the coccyx.[4] Type II, III, and IV configurations typically cause more pain than type I configurations.[1][5] Postacchini and Massobrio (1983)[5] stated that individuals with coccygodynia are more likely than the general population to have a configuration of Type II,III and IV.[5] Idiopathic coccygodynia occurs in the absence of any pathology in the coccyx.[1] This is typically a diagnosis of exclusion, and may result from spasticity or other abnormalities that affect the musculature of the pelvic floor.[1] For example, over-extension of the levator ani muscle can shift the coccyx into an abnormal position.[10]

Clinical Presentation[edit | edit source]

The most common complaint of coccygodynia is pain in and around the coccyx without any reports of severe low back pain or radiating pain.[1][2] The pain is typically localised to the sacrococcygeal joint[2] and is described as a “pulling” or “cutting” sensation.[3] Individuals will commonly report tenderness on palpation of the coccyx.[1][2]

Patients will usually exhibit a guarding seated posture, whereby one buttock will be elevated to take weight off of the coccyx.[3] Pain is usually exacerbated with repeated sitting or with transition from sitting to standing position.[1][2] Individuals will report that pain is alleviated with sitting on the legs or buttock.[2] Patients may also report pain with defecation or the frequent need to defecate.[1][2] Other complaints may include pain with coughing or increased pain during menstruation in females.[7][11]

Although not a hallmark sign of coccygodynia, low back pain may still arise in individuals with coccygodynia due to the morphological variations in the shape of the coccyx and it’s forward curvature.[1][2][5]

Diagnosis[edit | edit source]

Physical Exam[edit | edit source]

Palpation over the sacrococcygeal joint will display tenderness.[1][3][4] The coccyx should also be palpated to detect the presence of swelling, bone spicules or fragments, and coccygeal masses.[1][2] The soft tissues around the coccyx should be examined for the presence of pilonidal cysts (in-grown hairs).[1][2]

Palpating the coccyx can be used to differentiate between true coccygodynia, which is localised pain over the area of the coccyx, and pseudo coccygodynia, which is characterised by pain that is referred to the coccygeal area from visceral organs, a peripheral nerve, nerve root or plexus.[3] If referred pain is present, pain will radiate around the buttocks, thigh and back, and reports of pain will be present with lumbar movements.[7][11] Referred pain may also be indicative of psychogenic coccygodynia, in which pain will be more diffuse and pain will be experienced with lumbar and hip movements.[7][11]

Increased pain may also be reported during a straight leg raise test.[7][11]

Upon rectal examination, pain will be present when the tip of the coccyx is manipulated.[1][2]An internal mass, referred to as a chordoma, might also be present on the anterior surface of the sacrum.[2]

Imaging[edit | edit source]

Although primarily a clinical diagnosis, dynamic radiographs can be used in diagnosis.[1][2] Dynamic radiographs taken in both sitting and standing positions can provide measurements of coccygeal displacement.[2] Single-position radiographs are usually not used for diagnosis as they are unable to identify any morphological differences between individuals with and without coccygodynia.[1][2][5] Radiographs are usually taken if the pain persists for a duration that is greater than 8 weeks.[2]

Differential Diagnosis[edit | edit source]

The following differential diagnoses should be ruled out:[3][12]

Outcome Measures[edit | edit source]

Pain Measures[edit | edit source]

Level of Function in Activities of Daily Living[edit | edit source]

Condition Specific[edit | edit source]

Management[edit | edit source]

Conservative or non-surgical treatments are typically the gold standard when treating coccygodynia, being successful for 90% of cases.[1][2][3][4] Non-operative treatments may range from the recommendation of non-steroidal anti-inflammatory drugs (NSAIDs), activity modification, ergonomic adjustments, and physical therapy.[1][2][3][4] Surgery is usually only considered when patients continue to complain of coccygeal pain after the use of conservative treatments.[1][2][3][4]A coccygectomy, which is the removal of a section or all of the coccyx, is the most common surgical treatment performed.[1][2][3][4]

Physical Therapy Management[edit | edit source]

Ergonomic Adjustments[edit | edit source]

The initial goal of treatment should be focused on providing postural education.[13] Individuals should be taught to correct their sitting posture by sitting more erectly on a firm chair.[13][14] A proper sitting posture ensures weight is taken off the coccyx and is instead loaded onto the ischial tuberosities and the thighs.[13][14] Patients should be advised to avoid any positions or movements that might exacerbate their symptoms.[13]

Physiotherapists may also recommend the use of cushions. Modified wedge-shaped cushions (coccygeal cushions), which can be purchased over the counter, help to relieve the pressure placed on the coccyx during sitting.[4] Donut shaped or circular cushions may also be used.[3][4][13] Donut shaped cushions may actually increase pressure over the coccyx, but are more beneficial for rectal pain.[4]The use of cushions can be recommended over a 6-8 week period.[13] Although commonly recommended, the therapeutic outcomes of these conservative recommendations have not been evaluated in the literature.[13]

Manual Therapy[edit | edit source]

The manual therapy techniques suggested in the literature range from massage, stretching, mobilisation and manipulation, and may either involve internal or external contact with the coccyx.[2][15]

Internal techniques may include massage of the levator ani muscle or the coccygeus muscle,[15][16] joint mobilisation while the coccyx is hyperextended to stretch the levator ani,[15][17][18] or repeated mobilisations while the coccyx is rotated.[15][19]

External techniques may include manipulations of either the coccyx or sacroiliac joint,[15][20][21][22] mobilisations of the sacrococcygeal or intercoccygeal joints,[19] posterior mobilisations to the thoracic spine,[23] and stretching of the piriformis or iliopsoas.[23]Including thoracic spine mobilisations can help address compensatory patterns that affect the entire spine and pelvis, potentially influencing coccygeal pain. Additionally, mobilisations focusing on the lumbar spine are also beneficial as this area has a more direct relationship with pelvic tilt and alignment, impacting the position and stress on the coccyx.

The technique chosen will vary depending on what the originating cause of the coccygodynia is.[15] For example, massage or stretching of the levator ani might be chosen if the underlying cause is due to spasm of the pelvic floor musculature.[15][16][18] . Mobilisation techniques may be the preferred technique when the goal of treatment is to increase coccygeal mobility.[15][19]Manipulation techniques are helpful when the goal of treatment is to improve extension of the coccyx.[15][20]

A study by Maigne and Chatellier (2001)[15], who compared the effectiveness of various massage, mobilisation and manipulation techniques, reported that manual treatments were helpful for ~ 26% of cases with coccygodynia at 6 months and ~ 24% of the cases of coccygodynia at 2 years post treatment.[15] The findings of this study also reported that massage and stretching techniques of the levator ani muscle were more effective than joint mobilisation techniques.[15]

In support of manipulation, Maigne and colleagues (2006)[24] reported mild effectiveness of intrarectal manipulation in managing chronic coccygodynia when compared to shortwave diathermy.[24] Chakraborty (2012)[25] reported that combined manipulation and corticosteroid injection was more effective in treating coccygodynia than either technique alone.[25]

Mohanty and Pattnaik (2017)[23] reported that individuals with coccygodynia may benefit from stretching of the piriformis or iliopsoas muscles.[23] In this study, piriformis and iliopsoas stretches, as well as Maitland’s mobilisation of hypomobile thoracic spine, had a beneficial effect in increasing pain free sitting duration and pressure pain threshold.[23] Tightness of either the piriformis or iliopsoas can cause excessive anterior tilting of the pelvis and consequently place an excessive load on the coccyx.[23] Stretching these muscles can help to correct the load that is placed on the coccyx.[23] By increasing thoracic extension, thoracic mobilisations may also help to reduce the load on the coccyx.[23]In this study, stretching was performed for 2 minutes on each side of the hip, 5 times per week.[23]

Based on the work of Maigne and chatellier (2001)[15] and Wray (1991),[26]Fogel and Colleagues (2004)[2] designed a treatment algorithm for coccygodynia. When a patient is presenting with acute coccygodynia (less than 2 months in duration), 8 weeks of rest and adjustable seating should be recommended in conjunction with stool softener and NSAIDs.[2] When a patient  presents with chronic coccygodynia (greater than 2 months in duration), massage and stretching techniques should be initiated in conjunction with corticosteroid injections.[2]

Physical Modalities[edit | edit source]

Lin and colleagues (2015)[27], who compared the benefits of extracorporeal shockwave therapy (ESWT) with other physical modalities, reported that ESWT was more effective in decreasing visual analogue scale pain scores than shortwave diathermy and IFC.[27] Patients who received ESWT reported greater subjective satisfaction scores following treatment, with ~ 70% reporting good to excellent satisfaction.[27] In this study, 2000 shots of ESWT were applied to the coccyx area per session for 4 sessions at 5 Hz and a pressure of 3-4 bar.[27]The findings of this study can be supported by a case report by Marwan and colleagues (2014)[28], who reported the effectiveness of ESWT to relieve pain over 3 sessions in 2 cases of coccygodynia.[28] A quasi-experimental study by Haghighat and Mashayekhi (2016),[29] involving 10 patients with cocycgodynia, stated that ESWT significantly decreased visual analogue scale pain scores at 4 weeks and 2 months post treatment.[29] ESWT was delivered to the coccygeal area at 3000 shock waves per session, with a frequency of 21 Hz and pressure of 2 bar.[29]

Although the mechanism is still being debated in the literature, it is proposed that ESWT decreases the inflammatory response and the expression of inflammatory mediators present in coccygodynia through the induction of neovascularisation.[27][29]

When considering the effects of other modalities, Lin and Colleagues (2015)[27] reported that IFC and shortwave diathermy were able to decrease pain scores but not to the same extent as ESWT.[27] Wray and colleagues (1991)[26] reported minimal benefits with a combined treatment of ultrasound and shortwave diathermy. After receiving 2 weeks of ultrasound and 2 weeks of shortwave diathermy, only 16% of patients in the study report relief in their symptoms.[26] Given these discrepancies, more evidence regarding which modalities provide the greatest benefit to patients with coccygodynia.

References[edit | edit source]

  1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 1.20 1.21 1.22 1.23 1.24 1.25 1.26 Patel R, Appannagari A, Whang PG. Coccydynia. Current reviews in musculoskeletal medicine. 2008 Dec;1(3):223-6.
  2. ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 2.14 2.15 2.16 2.17 2.18 2.19 2.20 2.21 2.22 2.23 2.24 2.25 2.26 2.27 2.28 Fogel GR, Cunningham III PY, Esses SI. Coccygodynia: evaluation and management. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 2004 Jan 1;12(1):49-54.
  3. ↑ 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 3.12 3.13 3.14 3.15 3.16 Kerr EE, Benson D, Schrot RJ. Coccygectomy for chronic refractory coccygodynia: clinical case series and literature review. Journal of Neurosurgery: Spine. 2011 May 1;14(5):654-63.
  4. ↑ 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 4.11 4.12 4.13 4.14 4.15 4.16 4.17 4.18 4.19 4.20 4.21 4.22 4.23 4.24 4.25 4.26 4.27 4.28 4.29 4.30 4.31 4.32 Lirette LS, Chaiban G, Tolba R, Eissa H. Coccydynia: an overview of the anatomy, etiology, and treatment of coccyx pain. Ochsner Journal. 2014 Mar 20;14(1):84-7.
  5. ↑ 5.00 5.01 5.02 5.03 5.04 5.05 5.06 5.07 5.08 5.09 5.10 Postacchini FR, Massobrio MA. Idiopathic coccygodynia. Analysis of fifty-one operative cases and a radiographic study of the normal coccyx. The Journal of bone and joint surgery. American volume. 1983 Oct 1;65(8):1116-24.
  6. ↑ 6.0 6.1 6.2 Maigne JY, Doursounian L, Chatellier G. Causes and mechanisms of common coccydynia: role of body mass index and coccygeal trauma. Spine. 2000 Dec 1;25(23):3072-9.
  7. ↑ 7.0 7.1 7.2 7.3 7.4 Ombregt L, Bisschop P, ter Veer JH. A System of Orthopaedic Medicine. Elsevier Science Limited, 2003, p.968-969.
  8. ↑ Schapiro S. Low back and rectal pain from an orthopedic and proctologic viewpoint with a review of 180 cases. The American Journal of Surgery. 1950 Jan 1;79(1):117-28.
  9. ↑ Pennekamp PH, Kraft CN, Stütz A, Wallny T, Schmitt O, Diedrich O. Coccygectomy for coccygodynia: does pathogenesis matter?. Journal of Trauma and Acute Care Surgery. 2005 Dec 1;59(6):1414-9.
  10. ↑ Maigne R. Douleurs d’origine vertébrale et traitements par manipulations, medicine orthopédique des derangements intervertébraux mineurs, 2e editie, p. 473-476.
  11. ↑ 11.0 11.1 11.2 11.3 Gregory P. Grieve, De wervelkolom, veel voorkomende aandoeningen (The spine), 1984, p. 320-321.
  12. ↑ Schrot RJ. Coccygodynia. Epocrates Online (https://online. epocrates. com/u/29411067/Coccygodynia)[Accessed December 15 2010] Search Google Scholar Export Citation. 2010.
  13. ↑ 13.0 13.1 13.2 13.3 13.4 13.5 13.6 Chiarioni G, Asteria C, Whitehead WE. Chronic proctalgia and chronic pelvic pain syndromes: new etiologic insights and treatment options. World Journal of Gastroenterology: WJG. 2011 Oct 28;17(40):4447.
  14. ↑ 14.0 14.1 Thiele GH. Coccygodynia: cause and treatment. Diseases of the Colon & Rectum. 1963 Nov;6(6):422-36.
  15. ↑ 15.00 15.01 15.02 15.03 15.04 15.05 15.06 15.07 15.08 15.09 15.10 15.11 15.12 Maigne JY, Chatellier G. Comparison of three manual coccydynia treatments: a pilot study. Spine. 2001 Oct 15;26(20):E479-83.
  16. ↑ 16.0 16.1 Thiele GH. Coccygodynia and pain in the superior gluteal region: and down the back of the thigh: causation by tonic spasm of the levator ani, coccygeus and piriformis muscles and relief by massage of these muscles. Journal of the American Medical Association. 1937 Oct 16;109(16):1271-5.
  17. ↑ Maigne R, Nieves WL. Diagnosis and treatment of pain of vertebral origin. CRC Press; 2005 Sep 1.
  18. ↑ 18.0 18.1 Maigne R. Les Manipulations Vertébrales. 3rd ed. Paris: Expansion Scientifique Française, 1961: 180.
  19. ↑ 19.0 19.1 19.2 Mennell JB. The science and Art of Joint Manipulation. London: Churchill, 1952.
  20. ↑ 20.0 20.1 Bergmann TF, Petersen DH, Lawrence DJ. Chiropractic Technique-Principals and Procedures. New York: Churchill Livingston Inc. 803p. ISBN 0-443-0872-0; 1993.
  21. ↑ Polkinghorn BS, Colloca CJ. Chiropractic treatment of coccygodynia via instrumental adjusting procedures using activator methods chiropractic technique. Journal of manipulative and physiological therapeutics. 1999 Jul 1;22(6):411-6.
  22. ↑ Plaugher G, editor. Textbook of clinical chiropractic: a specific biomechanical approach. Williams & Wilkins; 1993.
  23. ↑ 23.0 23.1 23.2 23.3 23.4 23.5 23.6 23.7 23.8 Mohanty PP, Pattnaik M. Effect of stretching of piriformis and iliopsoas in coccydynia. Journal of bodywork and movement therapies. 2017 Jul 1;21(3):743-6.
  24. ↑ 24.0 24.1 Maigne JY, Chatellier G, Le Faou M, Archambeau M. The treatment of chronic coccydynia with intrarectal manipulation: a randomized controlled study. Spine. 2006 Aug 15;31(18):E621-7.
  25. ↑ 25.0 25.1 Chakraborty S. Nonoperative Management of Coccydynia: A Comparative Study Comparing Three Methods. The Spine Journal. 2012 Sep 1;12(9):S69-70.
  26. ↑ 26.0 26.1 26.2 Wray CC, Easom S, Hoskinson J. Coccydynia. Aetiology and treatment. The Journal of Bone and Joint Surgery. British volume. 1991 Mar;73(2):335-8.
  27. ↑ 27.0 27.1 27.2 27.3 27.4 27.5 27.6 Lin SF, Chen YJ, Tu HP, Lee CL, Hsieh CL, Wu WL, Chen CH. The effects of extracorporeal shock wave therapy in patients with coccydynia: a randomized controlled trial. PloS one. 2015 Nov 10;10(11):e0142475.
  28. ↑ 28.0 28.1 Marwan Y, Husain W, Alhajii W, Mogawer M. Extracorporeal shock wave therapy relieved pain in patients with coccydynia: a report of two cases. The Spine Journal. 2014 Jan 1;14(1):e1-4.
  29. ↑ 29.0 29.1 29.2 29.3 Haghighat S, Asl MM. Effects of extracorporeal shock wave therapy on pain in patients with chronic refractory coccydynia: A quasi-experimental study. Anesthesiology and pain medicine. 2016 Aug;6(4).
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