Coccygodynia (Coccydynia, Coccalgia, Tailbone Pain)

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Keywords: coccygodynia, physical therapy/physiotherapy, chronic pelvic pain

Definition/Description

Coccygodynia is defined as a disabling pain in and around the os coccyx.[1, D] This pain is usually provoked by sitting and especially when rising from a sitting to a standing position. It is also known as coccydynia or coccygeal neuralgia.[2, C] The pain caused by coccygodynia is disabling and has a significant impact on the quality of life of patients. The pain that is felt is pulling or lancinating and can also radiate to the sacrum, lumbar spine, buttocks or more rarely to the thighs.[2, C] 

Clinically Relevant Anatomy

The coccyx is the most distal aspect of the vertebral column. It consists of three to five rudimentary vertebral units that are typically fused. The ventral part of the coccyx is concave, the dorsal aspect convex and displays coccygeal articular processes. [3, D]
The coccyx articulates with the sacral cornu of the inferior sacral apex at S5.[3, D]
The anterior side of the coccyx serves for the attachment of ligaments and muscles important for many functions of the pelvic floor. The levator ani muscle includes m. coccygeus, m.pubococcygeus and m. iliococcygeus. The coccyx supports the position of the anus. Attached to the posterior side is m. gluteus maximus. Muscle weakness, disturbed tonus or damage to muscles or ligaments can cause abnormal positions of the coccyx. [3, D]

Epidemiology /Etiology

The prevalence for coccygodynia is five times greater in women than in men.[3] This may be related to increased pressure during pregnancy or delivery (post-partum coccygodynia). [6, E]
The pain in the coccyx can be caused by radiation from a lumbosacral segment, a direct trauma or an overcharge. [11, E] Congenital deviations can also cause complaints during long sitting. [11, E]
Coccygodynia may be classified as posttraumatic versus idiopathic. Posttraumatic coccygodynia may be due to a fall onto the buttocks, or to a difficult childbirth. [2, C] Other studies question the fact that coccygodynia could be caused by a direct trauma, because of its protection by the ischiadic bones.
Often a position change of the coccyx is caused by an overtension of the anal levator muscle. [10, E] In more than one third of the cases coccygodynia has an idiopathic cause.[2, C]
 

Characteristics/Clinical Presentation

A sitting position (test) can cause pain and/or complaints in the coccyx region during, going into or coming out of the sitting position, this is a first indication of coccygodynia. Tenderness is present, but dependable from the location we can distinguish between several forms of coccygodynia. [6,11, E]
Referred or radiated pain is caused by an arise from a lumbar disc lesion, irritation of lower pelvic structures or deviations of the lower lumbar and/or sacroiliac joints. [6,11, E]
Local pain or coccygodynia is usually caused by a direct hit on the coccyx bone. When there is no particular injury we’ll speak of idiopathic coccygodynia. This may include anatomical variations of the coccyx. Post-partum coccygodynia is caused by childbirth and is often the cause in women. [6,11, E]
 

Differential Diagnosis

• Local coccygodynia
o Traumatic coccygodynia
o Idiopathic coccygodynia
• Referred or radiated coccygodynia
• Psychogenic coccygodynia
• Chronic proctalgia
• Chronic pelvic pain and pudendal neuralgia

Diagnostic Procedures

Local coccygodynia is presented by pain felt on the coccyx during sitting and doesn’t 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 and dependable from the exact location of it walking, stair walking or getting up can be painfull. Other movements are painless and examination of lumbar spine and sacroiliac joints and hips are normal (>< referred pain and psychogenic). Trauma or overtension of the levator ani muscle can shift the coccyx into an abnormal position. There can be made a distinction based on the affected tissues. [6,11]
Psychogenic coccydynia is less precise and usually a vague and radiated pain in various directions. Lumbar and hip movements are painful. [6]
 

Examination

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.
To distinguish referred or radiated pain or coccygodynia from others (local), the pain will also arise during lumbar movements. Coughing is painfull and physical examination will show an increased pain during a straight leg raise test. There is radiation possible around the buttocks going to the back of the thigh. Women may have pain during menstruation. [6,11, E]
Palpation at the sacrococcygeal junction will elicit a tender point and will be painful. [2]

Medical Management

There is a growing evidence in literature that supports the efficacy of coccygectomy as treatment for coccygodynia. Coccygectomy showed a high percentage of patients with good results and this outcome is durable over time. [2, C]

Physical Therapy Management

Patients with coccygodynia are initially advised to avoid provocative factors and 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 patients posture. There is however no significant evidence that these minor changes reduce the complaints. [4, A]
To improve the position of the coccyx, the physiotherapist can use mobilizations. The first choice for mobilization is postero-anterior central vertebral pressure (first gently oscillating). Given that there is tenderness to pressure, it might be best to start with rotation mobilization. It is advised to begin mobilizing only one side at one treatment. [5, E]
Another manual therapy used, are deep transverse frictions (DTF) to the affected ligaments. The patient lies in prone position with a pillow under the pelvis, 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 are administered.
Manipulation of the coccyx is 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.[1, D]
Massage of the levator ani muscle and coccygeus muscles is also found to relieve pain.[7][8] To exclude the possibility of muscles pulling on the os coccyx, relaxation of the pelvic floor muscles can be integrated by using biofeedback.[9, F]
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.[1, D][8, B]
There are only a few studies/reviews available concerning the ‘ideal’ physiotherapy treatment for coccygodynia, more research is needed and the techniques described are insufficient.
 

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References 

1] Wray C.C., Easom S., Hoskinson J., Coccydynia: aetiology and treatment, J Bone Joint Surg [Br] 1991, 73-B:335-8. D
[2] Kerr E.E., Benson D., Schrot R.J., Coccygectomy for chronic refractory coccygodynia: clinical case series and literature review, J Neurosurg Spine 2011; 14:654-663. C
[3] Patel R., Appanagari A., Whang P.G., Coccydynia. Curr Rev Musculoskelet Med 2008, 1:223-226. D
[4] Chiarioni G. et al, Chronic proctalgia and chronic pelvic pain syndromes: New etiologic insights and treatment options, WJG, 2011, Vol. 17, Issue 40, p.4451-4455. A
[5] Maitland G.D. and Brewerton D.A., Vertebral Manipulation, Butterworths, 1973, p.236-239. E
[6] Ombregt L., Bisschop P., ter Veer J.H., A System of Orthopaedic Medicine, Elsevier Science Limited, 2003, p.968-969. E
[7] Thiele G.H., Coccygodynia: Cause and treatment, Diseases of the Colon and Rectum, 1963, p.422-436. E
[8] Wu C., et al., The Application of Infrared Thermography in the Assesment of Patients With Coccygodynia Before and After Manual Therapy Combined With Diathermy, Journal of Manipulative and Physiological Therapeutics, 2009, p.287-293. B
[9] Physiotherapist UZ Brussels, internal physiotherapy and gynaecology. F
[10] Robert Maigne, Douleurs d’origine vertébrale et traitements par manipulations, medicine orthopédique des derangements intervertébraux mineurs, 2e editie, p. 473-476. E
[11] Gregory P. Grieve, De wervelkolom, veel voorkomende aandoeningen (The spine), 1984, p. 320-321. E