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

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== Epidemiology and Etiology  ==
== Epidemiology and Etiology  ==


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" /> (Patel, Lirette). With obesity, the coccyx is more vulnerable to increases in intrapelvic pressure while sitting, increasing the risk of posterior subluxation of the coccyx (Patel, Maigne). With rapid weight loss, the cushioning around the coccyx may be lost (Lirette) and the coccyx is at an increased risk for anterior subluxation (maigne, patel). The risk of coccygodynia is 5 times higher in females than it is in males(Lirette), which may be a result of the increased pressure that occurs during pregnancy and delivery (Ombregt, Bishop). Furthermore, adults and adolescents are more likely to present coccygodynia than children (Lirette, Maigne).  
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 of the coccyx.<ref name=":0" /><ref name=":5">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.</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.<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>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 coccygodynia than children.<ref name=":3" /><ref name=":5" /> 


Coccygodynia may be classified as post-traumatic, non-traumatic or idiopathic (Lirette, Kerr). Post-traumatic coccygodynia is usually a result of internal or external trauma.  For example, external trauma could result from a backwards fall that might dislocate or break the coccyx (11 from lirrette) and internal trauma could result from a difficult childbirth or a childbirth with an assistive delivery (Lirette). Minor trauma, such as repetitive sitting on hard surfaces can also lead to coccygodynia (6 from Lirette). Non-traumatic coccygodynia can result from degenerative disc disease, hyper and/or hyper-mobility of the sacrococcygeal joint, infectious diseases and different variations in the configuration of the coccyx (Lirette). Type II, III, and IV configurations typically cause more pain than type I configurations (Postacchini, Patel). Furthermore, Postacchini and Massobrio (1983) stated that individuals with coccygodynia are more likely than the general population to have a configuration of Type II and IV. (Postacchini and Massobrio, 1983) Idiopathic coccygodynia occurs in the absence of any pathology in the coccyx (Patel). This is typically a diagnosis of exclusion, and may result from spasticity or other abnormalities affecting the musculature of the pelvic floor (Patel). For example, over-extension of the levator ani muscle can shift the coccyx into an abnormal position (6 from coccygodynia page)
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. 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. 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 hyper-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" /> Furthermore, 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 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 affecting 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>
== Clinical Presentation  ==
The most common primary 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 localized to the sacrococcygeal joint<ref name=":1" /> and is described as a “pulling” or “cutting” sensation.<ref name=":2" /> Individuals 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 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" /> As well, patients may report pain with coughing (4,5). Women might feel increased pain during menstruation (4,5 from physiopedia)The pain can be classified as acute or chronic (> 2 months) (Fogel, Kerr)  


The prevalence for coccygodynia is five times greater in women than in men<ref name="Patel">Patel R, Appanagari A, Whang PG. Coccydynia. Curr Rev Musculoskelet Med 2008;1:223-226.</ref>. 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">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>. 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>
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 (Patel, Fogel, Postacchini, Massobrio).  


== Characteristics / Clinical Presentation  ==
Individuals will commonly report tenderness on palpation of the coccyx (Fogel,Patel). 


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" />:  
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">Ombregt L, Bisschop P, ter Veer JH. A System of Orthopaedic Medicine. Elsevier Science Limited, 2003, p.968-969.</ref><ref name="Gregory">Gregory P. Grieve, De wervelkolom, veel voorkomende aandoeningen (The spine), 1984, p. 320-321.</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" />.
* '''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" />.


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== Examination  ==
== 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. 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>  
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">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>.<br>  


{{#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>
{{#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>

Revision as of 19:53, 26 June 2020

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

Definition / Description[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, which 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, it plays a role in providing weight-bearing support to an individual in a seated position in conjunction with the ischial tuberosities.[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 functions in providing support to the anus.[4]

Pelvic floor.png
Pelvic floor.jpg

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

  • Type I: The coccyx is slightly curved forward, with its apex positioned downward and caudally.[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 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.[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 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 hyper-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] Furthermore, Postacchini and Massobrio (1983)[5] stated that individuals with coccygodynia are more likely than the general population to have a configuration of Type II 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 affecting 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 primary 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 localized to the sacrococcygeal joint[2] and is described as a “pulling” or “cutting” sensation.[3] Individuals 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 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] As well, patients may report pain with coughing (4,5). Women might feel increased pain during menstruation (4,5 from physiopedia)The pain can be classified as acute or chronic (> 2 months) (Fogel, Kerr)

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 (Patel, Fogel, Postacchini, Massobrio).

Individuals will commonly report tenderness on palpation of the coccyx (Fogel,Patel). 

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[11][12]:

  • 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[11][12].
  • 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.[11][12].

Differential Diagnosis[edit | edit source]

Diagnostic Procedures[edit | edit source]

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.

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[11][12].

Psychogenic coccydynia features a less specific pain location and usually a vague and radiating pain in various directions. Lumbar and hip movements are painful[11].

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]

Examination[edit | edit source]

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. There may be radiating pain around the buttocks and going to the back of the thighs. Women may have pain during menstruation[11][12]. Palpation at the sacrococcygeal junction will elicit a tender point and will be painful[13].

[14]

Physical Therapy Management[edit | edit source]

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[15].

Mobilizations[edit | edit source]

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[16].

Another option for manual therapy is to apply 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[edit | edit source]

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[17].

Massage[edit | edit source]

Massage of the levator ani muscle and coccygeus muscles has also been found to relieve pain[18][19]. To exclude the possibility of muscles pulling on the os coccyx, relaxation of the pelvic floor muscles can be integrated by using biofeedback[20].

Evidence of Physical Therapy Treatments[edit | edit source]

  • 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.[21]
  • 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.[22]
  • 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.[23]
  • 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.[17][19]

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 Patel R, Appannagari A, Whang PG. Coccydynia. Current reviews in musculoskeletal medicine. 2008 Dec 1;1(3-4):223.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 Fogel G. Coccygodynia: Evaluation and Management. Spinal Cord. 2004;12(1):49-54<article><section> </section></article>
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 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 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. ↑ 5.0 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 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;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. ↑ 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 11.4 11.5 Ombregt L, Bisschop P, ter Veer JH. A System of Orthopaedic Medicine. Elsevier Science Limited, 2003, p.968-969.
  12. ↑ 12.0 12.1 12.2 12.3 12.4 Gregory P. Grieve, De wervelkolom, veel voorkomende aandoeningen (The spine), 1984, p. 320-321.
  13. ↑ Kerr EE, Benson D, Schrot RJ. Coccygectomy for chronic refractory coccygodynia: clinical case series and literature review. J Neurosurg Spine 2011;14:654-663.
  14. ↑ CRTechnologies Straight Leg Raise Test (CR) Available from https://www.youtube.com/watch?time_continue=2&v=KziCDXXfC-4 accessed on 13/6/19
  15. ↑ 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.
  16. ↑ Maitland GD, Brewerton DA. Vertebral manipulation. Butterworths, 1973, p.236-239.
  17. ↑ 17.0 17.1 Wray CC, Easom S, Hoskinson J. Coccydynia: aetiology and treatment. J Bone Joint Surg 1991;73(B):335-8.
  18. ↑ Thiele GH. Coccygodynia: cause and treatment. Diseases of the Colon and Rectum, 1963, p.422-436.
  19. ↑ 19.0 19.1 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.
  20. ↑ Physiotherapist UZ Brussels, internal physiotherapy and gynaecology.
  21. ↑ 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.
  22. ↑ 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.
  23. ↑ Chakraborty S. Nonoperative Management of Coccydynia: A Comparative Study Comparing Three Methods. The Spine Journal. 2012 Sep 1;12(9):S69-70.
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