Coccygodynia (Coccydynia, Coccalgia, Tailbone Pain)

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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, 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 commonly report tenderness on palpation of the coccyx.[1][2]

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] Other complaints may include pain with coughing or increase 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 localized pain over the area of the coccyx, and pseudo coccygodynia, which is characterized 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 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 experience 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 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]

  • Coccyx fracture
  • Lumbar spondylosis or disc herniation
  • Levator ani syndrome
  • Piriformis syndrome
  • Descending perineal syndrome
  • Perianal abscess
  • Rectal tumour or teratoma
  • Aclock canal syndrome
  • Proctalgia Fugax

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]

[13]

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 concervatie management.[1][2][3][4]A coccygectomy or 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.[14] Individuals should be taught to correct their sitting posture by sitting more erectly on a firm chair.[14][15] A proper sitting posture ensures weight is taken off the coccyx and is instead loaded onto the ischial tuberosities and the thighs.[14][15]  As well, patients should be advised to avoid any positions or movements that might exacerbate their symptoms.[14]

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] Alternatively, donut shaped or circular cushions may also be used.[3][4][14] Although donut shaped cushions may actually increase pressure over the coccyx, they are better able to relieve rectal pain.[4]The use of cushions can be recommended over a 6-8 week period.[14]

Although commonly recommended, the therapeutic outcomes of these conservative recommendations have not been evaluated in the literature.[14]

Manual Therapy[edit | edit source]

The manual therapy techniques suggested in the literature range from massage, stretching, mobilization and manipulation, and may either involve internal or external contact with the coccyx.[2][16]

Internal techniques may include: massage of the levator ani muscle or the coccygeus muscle,[16][17] joint mobilization while the coccyx is hyperextended to stretch the levator ani,[16][18][19] or repeated mobilizations while the coccyx is rotated.[16][20]

External techniques may include manipulations of either the coccyx or sacroiliac joint,[16][21][22][23] and mobilizations of the sacro-coccygeal or inter-coccygeal joints.[20] Posterior mobilizations to the thoracic spine may also help to decrease the load placed on the coccyx by increasing thoracic extension.[24] Stretching of the piriformis or the iliopsoas may also be beneficial.[24]

The technique chosen will vary depending on what the originating cause of the coccygodynia is.[16] 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.[16][17][19] . Alternatively, mobilization techniques may be the preferred technique when the goal of treatment is to increase coccygeal mobility.[16][20]Manipulation techniques are helpful when the goal of treatment is to improve extension of the coccyx.[16][21]

A study by Maigne and Chatellier (2001)[16], who compared the effectiveness of various massage, mobilization and manipulation techniques, reported that manual treatments were helpful for ~ 26% of cases with coccydynia at 6 months and ~ 24% of the cases of coccydynia at 2 years.[16] The findings of this study also reported that massage and stretching techniques of the levator ani muscle were more effective than joint mobilization techniques.[16]

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

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

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

Physical Modalities[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[25].[edit | edit source]

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[26].

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[27].

Massage[edit | edit source]

Massage of the levator ani muscle and coccygeus muscles has also been found to relieve pain[28][29]. To exclude the possibility of muscles pulling on the os coccyx, relaxation of the pelvic floor muscles can be integrated by using biofeedback[30].

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.[31]
  • 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.[32]
  • 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.[33]
  • 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.[27][29]

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;1(3-4):223.
  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 Fogel G. Coccygodynia: Evaluation and Management. Spinal Cord. 2004;12(1):49-54<article><section> </section></article>
  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 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;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. ↑ CRTechnologies Straight Leg Raise Test (CR) Available from https://www.youtube.com/watch?time_continue=2&v=KziCDXXfC-4 accessed on 13/6/19
  14. ↑ 14.0 14.1 14.2 14.3 14.4 14.5 14.6 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.
  15. ↑ 15.0 15.1 Thiele GH. Coccygodynia: cause and treatment. Diseases of the Colon & Rectum. 1963 Nov 1;6(6):422-36.
  16. ↑ 16.00 16.01 16.02 16.03 16.04 16.05 16.06 16.07 16.08 16.09 16.10 16.11 Maigne JY, Chatellier G. Comparison of three manual coccydynia treatments: a pilot study. Spine. 2001 Oct 15;26(20):E479-83.
  17. ↑ 17.0 17.1 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.
  18. ↑ Maigne R, Nieves WL. Diagnosis and treatment of pain of vertebral origin. CRC Press; 2005 Sep 1.
  19. ↑ 19.0 19.1 Maigne R. Les Manipulations Vertébrales. 3rd ed. Paris: Expansion Scientifique Française, 1961: 180.
  20. ↑ 20.0 20.1 20.2 Mennell JB. The science and Art of Joint Manipulation. London: Churchill, 1952.
  21. ↑ 21.0 21.1 Bergmann TF, Petersen DH, Lawrence DJ. Chiropractic Technique-Principals and Procedures. New York: Churchill Livingston Inc. 803p. ISBN 0-443-0872-0; 1993.
  22. ↑ Polkinghorn BS, Colloca CJ. Chiropractic treatment of coccygodynia via instrumental adjusting procedures using activator methods chiropractic technique. J Manipulative Physiol Ther 1999; 22: 411–6.
  23. ↑ Plaugher G, editor. Textbook of clinical chiropractic: a specific biomechanical approach. Williams & Wilkins; 1993.
  24. ↑ 24.0 24.1 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.
  25. ↑ 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.
  26. ↑ Maitland GD, Brewerton DA. Vertebral manipulation. Butterworths, 1973, p.236-239.
  27. ↑ 27.0 27.1 Wray CC, Easom S, Hoskinson J. Coccydynia: aetiology and treatment. J Bone Joint Surg 1991;73(B):335-8.
  28. ↑ Thiele GH. Coccygodynia: cause and treatment. Diseases of the Colon and Rectum, 1963, p.422-436.
  29. ↑ 29.0 29.1 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.
  30. ↑ Physiotherapist UZ Brussels, internal physiotherapy and gynaecology.
  31. ↑ 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.
  32. ↑ 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.
  33. ↑ 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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