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  • Deborah Thomas BPT MCSP MAPPI Chartered Physio

Coccygodynia

The term coccygodynia was first introduced in 1859 by Simpson. It refers to Symptoms of pain in and around the tailbone, or the Coccyx. There are several synonyms often used: coccygodynia, Coccyx pain, Tail bone pain.



The coccyx is the terminal part of the spinal column and consists of 3-5 vertebrae which are, in most people, fused. Several ligaments & muscles attach onto the coccyx, amongst them, the Levator Ani muscles– part of the pelvic floor muscles, the Piriformis – which can be considered a hip joint muscle. The tip of the coccyx protects the rectum. Several morphological (form or structure) differences have been reported, and there is possibly a link between different shapes of coccyx and response to treatment. The name ‘Coccyx’ is derived from the Greek word ‘Cuckoo’ due to its resemblance to the beak of this bird.


The coccyx may functionally be a weight-bearing structure, depending on the posture of the lumbar spine and pelvis in sitting(1), the primary function of the coccyx is to act as a shock absorber when sitting, providing weight-bearing support(4); however, it should not be the main weight-bearing structure in sitting.


The presentation of symptoms is usually clear: Pain becomes sharp during periods of sitting, when getting up from a sitting position, during sexual intercourse, defecation, and menstruation in females(4). Tail bone pain affects females 5 times more than males.


Diagnosis is made predominantly on clinical examination. It is recommended to have blood tests in all cases: ‘Causes of coccyx pain such as infections, masses, and tumours should be ruled out in every case’(4) – however, this is the only reference I have found that makes this recommendation.


The aetiology (the cause) can be multifactorial. Several factors have been described in literature; I will outline several here:

  • Tailbone fractures (fractured coccyx, “broken tailbone”, chipped tailbone, “cracked tailbone”) - Fractures are usually associated with blunt trauma for example falling onto the buttocks (common is skiing and snowboarding) and childbirth.

  • Tailbone dislocations - Cases of partial dislocation of the coccyx have been reported, resulting in inflammation of tissues and pain. These will result in disruption to ligaments attached to the coccyx

  • Tailbone sprains

  • Tailbone injuries from pregnancy (coccyx injuries while pregnant or from childbirth, vaginal labour, and delivery)

  • Tailbone injuries from sports (skateboarding, skiing, snowboarding, roller skating, football, basketball, cycling). It has been reported that the posture and seat type during cycling may be a cause in coccydynia, however, the advice is conflicting: ‘Position - adjust the handlebars so that you lean well forward, taking the weight off the tailbone.’ (coccyx.org), and ‘This is due to continually leaning forward and stretching the base of your spine. If this motion is repeated many times, the muscles and ligaments around your coccyx can become strained and stretched.’(NHS.uk.) It is important for cyclist to have their posture and seating assessed and the position of the saddle assessed: adjusting the tilt of the saddle so it is roughly level to the ground. It’s important to make sure when one is seated that their weight is placed squarely on the "sit bones" (Ischial Tuberosities).

  • Surgery has been cited as a potential factor: recent lumbar spinal surgery, rectal surgery, or epidural injections’ (4)

  • Non-traumatic tailbone pain aching or discomfort that began without any trauma or injury at all: It may develop from a prolonged sitting posture (repetitive micro-trauma) in a Posterior pelvic tilt (tail bone tucked under) or on a hard surface. Other causes, including degenerative joint disease, hyper or hypo mobility of the joint between the coccyx and the sacrum, infections and variants in the bony structure have been reported. The most common cause of pain is dynamic instability – an unstable joint at the coccyx. The term dynamic is helpful here – as the pain will often be related to movement – especially from sitting to standing.

  • Other causes of symptoms: low back pain, buttock pain, pelvic pain, muscle pain, etc. (including screening for pilonidal cysts, coccyx cancer, sciatica, sacroiliac joint pain, lumbosacral facet pain, lumbar disc herniations, piriformis muscle pain, and other problems, etc.)


As pain in the coccyx can be referred from other areas, such as the lumbar spine, pelvic floor muscles, cysts or infections, it is important to have a thorough examination by a pelvic physiotherapist, to establish the source of the pain & the structures involved: Pelvic floor muscle dysfunction, especially hypertonic muscles, may contribute to, or exacerbate coccyx pain.


Assessment of a patient with Coccydinea will include:

  • History gathering: As explained above, pain during sitting, and especially, on the transition from sitting to standing, is the most common symptom. Symptoms often are eased once a person is standing/pressure is relieved. People may find the naturally shift to sit on one buttock or sit leaning forward on their ‘sit bones’ to avoid the symptoms. There is variability regarding whether hard or soft surfaces affect the symptoms.

  • A local, palpable tenderness of the coccyx. Often, the tip of the coccyx is the most tender part.

  • Long term, the compensations in sitting postures, may lead to further problems in the lumbosacral and pelvic regions, as the loads become asymmetrical. This can result in a variety of secondary musculoskeletal complaints, affecting the sacroiliac joints, piriformis and gluteal muscles, sciatic nerve to name a few. It is important to examine these structures and confirm whether they are sources of referral.

  • The pelvic floor muscle may respond to the localized pain by going into a ‘protective mode’ of spasm and guarding, and this can further exacerbate the pain. Establishing if there is a hyper-toned pelvic floor is key to enhancing recovery.


Treatment:

The gold standard for treatment is non-surgical management: conservative management.


Within physiotherapy - Addressing sitting posture, lumbar & pelvic mobility, soft tissue manipulation, pelvic floor muscle rehabilitation, hip & gluteal muscle rehabilitation (muscle length, strength, coordination) are important. Several factors within, as well as further away from the pelvis require assessment and treatment. Treatment modalities may include exercises, manual therapy to joints and soft tissue, acupuncture, TENS, taping & strapping, advise & education. Often, it is effective to treat the person internally as this gives easier, more effective access to the coccyx and the pelvic floor muscles attached to it. A combination of these modalities will often be used.


Often, the treatment will involve the Piriformis muscle. This muscle attaches to the border of the Sacrum and reaches all the way to the hip, and therefore is one of the hip external rotators, as well as an abductor. It is active in walking. It works together with the Gluteus Maximus to alter the movement/position of the sacrum. If this muscle is working in a tight or shortened position, it may affect the movement of the sacrum within the pelvis, a lead to coccyx pain.


A side-on image here, shown clearly how the Piriformis muscle is related to the coccyx:




Another muscle, external to the pelvis, that may be treated is the Iliopsoas muscle. If a patient is displaying and anteriorly tilted pelvic position and this muscle is found to be tight or short upon examination – treating this muscle has been shown to alleviate tail bone pain, and the theory behind this is that altering the pelvic alignment will offload the pressures on the sacrum & coccyx complex.


Several ‘coccyx-pillows’ are on sale to support the sitting posture and alleviate the symptoms. Often, they will have a section of the cushion removed, to allow offloading and non-weight bearing on the actual coccyx. Some people do find relief from using these.

Pelvic physiotherapists specialise in treating the internal as well as the external pelvic muscles: isolating the pelvic floor muscles, utilising ‘down-training’ techniques to address the ‘over-guarding’ of the muscles, via pelvic, hip, lumbar exercises, diaphragmatic breathing and manual therapy.


Manual therapy, can address the alignment of the coccyx, and therefore affect the tension on the neural (related to nerves) and soft tissue structures:


There are options of local injections of steroids and anaesthetics available if the above do not help. Manipulation under anaesthetic (MUA) is also described as an option if conservative management is unhelpful.


Surgery is rare and would involve surgical removal of the coccyx: a coccygectomy. The long-term results of this type of intervention are variable and range from 63-90% (3) although others report ‘coccygectomy yields a high percentage of success’ (4). There are of course potential side effects and risks to any surgery; Here persistent pain and pelvic organ prolapse are some of them. ‘Removal of the coccyx via surgical intervention is used when all other treatment options have not provided the patient with adequate relief’ (4).


Appropriate care is crucial since coccydynia is at high risk for becoming a chronic source of pain and disability that can significantly impair quality of life.


Therefore, a physiotherapist specialising in pelvic pain is your first port of call to seek assessment, advice, and treatment.


To book an appointment with Deborah Thomas: www.deborahthomasphysio.co.uk


References:

  1. Effects of stretching of piriformis and iliopsoas on coccydynia 2017: Mohanty et all. Journal of Bodywork & Movement Therapies 21 (207) 743-746

  2. Coccydynia: Tailbone pain, Foye P.M. 2017: Phys Med Rehabil Clin Am 28 (2017) 539-549

  3. Coccydynia-could age, trauma and body mass index be independent prognostic factors for outcomes of intervention? Kodumuri P et al 2018: Ann R Coll Surg Engl 2018: 100:12-15

  4. Coccydynia: A Literature Review of Its Anatomy, Etiology, Presentation, Diagnosis, and Treatment. Mahmood S, et al. Int J Musculoskelet Disord: IJMD-109

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