Coccygodynia (tailbone pain)

Diagnosis of Coccygodynia (Tailbone Pain)

A thorough diagnostic evaluation is essential for coccygodynia to identify the underlying cause and rule out other conditions. This typically involves:

Physical Examination

• External Palpation: Direct pressure over the coccyx externally will usually reproduce the patient's pain. The physician will assess for tenderness, swelling, or any deformity.
• Digital Rectal Examination (DRE): The presence of pain in the coccyx area often necessitates a digital examination of the rectum. Objectively, when examining with a finger through the rectum (per rectum), significant tenderness in the coccyx area is almost always found. Painful compaction, sometimes in the form of a radial cord-like structure, may be palpated along the posterior sector during the examination. Pressure on this cord typically results in a significant increase in pain in the coccyx. Patients often describe this pain as deep, "acting on the nerves," or "boring." Sometimes it is possible to palpate the painful sacrospinous ligament, which may feel like a very tight cord. Movement of the coccyx during DRE (gentle flexion and extension) can also reproduce the pain and assess for hypermobility or instability of the sacrococcygeal joint.
• Pelvic Floor Muscle Assessment: Palpation of the pelvic floor muscles (e.g., levator ani, coccygeus) may reveal hypertonicity, spasm, or trigger points, which can contribute to or result from coccygodynia.
• Neurological Examination: To rule out lumbosacral radiculopathy or other neurological causes of referred pain.

The pathogenesis of some forms of coccygodynia syndrome is thought to be caused by local spasm of a part of the perineal musculature (e.g., coccygeus muscle, levator ani) and shortening or tension in the pelvic ligaments (e.g., sacrospinous, sacrotuberous ligaments). Local hypertonicity of these perineal muscles does not necessarily represent a unique feature in its origin; it often arises according to the general principles of trigger point formation in skeletal muscles due to trauma, overuse, or chronic strain. In an isolated form, hypertonicity of these muscles can create the appearance of an independent disease that may not fit neatly into the framework of classical diseases of the pelvic organs.

Imaging and Other Investigations

• X-ray of the Sacrococcygeal Spine: Anteroposterior and lateral views of the sacrum and coccyx are performed. Dynamic X-rays, taken in both standing and sitting positions, can be particularly useful to assess for coccygeal instability (hypermobility or subluxation) or abnormal angulation during weight-bearing. X-rays can also reveal fractures, dislocations, arthritic changes, or bony spicules.
• Magnetic Resonance Imaging (MRI) or Computed Tomography (CT) Scan: These may be indicated if X-rays are inconclusive, if a tumor or infection is suspected, or to evaluate surrounding soft tissues, nerve plexuses, or lumbosacral spine pathology that might refer pain to the coccyx.
• Local Anesthetic Injection: Injecting a small amount of local anesthetic into the painful area around the coccyx (e.g., sacrococcygeal joint, pericoccygeal tissues, or specific trigger points) can be diagnostic. Significant pain relief after the injection supports the coccyx as the source of pain.
• Other Examinations (to rule out referred pain): If indicated by history or examination, further investigations such as sigmoidoscopy (to examine the rectum and lower colon), orthopedic evaluation of the lumbosacral spine and pelvis, urological assessment, or gynecological examination may be necessary to exclude diseases of nearby organs that could be causing or contributing to the pain.

Treatment of Coccygodynia (Tailbone Pain)

The treatment for coccygodynia is primarily conservative and aims to relieve pain, reduce inflammation, and improve function. A multimodal approach is often most effective.

Conservative Management

• Activity Modification: Avoiding activities that exacerbate pain, such as prolonged sitting or sitting on hard surfaces.
• Cushions: Using specialized coccyx cushions (wedge-shaped or donut-shaped with a cutout for the tailbone) can significantly relieve pressure on the coccyx when sitting.
• Postural Advice: Maintaining good posture while sitting (e.g., sitting upright with lumbar support, feet flat on the floor).
• Heat and Cold Therapy: Applying ice packs to reduce acute inflammation and pain, or warm compresses to relax muscles and soothe chronic discomfort.

Pharmacological Therapy

• Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): Oral NSAIDs (e.g., ibuprofen, naproxen) or topical NSAID creams/gels can help reduce pain and inflammation.
• Analgesics: Acetaminophen (paracetamol) for pain relief.
• Muscle Relaxants: If significant pelvic floor muscle spasm is present.
• Neuropathic Pain Medications: If nerve irritation is a component (e.g., gabapentin, pregabalin, tricyclic antidepressants).
• Stool Softeners: To prevent constipation and straining during defecation, which can aggravate coccyx pain.
• Neuropsychotropic Drugs: In cases where pain in the coccyx is significantly impacting the patient's emotional well-being, or if a strong psychosomatic component (like depression or anxiety) is contributing to pain perception, neuropsychotropic medications (e.g., antidepressants, anxiolytics) may be prescribed by a psychiatrist or appropriate specialist to help weaken the negative emotional background and improve coping.

 

Interventional Pain Management (Injections/Blockades)

If pain is severe or unresponsive to conservative measures, therapeutic injections may be considered:

• Local Anesthetic and Corticosteroid Injections: Injections into the sacrococcygeal joint, around the coccyx, into pericoccygeal ligaments, or into specific trigger points in the pelvic floor muscles (e.g., with lidocaine/novocaine and a corticosteroid like hydrocortisone, diprospan/betamethasone, or Kenalog/triamcinolone) can provide significant pain relief by reducing inflammation and blocking pain signals. These are often performed under imaging guidance (fluoroscopy or ultrasound).
• Ganglion Impar Block: A nerve block targeting the ganglion impar (a sympathetic ganglion located anterior to the sacrococcygeal junction) can be effective for some types of chronic coccygeal pain.
• Radiofrequency Ablation: In refractory cases, radiofrequency ablation of nerves supplying the coccyx has been explored.

Manual Therapy and Physiotherapy

• Manual Therapy: Techniques performed by a qualified physical therapist, osteopath, or chiropractor are mandatory if there are no contraindications. This can include:
  • Mobilization or manipulation of the coccyx (externally or internally via the rectum) to correct malalignment or improve mobility of the sacrococcygeal joint.
  • Soft tissue mobilization and myofascial release of tight pelvic floor muscles (e.g., levator ani, coccygeus) and surrounding ligaments.
  • Post-isometric relaxation (PIR) techniques for pelvic floor muscles, which serve not only as a therapeutic but also as a diagnostic technique, often relieving the patient's fear of the unknown by demonstrating a non-pharmacological way to influence their pain.
  Manual therapy aims to improve regional blood circulation and can sometimes completely restore the lost range of motion of an injured or stiff coccyx, particularly in women.
• Physiotherapy Modalities: Application of heat, cold, ultrasound, transcutaneous electrical nerve stimulation (TENS), UHF (Ultra-High Frequency) therapy, CMT (Sinusoidal Modulated Currents), or infrared radiation therapy to the coccygeal region can help reduce pain and inflammation.
• Exercise Therapy: Stretching and strengthening exercises for the pelvic floor, gluteal, and core muscles. Postural correction exercises.

Acupuncture

Acupuncture may be used as an adjunctive therapy to help manage pain in some individuals with coccygodynia.

Surgical Treatment (Coccygectomy - Rare)

Surgical removal of the coccyx (coccygectomy) is considered a last resort and is reserved for a small percentage of patients with severe, intractable coccygodynia that has failed to respond to all forms of comprehensive conservative and interventional management for an extended period (e.g., >6 months). The decision for surgery requires careful patient selection and thorough preoperative evaluation to confirm that the coccyx is indeed the primary source of pain. While it can provide relief for some, success rates vary, and potential complications exist.

Depending on the severity of pain manifestations, a combination of the following therapeutic actions is often employed: drug therapy (NSAIDs, analgesics, hormones if indicated for underlying conditions), therapeutic injections (into sacroiliac joints, spinal canal if related to referred pain, or trigger points in muscles), manual therapy (muscle, articular, and radicular techniques), physiotherapy, and acupuncture.

Differential Diagnosis of Coccydynia

Pain in the coccygeal region is not always due to direct coccyx pathology. A thorough differential diagnosis is important:

Condition	Key Differentiating Features
Coccygodynia (Primary)	Pain localized to coccyx, worse with sitting, rising, defecation. Tenderness on palpation of coccyx externally or via DRE. Dynamic X-rays may show instability/hypermobility.
Lumbosacral Radiculopathy (e.g., S2-S4 roots)	Pain may radiate to perineum/coccyx but often associated with low back pain and other neurological signs (sensory changes, reflex loss) in a dermatomal pattern. SLR may be positive.
Sacroiliac Joint Dysfunction/Arthritis	Pain often over SI joint, buttock, may refer to groin or posterior thigh, but typically not directly over coccyx tip. Positive SI joint provocative tests.
Piriformis Syndrome	Buttock pain, may radiate down leg (sciatica-like). Tenderness over piriformis muscle. Pain with specific hip movements. Coccyx usually not primary tender point.
Pelvic Floor Myofascial Pain / Levator Ani Syndrome	Deep pelvic ache, rectal pressure, pain with sitting. Tender trigger points in pelvic floor muscles on DRE or vaginal exam. Coccyx may be secondarily tender.
Pilonidal Sinus/Cyst (infected)	Pain, swelling, redness, drainage in the sacrococcygeal cleft (natal cleft). Visible sinus opening or abscess.
Proctalgia Fugax	Sudden, severe, episodic rectal pain lasting seconds to minutes, then resolves completely. Coccyx not typically tender between episodes.
Perianal Conditions (e.g., Anal Fissure, Hemorrhoids, Perianal Abscess)	Pain often related to defecation, bleeding, itching. Specific findings on anoscopy/proctoscopy.
Gynecological Conditions (in females)	Endometriosis, pelvic inflammatory disease, ovarian cysts. Pain often cyclical or associated with other gynecological symptoms. Pelvic exam findings.
Urological Conditions (in males)	Prostatitis. Pain often in perineum, pelvis, with urinary symptoms.
Tumors (rare - e.g., Chordoma, Sacrococcygeal Teratoma)	Persistent, progressive pain, may have palpable mass. Neurological deficits if advanced. Requires imaging (MRI/CT) and biopsy.

Prognosis and Prevention

The prognosis for coccygodynia is generally good with conservative treatment, with many patients experiencing significant relief. However, it can sometimes become a chronic and frustrating condition.

Preventive measures include:

• Using appropriate cushioning when sitting for long periods, especially on hard surfaces.
• Avoiding direct trauma to the tailbone.
• Maintaining good posture.
• Strengthening core and pelvic floor muscles.

When to Seek Medical Attention

It is advisable to seek medical attention for tailbone pain if:

• The pain is severe or does not improve with self-care measures after a few days/weeks.
• The pain started after a significant trauma or fall.
• There are associated symptoms like fever, unexplained weight loss, persistent numbness or weakness in the legs, or changes in bowel/bladder function (which could indicate a more serious underlying condition).
• The pain significantly interferes with daily activities and quality of life.

A healthcare professional can help determine the cause of the pain and recommend an appropriate treatment plan.