by Lauren Mathews
Coccydynia, also known as coccygodynia, is characterized by pain in and around the region of the coccyx. The cause is most often of a traumatic nature but it can also be from an infection or tumor. An injury can result in a bruise, dislocation or fracture of the coccyx bone.
The anatomy of the coccyx varies between individuals. It is the final segment of the vertebral column and is comprised of three to five fused segments. Between the first two segments an intervertebral disc may be present and can potentially be a site for hypermobility.1 The coccyx is attached to the sacrum via a fibrocartilaginous joint, called the sacrococcygeal symphysis, as well as the anterior sacrococcygeal ligament. The anterior side of the coccyx serves as an attachment site for the muscles of the pelvic floor including the levator ani (puborectalis, pubococcygeus and iliococcygeus) and the coccygeus muscle. The gluteus maximus attaches to the posterior side of the coccyx.1
The coccyx is a weight bearing structure during sitting and is stressed further when leaning backwards. Consequently, patients with coccydynia may find relief when sitting in a forward-leaning position.
Coccydynia is the cause of less than 1% of all reported cases of back pain and is five times more common in women1-3. The increase in incidence in women may be related to the increased pelvis width compared to men. Also a coccyx injury can occur during childbirth from increased pressure as the baby descends through the pelvis. There are studies that indicate an increase incidence in people with a higher BMI.3 However, it is also said to be seen in slim patients due to decreased amounts of buttock fat padding which allows the coccyx to rub against subcutaneous tissue or less padding during falls.2
The biggest complaint for patients with coccydynia will be pain in and around the coccyx and pain during sitting, especially in a backward-leaning sitting position. The pain onset is usually due to a traumatic incident to the area and may be accompanied by a bruise. Symptoms include:
- severe localize pain in the coccyx region
- visible bruising in the coccyx region
- pain is worse with prolonged sitting or direct pressure to the coccyx
- pain moving from sitting to standing
- pain during bowel movements or straining
- women may have pain during sexual intercourse
The most common etiology for a coccyx injury is trauma to the coccyx from a fall or a direct blow during contact sports. This type of injury can result in a fracture or dislocation at the sacrococcygeal junction that causes abnormal movement during sitting and significant pain. It is also commonly seen in bike riders after prolonged pressure to the area.
Childbirth is another common cause of coccyx injury. During the last trimester of childbirth the coccyx becomes more mobile, allowing for greater flexion and extension, which can cause damage to the tissues that attach to it as well as an inflammatory response.
Often times coccydynia is idiopathic in nature. Some less common causes are pudendal nerve injury, pilonidal cyst, obesity and piriformis pain.
Diagnosis can be made with a good subjective exam in conjunction with pain in the coccyx region, usually provoked during sitting. However, it is still important to do a complete examination. The physical examination should include clearing the lumbar spine and the SIJ, as these regions can cause pain to the coccyx. Palpation of the coccyx should provoke pain. The coccyx can be palpated internally or externally, however, proper palpation requires a rectal examination. To palpate, using a gloved hand, the index finger is inserted into the anus while the patient relaxes the sphincter muscles. The finger is inserted as far as possible while feeling for the anterior surface of the coccyx. The thumb of the same hand is placed on the outer, posterior aspect of the coccxy.6 (Therapist discretion is advised when doing this examination.) The coccyx then can be moved back and fourth. If palpation is not provocative then it may indicate referred pain from the lumbar spine, pelvic region or visceral structures such as the colon, rectum or urogenital system.2 The Valsalva maneuver may be positive.3
X-rays help to visualize a possible fracture or dislocation in the coccyx. Lateral X-rays can be taken in a standing then sitting position and can be used to measure the angle of the coccyx in each. Between 2° and 25° of movement is normal.3 MRI can also be used to assess the sacrum and coccyx to see if the pain is coming from a tumor or infection.2,3
The conservative approach to a coccyx injury includes the use of NSAIDs to reduce inflammation and pain. Anti inflammatory drugs can be injected in the area to help reduce pain. A donut shaped pillow can be used during sitting to reduce pressure to the area. Hot baths are often recommended to help soothe the irritated tissues.1-3
Manual therapy can also be used as a conservative treatment for a coccyx injury by aiming to relax and extend the muscles in the area to help move the coccyx back into a correct position. The two manual methods that can be used are an external or internal manipulation and mobilization.
The external manipulation is done by pulling the coccyx posterior towards the skin. This can be done in a sitting, prone or side lying position. The therapist palpates the coccyx and pulls in a posterior direction. After holding for a period of 10-60 seconds the tissues surrounding the coccyx should begin to release. A contract-relax method can be used in conjunction with this technique. As the coccyx is pulled posterior, the patient is asked to do a gentle contraction of the pelvic floor muscles for 3-5 seconds. Upon relaxation, the coccyx can be moved further posterior.1
The internal mobilization is done using a gloved hand and inserting one finger into the anus and massaging the muscles and ligaments attached to the coccyx. This positioning can be used to do anterior-posterior, lateral and medial mobilizations of the coccyx. If the coccyx is out of place, the therapist can use this positioning to move it back into a correct position.1 This is a sensitive procedure and it is important to explain its importance for physical therapyand the procedure to the patient. In addition, it is important to maintain paitent modesty.
Surgery & post-op treatment
Coccydynia is most often managed with conservative treatment. When conservative treatment does not work surgery may be an option. The surgical intervention involves removing the coccyx. Althought there are still current studies about the effectiveness of a coccygectomy for those who do not have sucess with conservative treatment,6 strong contraindications exist such as the long-term moderate results and chance of serious complications.7 The recovery period can be anywhere from 6 months to more than a year due to the fact that the patient has to sit on the surgical site.1
As with many trauma related injuries, cryotherapy can be beneficial to reduce pain and control inflammation and edema. Using cooling agents such as cold/ice packs, ice massage or ice bath, causes vasoconstriction of the cutaneous blood vessels and decreases blood flow to the area. By decreasing blood to the area of injury, the amount of bruising and edema is decreased. To minimize edema and the painful effects of inflammation, cryotherapy should be applied immediately after the injury and up to 72 hours after. The use of cooling agents is thought to decrease the activity of the A-delta pain fibers, thus cryo therapy can be used following the acute stage of inflammation for reducing pain as well. The following are contraindications for use of cryotherapy:
- Cold hypersensitivity
- Cold intolerance
- Paroxysmal cold hemoglobinuria
- Raynaud's Disease and Phenomenon
- Over an area with circulatory compromise or peripheral vascular disease
- An open wound
- Impaired sensation or poor mentation
- Very young or very old patients
- Patients with hypertension
Following the acute inflammation stage of healing, thermotherapy through the use of heat packs or warm whirlpool can be used to help relieve pain, promote tissue extensibility, and help with healing. For patients who require coccyx mobilization, heating the tissue prior to mobilizing may help with loosening the muscles that attach the coccyx. Heating the tissue reduces pain sensation by altering nerve conduction and transmission. Additionally, thermotherapy increases circulation and promotes vasodialation. Increased blood flow to the injured area accelerates healing by helping to bring oxygen and other nutrients as well as removing waste products from the area. The following are contraindications for the use of thermotherapy:
- Recent or potential hemorrhage
- Impaired sensation or mentation
- Malignant tumor
- Infared irradiation of the eyes
- Acute injury or inflammation
- Poor thermal regulation
- Cardiac insufficiency
- Over an open wound
- Demyelinated nerves
- Over areas where topical counterirritants have recently been applied
Ultrasound is often used for treating soft tissue injuries such as bruises. Ultrasound uses sound waves that penetrate tissues and can help with accelerating metabolic rate, reduce or control pain, decrease muscle spasm, alteration of nerve conductivity, increase circulation, and increase soft tissue extensibility. If a fracture is suspected, use caution, as ultrasound causes severe pain over fractured bones. Contraindications for ultrasound include:
- Malignant tumor
- CNS tissue (be aware of the proximity of the spinal cord to the treated area)
- Cement or plastic in the area to be treated
- Over reproductive organs
- Acute inflammation
- Epiphyseal plates
Transcutaneous electrical nerve stimulation (TENS) is also a common method of pain relief. TENS uses a comfortable level of electrical stimulation to stimulate A-beta fibers. By stimulating more A-beta fibers than pain fibers (A-delta and C fibers) pain perception is decreased. TENS should be used when the patient is experiencing pain and can be used up to 24 hours/day. The following parameters can be used when using TENS for pain relief: Frequency- high rate TENS, 100-150 pps; low rate TENS, below 10 pps. ON/OFF time- stimulation should be provided throughout the treatment, with no off time. Current Amplitude- should be set to the patients comfort. Treatment time- low rate or burst mode should be applied for a maximum of 20-45 minutes. Longer times may cause DOMS. High rate TENS can be worn as long as needed for pain relief. Contraindications of TENS includes:
- Pacemaker or unstable arrhythmias
- Over areas where venous or arterial thrombosis or thrombophebitis is present
- Pregnancy- over abdomen or low back
- Cardiac disease
- Patients with impaired mental status
- Over areas with impaired sensation
- Malignant tumors
- Areas of skin irritation or open wounds
Additional Web Based Resources
1. Coccyx Pain. Available at: http://www.coccyx.org///. Accessed November 19, 2010.
2. Coccygodynia. Available at: //http://emedicine.medscape.com/article/309486-overview//. Accessed November 19, 2010.
3. Pattijn J, Manssen M, Hayek S, Mekhail N, Zundert JV, van Kleef M. Coccygodynia. //Pain Practice. 2010;10:554-559.
4. Maigne JY, Chatellier G. Comparison of three manual coccydynia treatments: a pilot study. Spine. 2001;26:479-484.
5. Macgee DJ. Lumbar Spine: Orthopedic Physical Assessent. 5th ed. St. Louis: Saunders Elsevier;2008.
6. Traub S, Glaser J, Manino B. Coccygectomy for the treatment of therapy-resistant coccygodynia. J Surg Orthop Adv. 2009;18:311-316.
7. De Andres J, Chaves S. Coccygodynia: a proposal for an algorithm for treatment. J Pain. 2003;4:257-266.
8. Cameron MH. The Physical Agengs: Physical Agents in Rehabilitation. 3rd ed. St. Louis: Saunders Elsevier;2009.