Coccydynia; Causes, Symptoms, Diagnosis, Treatment

Coccydynia means the inflammation of the tailbone (coccyx or bony area located deep between the buttocks above the anus) is referred to as coccydynia. Coccydynia is associated with pain and tenderness at the tip of the tailbone between the buttocks. Sitting often worsens coccyx pain.

Another Names of Coccydynia

Coccygodynia (also referred to as coccydynia, coccalgia, coccygalgia, or coccygeal pain) is a painful syndrome affecting the tailbone (coccygeal) region. The word coccyx is derived from the Greek word kokkyx (“cuckoo”), on the basis of this structure’s resemblance to the shape of a cuckoo’s beak (see the image below).

Coccyx as compared with cuckoo’s beak.

Coccygodynia is a rare condition but can be highly unpleasant when it does occur. Patients’ chief complaint is pain, which typically is triggered by or occurs while sitting on hard surfaces. The pain often varies and sometimes is aggravated by arising from the sitting position.

Direct trauma to the tailbone is the most common cause of coccydynia, and usually leads to inflammation surrounding the coccyx, which contributes to pain and discomfort.

There are many cases reported in which pain begins with no identifiable origin (called idiopathic coccydynia

Anatomy of Coccyx

The coccyx or tailbone – is the very bottom portion of the spine. It is a small triangular bone at the base of the spinal column (backbone). It is located just above the cleft in the buttocks and curves forwards so that it points towards the front of the body. It represents a vestigial tail or the tail bone. It consists of 3-5 very small bones fused together. Movement between the bones is permitted by the fibrous joints and ligaments.

Derivation – The word coccyx is derived from the Greek word for cuckoo. It resembles the beak of a cuckoo.

Articulations – The coccyx articulates with the sacrum through a vestigial disc and is also connected to the sacrum with ligaments. There is very limited movement between the coccyx and the sacrum. The attachment is either a symphysis (Fibrocartilaginous fusion between 2 bones) or is a true synovial joint.

Ventral side – (part facing front) – This part is slightly concave and dorsal side is convex.

Transverse grooves – Present on both ventral and dorsal sides. These grooves show where the vestigial coccyx units had fused previously

The coccyx bones become more flexible – in pregnant women to facilitate them to give birth more easily . Coccydynia is typically caused by the following underlying anatomical issues:

Hypermobility, or too much movement of the coccyx puts added stress on the joint between the sacrum and coccyx and on the coccyx itself. Too much mobility can also pull the pelvic floor muscles that attach to the coccyx, resulting in tailbone and pelvic pain.
Limited mobility of the coccyx causes the tailbone to jut outward when sitting, and can put increased pressure on the bones and the sacrococcygeal joint. Limited coccyx movement may also result in pelvic floor muscle tension, adding to discomfort.
In rare cases, part of the sacrococcygeal joint may become dislocated at the front or back of the tailbone, causing coccyx pain.
A fall onto the tailbone in the seated position, usually against a hard surface, is the most common cause of coccyx injuries.
A direct blow to the tailbone, such as those that occur during contact sports, can injure the coccyx.
The coccyx can be injured or fractured during childbirth.
Repetitive straining or friction against the coccyx (as happens in bicycling or rowing) can injure the coccyx.
Sometimes, the cause of coccyx injuries is unknown.
Less common causes of coccyx injuries include bone spurs, compression of nerve roots, injuries to other parts of the spine, local infections, and tumors.

Coccyx bears the weight of our body when we sit down.
Muscles inserting on the anterior coccyx include the levator ani, which is sometimes considered as several separate muscle parts including the coccygeus, iliococcygeus and pubococcygeus muscles. This important muscle group supports the pelvic floor (preventing inferior sagging of the intrapelvic contents) and plays a role in maintaining faecal continence. Muscles originating on the posterior coccyx include Gluteus maximus, which is the largest of the gluteal muscle (buttock muscle) and functions to extend the thigh during ambulation.

Function of coccyx

Coccyx serves as a weight-bearing structure when a person is seated, thus completing the tripod of weight bearing composed of the coccyx and the bilateral ischium.
The coccyx bears more weight when the seated person is leaning backward. Therefore many patients with coccydynia sit leaning forward which shifts more of the weight to the bilateral ischium rather than coccyx.
Alternatively, patients with coccydynia may sit toward one side so that the body weight is exerted mainly on the ischial tuberosity with less pressure on coccyx. Such side leaning may lead to concomitant ischial bursitis in addition to the antecedent coccydynia.

The above factors may result from an injury to the coccyx, or may develop as idiopathic coccydynia.

Causes of Coccydynia

A diagnosis of coccydynia will usually identify one of the following underlying causes of pain

Local trauma – A direct injury to the coccyx is probably the most common cause of coccydynia. A fall on the tailbone can inflame the ligaments and injure the coccyx or the coccygeal attachment to the sacrum. Coccygeal trauma usually results in a bruised bone, but may also result in a fracture or dislocation either in the front or back of the coccyx.
Repetitive stress – Activities that put prolonged pressure on the tailbone, such as horseback riding and sitting on hard surfaces for long periods of time, may cause the onset of coccyx pain. Tailbone pain from these causes usually is not permanent, but if inflammation and symptoms are not managed, the pain may become chronic and cause long-term altered mobility of the sacrococcygeal joint.
Childbirth – During delivery, the baby’s head passes over the top of the coccyx, and the pressure against the coccyx can sometimes result in injury to the coccygeal structures (the disc, ligaments, and bones). While uncommon, the pressure can also cause a fracture in the coccyx.
Tumor or infection – Rarely, coccydynia can be caused by a nearby tumor or infection that puts pressure on the coccyx.
Referred coccyx pain – In rare cases pain will be referred to the coccyx from elsewhere in the spine or pelvis, such as a lumbar herniated disc or degenerative lumbar disc.
Obesity – Pelvic rotation, including movement of the coccyx, is usually lessened in individuals who are overweight, leading to more continual stress being placed on the coccyx and increasing the chances of developing coccyx pain. One study found that a Body Mass Index (BMI) of more than 27.4 in women and 29.4 in men increases the risk for coccydynia following repetitive stress or a one-time injury.

Gender – Women have a higher chance of developing coccydynia than men, due to a wider pelvic angle as well as trauma to the coccyx endured during childbirth.

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If pain is mild or moderate, it may not be necessary to identify the exact cause of coccydynia. In some cases, however, coccyx pain is severe or of a serious origin, so it is important to have a general idea why pain has developed so that it can be treated most effectively.

Symptoms of coccydynia

Because coccydynia strictly refers to inflammation in or near the tailbone, symptoms are highly localized. An individual experiencing coccydynia may encounter-

Pain in the coccygeal region (tip of the tail bone)
Local tenderness
The pain can range from mild to severe. It is usually worse when
- Sitting down
- Moving from sitting to a standing position
- When touched or when some pressure falls on the coccyx
Worsens with constipation, feels better after bowel movement
Some people can tolerate sitting in the same position for only a few minutes. They feel restless after a few minutes. They have to get up and move around to get relieved of the pain
Pain makes everyday activities difficult Ex. Driving, bending over, sitting down etc.
Sitting on a soft surface may be more painful than sitting on something hard. Sitting on a soft surface places most of your weight on your coccyx rather than on the hard bones below your pelvis.
Difficulty in sitting and leaning against the buttocks

Other symptoms of coccydynia

Backache
Shooting pain down the legs
Pain before or when stools are passed
Pain during sex (aggravates at or after sex)
Painful buttocks and hips
Increased pain during monthly periods in women
Difficulty to sleep comfortably at night, you may need to keep changing the positions while you sleep
Symptoms usually improve with relief of pressure when standing or walking

Pain in the tailbone area that worsens when sitting or leaning against something
Tenderness and redness in the affected area
Discomfort during bowel movements
Difficulty standing up from a resting position and performing other everyday activities, such as driving or bending down
Bruising near the coccyx
Some low back pain
Deep, intense aches in the tailbone region
Sharp pangs in the coccyx area

Test for coccygeal pain

A local anaesthesia is injected into the coccygeal area. If the pain is related to the coccyx, it reduces and there is immediate relief.
If this anaesthetic test is positive then a dynamic (sit/stand) X-ray or MRI scan show whether the coccyx dislocates when the patient sits

Other investigations

Stool guaiac test – should be done for occult test to assess for Gastro-intestinal pathology
Dynamic radiographs – obtained in both sitting and standing positions may be more useful than static
X-rays – because they allow for measurement of the saggital rotation of the pelvis and the coccygeal angle of incidence. A comparison of sitting and standing films will yield radiographic abnormalities in up to 70% of symptomatic coccydynia
MRI and technetium Tc-99m bone scans – may demonstrate inflammation of sacrococcygeal area indicative of coccygeal hypermobility
Provocative testing – of the coccyx such as pressing on the region with a blunted needle to elicit pain and pain relief with injection of local anaesthesia under fluoroscopic guidance may be helpful in diagnosis
Basically the diagnosis of coccydynia is done by a health care professional by taking a thorough medical history from the patient and completing a physical examination
X-ray of the sacrum and coccyx – to rule out an obvious fracture or a large tumour
An MRI scan – to rule out infection or spinal tumour as a cause of pain
Bone scans and CT scans – give little information. They are generally not done. Typically all imaging studies will be negative.
A thorough inspection / palpation of this area – is needed to detect any abnormal masses or abscesses (infections)
A lateral X-ray of the coccyx – is taken to help detect any significant coccygeal pathology such as a fracture

Differential Diagnosis

Coccyx Fracture (broken tailbone)
It presents with –

Pain that increases in severity when sitting or getting up from a chair or when experiencing a bowel movement
Provoked pain over the tailbone
Nausea
Bruising or swelling in the tailbone area

Sacro-coccygeal dislocation

It is a rare injury
Presents with pain in the sacro-coccygeal area generally followed by a fall or injury
On examination, a step will be felt in the continuity of sacrum and coccyx
The tip of the coccyx will not be palpable
Per rectal examination reveals a small bump on running the finger along the sacrococcygeal curvature
Plain radiographs of sacrococcygeal region – reveals anterior dislocation of coccyx over sacrum

Intracoccygeal dislocation – Here there is dislocation of one coccygeal segment from the other

Intrapelvic malignancy and / or metastatic lesions ,Ischial bursitis / Ischiogluteal bursitis

Ischial bursa (small sac filled with lubricating fluid) is located in the upper buttock area
Inflammation in this bursa is called Ischial bursitis
It causes dull pain in this area which is most noticeable when climbing uphill
The pain sometimes occurs after prolonged sitting on hard surfaces
It is also called as ‘weaver’s bottom’ or ‘tailor’s bottom’

Sacro-iliac joint pain or Sacroiliac joint dysfunction

It presents with pain in sacroiliac joint
Pain is experienced often in the lower back or at the back of the hips
Pain is sometimes present in the groins and thighs
Pain is typically worse with standing and walking and improves while lying down
Stiffness and burning sensation can be felt in the pelvis

Treatments of coccydynia

Many studies find that non-surgical treatments are successful in approximately 90% of coccydynia cases.^1,2 Treatments for coccydynia are usually noninvasive and include activity modification.

The first line of treatment typically includes self-care that can be done without the assistance of a medical professional, such as some of the following

Rest
Avoiding re-injury to the affected area
Anti-inflammatory medications – Non-steroidal anti-inflammatory drugs (NSAID’s). Common NSAID’s used are ibuprofen, naproxen, COX-2 inhibitors – they help to reduce inflammation around the coccyx which is causing the pain
Other pain killers – Tramadol (strong painkiller) – may be required in chronic and severe coccydynia. It may cause side effects like constipation, headaches and dizziness. It is usually prescribed for a short time because it is habit forming (addictive).
Avoid sitting for prolonged periods or placing pressure on the area as much as possible
Use a custom pillow to help take pressure off the coccyx when sitting. For some, a donut-shaped pillow works. Many prefer foam pillow that is more of a U or V shape (with the back open so that nothing touches the coccyx). In short, any pillow or sitting arrangement that keeps the pressure off the coccyx is welcome. A cushion with a cut-out at the back, under the coccyx is recommended while sitting
If the tailbone pain is caused or increased with bowel movements or constipation, then stool softeners and increased fibre and water intake is recommended
Increased fibres, stool softeners and mild laxatives are advised if the tailbone pain persists with bowel movements
Anti-depressants such as Elavil (amitriptyline) – relieves constant pain
Nerve block injection at the ganglion
If the pain is due to mal-alignment of the coccyx, manipulation by a chiropractor, osteopathic physician or physical therapist can offer relief

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Additional non-surgical treatments (when the pain is persistent or severe):

Injection – A local injection of a numbing agent like lidocaine and steroid (to decrease the inflammation) provides relief. These are done under fluoroscopic guidance. Relief lasts from 1 week to several years. More than 3 injections per year are not recommended
Manipulation – Manual manipulation Ex. Chiropractic treatment
Stretching – It involves gentle stretching of ligaments attached to the coccyx. A physical therapist, chiropractor, physiatrist or other trained healthcare practitioner can provide instruction on the appropriate stretches
Ultrasound: Physical therapy with ultrasound relieves pain

Corticosteroid injections

They reduce inflammation (swelling) and pain. They are sometimes combined with local anaesthetic for better efficacy. The pain relief from these may last for several weeks.

These injections cannot cure the condition and too many injections can damage the coccyx and lower back. Thus corticosteroid injections can be taken once or twice a year.

Ganglion impar nerve block

Ganglion impar are a cluster of nerves next to the coccyx. It is through these nerves that many of the pain signals travel. A ganglion nerve block temporarily suppresses these nerves by injecting them with a local anaesthesia to stop them transmitting pain signals.
This can be permanent in a few people while in others the pain will return after a few weeks or months. But the level of pain is usually lower. It is usually safe to have repeated injections of local anaesthesia.

Sacrococcygeal joint injections

When these joints are causing coccydynia, the joints are directly injected with a combination of corticosteroids and local anaesthetic.

Spinal manipulation

Physiotherapy – In this form of treatment physical methods like massage and manipulation are used to promote healing
Osteopathy – It is a manipulation technique that can detect and treat problems related to the muscles, nerves and joints
Chiropractic – It is a manipulation technique based on the theory that many health problems are related to the misalignments of the spine. It helps dealing with these misalignments.
Depression and anxiety which might be present especially if the pain has been there for a long period of time should be treated simultaneously.
Ice or cold pack. Applying ice or a cold pack to the area several times a day for the first few days after pain starts can help reduce inflammation, which typically occurs after injury and adds to pain.
Heat or heating pad. Applying heat to the bottom of the spine after the first few days of pain may help relieve muscle tension, which may accompany or exacerbate coccyx pain. Common heat sources include a hot water bottle, chemical heat pack, long-lasting adhesive heat strip, or hot bath (as long as weight is kept off the tailbone in the bathtub)
Activity modification. Alterations to everyday activities can help take cumulative pressure off of the tailbone and alleviate pain. These activity modifications may include using a standing desk to avoid prolonged sitting, using a pillow to take the weight off the coccyx, or adjusting posture so weight is taken off the tailbone when sitting.
Supportive pillows. A custom pillow that takes pressure off the coccyx when sitting may be used. Pillows for alleviating coccydynia may include U- or V-shaped pillows, or wedge-shaped pillows with a cutout or hole where the tailbone is. Any type of pillow or sitting arrangement that keeps pressure off the coccyx is ideal and largely a matter of personal preference. A supportive cushion can be useful in the car, as well as in an office, classroom, or at home.Using stool softener and increased water and stool softeners, when the tailbone pain is caused or increased with bowel movements or constipation;

- Ultrasound. Physical therapy with ultrasound can also be helpful for pain relief.

- Dietary changes. If tailbone pain is caused by or worsened with bowel movements or constipation, increased fiber and water intake, as well as stool softeners, is recommended

If the above treatments do not help manage or alleviate coccyx pain, additional treatments administered by a doctor, chiropractor, or other medical professional may be necessary.

Additional Non-Surgical Treatments for Coccydynia

If tailbone pain is persistent or severe, additional non-surgical treatment options for coccydynia may include:

- Manual manipulation. Some patients find pain relief through manual manipulation of the coccyx. Through manual manipulation, the joint between the sacrum and the coccyx can be adjusted, potentially reducing pain caused by inadequate coccyx mobility.

- Massage. Coccydynia may be reduced or alleviated by massaging tense pelvic floor muscles that attach to the coccyx. Tense muscles in this region can place added strain on the ligaments and sacrococcygeal joint, limiting its mobility or pulling on the coccyx.

- Stretching. Gently stretching the ligaments attached to the coccyx can be helpful in reducing muscle tension in the coccygeal area. A physical therapist, chiropractor, physiatrist, or other appropriately trained healthcare practitioner can provide instruction on appropriate stretches for relieving coccyx pain.

- TENS unit. Transcutaneous Electrical Nerve Stimulator (TENS) units apply electric stimulation that interferes with the transmission of pain signals from the coccyx to the brain. These devices can be good option for patients who wish to keep their intake of medications to a minimum. There are many varieties of TENS units, with some using high-frequency stimulation that are worn for short periods of time, and others using low-frequency stimulation that may be worn longer.

After attaining sufficient pain relief so movement is better tolerated, daily low-impact aerobic activity is beneficial, as the increased blood flow brings nutrients to the area and encourages the body’s natural healing abilities. An additional benefit of aerobic activity is the release of endorphins, the body’s innate pain relieving chemicals.

If non-surgical treatments or pain management methods are effective, prolonged use of these methods is a reasonable treatment option. In rare cases, a patient’s pain does not respond to non-surgical treatments and surgery on the coccyx may be considered.

Surgery

Neurotomy to denervate the peripheral nerve going to the coccyx. Under fluoroscopic guidance, the peripheral nerves are burned through radiofrequency thermal lesioning;
Partial rhizotomy, which involves drilling holes through the sacral plate lesioning of the dorsal root ganglia to the S5; and/or
Coccygectomy. If all else fails, a surgical coccygectomy can be performed for patients whose tailbone pain failed to respond to more conservative measures. The procedure involves the surgical removal of all, or part, of the coccyx. The recovery period for the patient is quite involved, and infection is a significant concern. A 2011 University of California Medical Center clinical case series, the largest in North America, monitored 62 consecutive cases of coccygectomy for coccydynia between 1997 and 2009. 26 patients were contacted for follow-up, on average 37 months post surgery. The clinical results among the 26 patients were as follows: 13 excellent, 9 good, 2 fair and 2 poor. The overall favorable (excellent and good) outcome after coccygectomy was 84.6%. There were 3 wound infections. There were no rectal injuries. An overwhelming majority of patients were satisfied with the procedure

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Indications for Coccygectomy Success

Coccygectomy tends to be most successful in carefully selected cases. The following criteria have shown an increased chance of positive results after surgery:^6,7

Patients whose pain is caused by changes in the shape of the coccyx, such as the presence of a spicule (a small bone spur at the end of the coccyx)
Patients with excessive mobility of the coccyx
The presence of a bursa, or a fluid-filled sac at the joint between the sacrum and coccyx
A good response to injection treatments

Many studies have reported good or excellent results following coccygectomy surgery, but the procedure is not recommended for all patients. If a patient is not considered a good candidate for coccygectomy, non-surgical treatments will likely be adapted to the patient’s needs and attempted again.

Potential Risks and Complications of Coccyx Surgery

Perhaps the biggest risk is continued pain in the coccyx post-operatively, meaning that the patient has endured the long healing process and still has not had improvement in the symptoms. For this reason, patient selection is crucial to a positive surgical outcome.

A possible but uncommon risk of coccygectomy is injury to the rectum as the coccyx is being removed. While it is unlikely, it is possible that if this were to happen, a diverting colostomy would be necessary to allow the rectum to heal.

Other potential risks include wound healing difficulties and/or local infection, which can delay the overall healing process. Unlike most other spine surgeries, there are no significant nerve roots in the region that would be at risk

Prevention:

Body positioning and alignment so as to produce less stress in the coccyx region, correcting daily activities like sitting etc that contribute to pain
Avoiding bad postures during daily activities
Not carrying excessive weights can reduce tension and pressure on the coccyx. We should also avoid sitting while carrying heavy weights
Maintaining body weight also reduces tension and pressure on the coccyx because over body weight and obesity are risk factors for Coccydynia
Avoidance of contact sports like basketball, football and or hockey can decrease the risk of coccydynia because it can help to reduce chances of falling
Use of proper safety equipment to prevent coccyx pain. Example – Hockey pants provide extra cushion that protect the thigh, coccyx and buttock. These will help in less falls which will reduce damage to coccyx
Stretches and strengthening exercises

Home Remedies

Epsom Salt

This home remedy can surely provide you quick relief. To try this you need to take a bath in the bath tub. Add two cups Epsom salt in the bath tub, when it is full of water. Mix the Epsom salt effects and then sit inside the bathtub for at least ten minutes. Epsom has ability to reduce pain occurring in the tailbone and it can effectively shrink the cyst.

Levator Ani Massage

Your tailbone pain can be easily terminated by applying Levator Ani massage. You have to take effective pain relief massage oil and do massage in the surrounded area of tailbone. It is how you can preciously reduce the pain and feel better for the work.

Avoid Tight Jeans

You should avoid wearing clothing like tight jeans, when you are suffering from tailbone pain. It increases inflammation and pain of tailbone, which is not good for your health. Wear lose clothes and sleep properly during the night to avoid increment in tailbone pain.

Tea Tree Oil

Tea tree oil can be an efficient cure for infected tailbone. This oil has ability of reducing infection plus increasing the healing process. You can apply tea tree oil as massage oil over an infected region and wear loose clothes to speed up healing process. It works and preciously reduces pain.

Use Special Cushions For Sitting

Dealing with tailbone pain can be daunting and irritating. Sitting and sleeping also becomes quite difficult with this pain that’s why special cushions are available for you. These cushions offer effective relief in sitting and thus you can complete your work without getting worried about tailbone pain.

Walking

Muscle strain is quite common during tailbone pain. This condition may turn into a very painful condition and it is quite important to relax muscles. You can do it by walking. Regularly walk, at least for ten minutes because it unblocks strained muscles. Walking can also help you in fixing tailbone’s displacement.

Turmeric

Famous as an efficient antibiotic ingredient, turmeric can also help you with healing tailbone pain. It prevents you from suffering from swelling around the tailbone. You should drink one-glass milk with turmeric daily. It is the cheapest way of reducing pain and avoiding infection.

Change In Sleeping Position

You need to prevent pressure on tailbone, which can be a little bit difficult during sleep. You should sleep on the stomach because thus you can easily prevent your tailbone from pressure. Some people prefer to sleep inside pose, but it is not a way of reducing tailbone pain.

Lime

Tailbone pain may come with infection around the tailbone. You should apply slaked lime with turmeric powder to treat it. Prepare a paste of slaked lime with turmeric and water and then apply it over the tailbone, you will get relief from the pain.