Coccydynia has been defined as pain in and around the region of the tailbone. The word coccyx comes from the Greek term kokkoux for cuckoo, as it resembles the shape of a cuckoo's beak. It accounts for around 1% of all back pain conditions and is five times more common in women, perhaps because the coccyx is more exposed and prominent in women than in men.

What is the Coccyx?

The coccyx is a small triangular bone made up of 3 - 5 rudimentary vertebrae. These segments may or may not be fused together.

• It is joined to the lower part of the sacrum by the synovial sacro-coccygeal joint.
• It is supported by ligaments to the front (anterior sacro-coccygeal), side (lateral sacro-coccygeal) and back (posterior sacro-coccygeal).
• It has a nerve supply from the sacral plexus and the coccygeal nerve.
• The pelvic floor muscles attach to its tip

The coccyx flexes forward during contraction of the pelvic floor muscles eg during intercourse and extends backwards during labour and defecation. It can also bend to each side and rotate a little on its long axis. In many normal people the coccyx is angled forwards making it difficult to feel.

Causes of pain

Trauma

• Direct blow to the coccyx. The coccyx can be fractured, bruised or partially dislocated leading to abnormal movement of the coccyx when sitting or riding in a car.
• Childbirth
• Inflammation of the sacro-coccygeal joint.
• Sacro-coccygeal ligament sprain. Repetitive trauma (stretching) of the surrounding ligaments and muscles attached to the coccyx can result in pain and soreness when sitting or with straining.

Referred pain from other sources

• Lumbar spine facet joints and muscles
• Pelvic Floor Muscles
• Sacrospinous / Sacrotuberous Ligaments
• Buttock Muscles (Gluteus Maximus)

Tumours

• Secondary spread to the sacrum and coccyx bones
• Referred pain from lower rectal and anal tumours. If there is a history of altered bowel function or rectal bleeding, then this cause should be excluded before proceeding to any other treatments.

Investigations

X-rays shortly after an injury can reveal coccyx fractures. Spinal MRI scans can help to rule out a disc prolapse as a cause of referred pain. Dynamic x-rays or MRI scans can give a better insight into why the joint causes pain in different positions (seated being the most common).

Dynamic x-rays of the coccyx bone

Treatment

Coccygeal pain (coccydynia) is notoriously difficult to treat. Like any other painful condition, treatment should be directed to the source of the pain. However, the source can only be found after a thorough examination whilst considering all the possible local and referred causes.

Spinal Manipulation

When the cause of the coccyx pain is due to referred pain from the lumbar joints and paraspinal muscles, spinal manipulation can be very helpful.

Trigger Point Therapy (TPT)

Trigger point therapy to the Gluteal Muscles can be useful when these are the cause of referred pain to the coccyx. Exercises for these specific muscles can be extremely helpful.

Manipulation of the coccyx via the rectum

After an injury the coccyx can get stuck in one position. This can be due to stiffness of the sacro-coccygeal joint and spasm of the surrounding pelvic muscles. In women this can make sexual intercourse very painful, as using the pelvic floor muscles cause the coccyx to flex forwards.

The coccyx can be held using a pincer grip between the doctor's index finger (placed in the patient's rectum) and the doctor's thumb on the outside. The coccyx can then be gently manipulated into flexion / extension, side bending and rotation. Moving the coccyx backwards into extension also stretches the pelvic floor muscles when they are in spasm.

Sometimes a small click is heard when the coccyx is manipulated. This comes from the sacro-coccygeal joint as it releases.

Manipulation of the coccyx can be combined with a caudal epidural injection, sacro-coccygeal joint injection and intravenous sedation.

Sacro-coccygeal Joint Injection

Injection of a small amount of local anaesthetic and steroid into this joint can help when it is inflamed after an injury (eg fall onto the bottom). To make this treatment less painful a small volume caudal epidural injection can be done first helping to numb the area. The joint injection can also be combined with manipulation of the coccyx via the rectum.

Surgery

Removing the coccyx will fail to help if the coccyx is not the cause of the pain. It is important that all the other causes of referred pain to the coccyx are explored / treated before resorting to surgical removal. Surgical removal may be helpful where a posterior dislocation has been demonstrated in the seated position.

The latest research shows that common coccydynia is related to coccygeal instability in almost half of the cases. The diagnosis should be documented with dynamic X-ray films to evidence subluxations and hypermobility, which may need specific treatments. Treatment of common coccydynia should be considered according to this diagnosis.

PRESS RELEASE - Local Chiropractor wins national quality award

Dr Rebecca Willard was among the first to be awarded the ‘Clinical Management Quality Mark’ (CMQM) last week by The College of Chiropractors. Rebecca accepted her award at The Royal Society in London from Tim Jay FCC, President of the College.

"Chiropractors provide safe and effective treatment; we are proud to say that the award of the Clinical Management Quality Mark recognises this clinic’s commitment to operating in a professionally managed environment where we constantly strive to improve our level of service."

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