Coccydynia (Tailbone Pain)
The medical name “coccydynia” (coccyalgia, coccygodynia) is commonly called tailbone, coccyx or coxxygeal pain. It is a fairly rare and relatively poorly understood condition that can cause persistent severe and disabling localized pain at the very bottom of the spine.
The coccyx (tailbone) is a small triangular shaped bone composed of 3-5 fused or semi-fused segments is located at the end of the sacrum, which is part of the pelvis.
The various terms are all used to describe a set of symptoms in the tailbone that can be caused by various injuries or conditions. Treatment may vary depending on the underlying cause of the symptoms and the severity and duration of the symptoms.
Coccydynia is often associated with a local trauma such as falling on your behind or other events such as giving birth... but in many cases there are no obvious reasons. Quite often pain is referred from the sacroiliac joints, pelvic muscles and the lower back. It is therefore important to have a proper examination to determine why the pain is there and where it is coming from.
On rare occasions, an infection or tumor can also cause pain in the coccyx. In this instance, a medical referral is appropriate.
Sometimes the pain may be due to an unstable coccyx. You have a joint between the coccyx and the sacrum, which can be sprained. If this joint is unstable you may sprain it every time you sit down, hence recurring and chronic pain. When you have coccydynia it is especially painful to sit down or with any activity that puts pressure on the bottom area of the spine.
Why Do More Coccyx Injuries Occur in Women Than Men?
The majority of coccyx injuries occur in women because:
- The women's coccyx is rotated, leaving it more exposed to injury
- Women have a broader pelvis, which means that sitting places pressure on their coccyx (male anatomy causes them to sit without much pressure on the coccyx)
- Childbirth is a common cause of the condition.
History of Coccydynia
Coccydynia has a long history of being poorly understood. In the early 1900s, coccydynia was a popular diagnosis for all types of lower back pain. A fairly extreme treatment, the surgical removal of the coccyx (coccygectomy), was commonly undertaken to treat low back pain. At best, this operation had variable results.
Then the pendulum swung the other way, and the general opinion was that since the condition was mostly in women it was in some way related to "neurosis". The corollary was that if the operation did not work, it was because the pain was in the individual’s head; therefore the operation fell into disrepute and was no longer commonly performed. Subsequently, little research on the subject has been done.
Both extremes of opinion have long since fallen by the wayside, and it is now known that coccydynia does exist as a medical condition. However, it is fairly uncommon.
Anatomy of the Coccyx (Tailbone)
The coccyx is the very bottom portion of the spine. It represents a vestigial tail (hence the common term "tailbone") and consists of three or more very small bones fused together. The coccyx is made up of between three and five separate or fused vertebrae.
While it was originally thought that the coccyx is always fused together (with no movement between the coccygeal vertebrae), it is now known that the entire coccyx is not one solid bone but often there is some limited movement between the bones permitted by the fibrous joints and ligaments.
Specifically, coccydynia symptoms may consist of one or all of the following:
- Pain that is markedly worse when sitting
- Local pain in the tailbone area that is worse when touched or when any pressure is placed on it
- Pain that is worse when moving from a sitting to standing position
- Pain that is worse with constipation and feels better after a bowel movement.
Diagnosis and Investigations
The patient’s history can give a clear indication of what the cause is but that is not the case for every person. The first aim for the chiropractor is to find out if chiropractic treatment is appropriate for you. It is therefore often necessary to take x-rays or even MRI-scans to rule out more sinister causes of pain.
Dynamic x-rays are often very useful in order to rule out a dislocating coccyx, which can account for as many as 50% of the cases of pain from the coccyx.
The chiropractor would also palpate the coccyx and related muscles from the outside to determine if there is any localized tenderness on or around it. In some cases it might be necessary to do this internally.
The chiropractor will also examine related areas such as the pelvic joints and the lumbar spine.
The chiropractor will order to take two X-rays, one sitting and one standing. Comparing the X-rays shows whether your coccyx moves more than normal when you sit down.
Flexion greater than 25-30 degrees represents a hypermobile coccyx.
It is very rare to have instability in extension, but movement greater than 15-20 degrees is a sign of instability.
In about 40-50% of the cases, the dynamic X-ray examination fails to demonstrate a problem. In these cases with normal x-ray films the diagnosis is "idiopathic" coccydynia and the pain may be related to different problems such as:
- Intradiscal inflammation or chronic joint inflammation.
- In case of a rigid coccyx, with pain located at the tip, a bursitis is possible.
- In some cases, the pain is located at the sacral insertion of the sacrotuberous ligament.
- Pain referred from the sacroiliac joints and the lumbosacral area are often possible origins of referred pain over the coccyx.
When there is no obvious problem on the x-ray films, careful palpation is the only way to determine where the pain is coming from.
If the cause of coccydynia is within the scope of chiropractic, a combination of treatments to reduce the pain and activity modification to keep pressure off the tailbone usually suffices to control or alleviate the pain. In very rare cases, surgery to remove the coccyx may be recommended, but the surgery (a coccygectomy) will typically only be considered if the pain is severe and at least several months of non-surgical treatment and activity modification has not been effective in relieving the pain.
Treatments for coccydynia are usually noninvasive and local. The first line of treatment typically includes:
- Non-steroidal anti-inflammatory drugs (NSAIDs). Common NSAIDs, such as ibuprofen, naproxen and COX-2 inhibitors, help reduce the inflammation around the coccyx that is usually a cause of the pain.
- Applying ice or a cold pack to the area several times a day for the first few days after the pain starts.
- Applying heat or a hot pack to the area after the first few days.
- Avoiding sitting for prolonged periods, or placing any pressure on the area, as much as possible.
- A custom pillow, "Kabooti", to help take pressure off the coccyx when sitting. Some find a donut-shaped pillow works well, and for others it is not the right shape and still puts pressure on the coccyx. Many prefer a foam pillow that is more of a U-shape or V-shape (with the back open so nothing touches the coccyx). Any type of pillow or sitting arrangement that keeps pressure off the coccyx is ideal.
- If the tailbone pain is caused or increased with bowel movements or constipation, then stool softeners and increased fiber and water intake is recommended.
Additional Non-Surgical Treatments for Coccydynia
If the pain is persistent or severe, additional non-surgical treatment options for coccydynia (tailbone pain) include:
- Manipulation. Some patients find pain relief through manual manipulation (e.g. chiropractic treatment). Click here for study on chiropractic 'activator instrument' methods adjustment treatment of coccydynia.
- Stretching. Gently stretching the ligaments attached to the coccyx can be helpful. A chiropractor, physical therapist, physiatrist or another appropriately trained healthcare practitioner can provide instruction on the appropriate stretches.
- Ultrasound. Physical therapy with ultrasound can also be helpful for pain relief.
- Low-Level Laser Therapy: (LLLT) can also be helpful for pain relief.
- Injection. A local injection of a numbing agent (lidocaine) and steroid (to decrease inflammation in the area) can provide some relief. Fluoroscopic guidance is recommended. Relief can last from 1 week up to several years. No more than 3 injections per year are recommended.
Coccydynia is related to coccygeal instability in almost half of the cases. The diagnosis can be documented with dynamic X-ray films, which will show evidence of hypermobility.
Many times the coccydynia is due to referred pain from the lumbar spine, pelvic joints (sacroiliac joints) and related musculature.
An accurate diagnosis is important in order to direct the most appropriate treatment. Certain conditions are not suitable for chiropractic treatment and may require referral for a medical assessment.
An excellent website for more information on coccydynia is www.coccyx.org
Source: Richard A. Staehler, MD: www.spine-health.com