Tailbone Pain, Coccyx pain, Coccydynia, Coccygodynia

 

Coccydynia is the medical term for pain of the coccyx (tailbone). Coccydynia is

also known as coccygodynia. Patients will often simply refer to this as “tailbone

pain” or "coccyx pain". The coccyx, or tailbone, is a group of small bones. These

bones are the lowest part of the human spine. They are located at the back of the

pelvis, between the buttocks, above the anus. Coccydynia is an uncommon

painful condition that originates from the coccyx, the tailbone at the end of the

spine. Trauma and falls are the most frequent causes of coccydynia. In the vast

majority of cases, nonsurgical treatment, such as medications and physical

therapy work well to ease symptoms.


Anatomy

The spine is composed of a series of bones called vertebrae. Joints that allow

movement while providing stability connect the vertebrae. The end of the spine,

the coccyx, has 3-5 small bones.The coccyx bones align in a curve like a small

tail. Some of the coccyx bones may be fused together. However, fewer than

10% of people have a completely fused coccyx.Muscles, ligaments, and tendons

attach to the coccyx. It plays a role in weight bearing when seated.

The primary conditions they found to be associated with coccyx pain were:

coccyx angled sharply forward; coccyx side-bending more to one side than the

other; and coccyx completely rigid (all segments fused together and fused to the

sacrum).


Why some hurt and others don’t is unclear. In the case of a misaligned coccyx, it

might be that the pain is caused by the coccyx pulling on muscles, ligaments or

overstretching the filamen terminale (end of the dural tube). Connective tissues

called the filum durae spinalis enclose the end of the spinal cord and attach it to

the deep dorsal sacrococcygeal ligament.

A major source of hip and back pain occurs as fibrotic sacrococcygeal ligaments

anteriorly flex (hook) the coccyx and compress/overstretch the sensitive filum

terminale In the case of a rigid coccyx, it might be that the tissues under the

inferior segments might create a pad of irritated tissue (like a bunion) that can rub

the dura raw.


Causes

Coccydynia is caused by trauma to the coccyx, such as from a fall, injury during

childbirth, or prolonged sitting. Trauma can cause ligament inflammation or

injure the coccyx where it attaches to the spine. In some cases, the cause is

unknown. When sitting, the coccyx shifts forward and acts as a shock absorber.

However, falling on the tailbone or events such as childbirth can lead to

coccygeal pain, known as coccydynia. In most cases, the pain is caused by an

unstable coccyx, resulting in chronic inflammation of the sacrococcygeal joint.

Coccydynia also can be attributed to a malformed or dislocated coccyx and the

growth of bony spurs on the coccyx. Resulting pain often is resolved by

performing specific soft tissue techniques to release the levator ani muscle,

anococcygeal, sacrotuberal and sacrospinal ligaments, as well as the gluteus

maximus muscles.


Another common etiology is childbirth. The coccyx is considered by some to be

in the way during childbirth. At the end of the third trimester, certain hormonal

changes enable the synchondrosis between the sacrum and the coccyx to soften

and become more mobile. This increased mobility of three to five coccygeal

segments allows for more flexion and extension, which might permanently

change the resting tension of the surrounding ligaments and muscles. Unlike

fractures, which can remodel, injuries to the sacrococcygeal junction often

become inflamed as the joint is repeatedly forced out of its normal position.

Physical examination should include direct palpation of the coccyx for

tenderness. In true coccydynia, the coccygeal region usually is markedly tender.

Direct trauma to the coccyx can result in coccyx fractures, dislocations, alignment

abnormalities, etc.. Examples of trauma to the coccyx could include a fall onto

the tailbone, pregnancy (and especially childbirth, which can put substantial

pressure onto the coccyx as the baby moves down within the pelvis), prolonged

sitting (especially sitting on a hard surface, or sitting on a narrow surface such as

a bicycle seat, or increased sitting due to immobility because of an injury at a

totally unrelated body region).


Pain referred to the coccyx from nearby body regions: Sometimes pain can be

referred to the coccyx from medical conditions at adjacent body regions. Thus, it

is often worthwhile to consider whether any medical conditions within the pelvis

and rectum may actually be the underlying source of the pain that the patient

feels predominantly at the coccyx. Other conditions that present with pain in the

buttock region can include bursitis (inflammation of a bursa, which is a fluid-filled

sac, of which there are many throughout the body).

"Idiopathic" coccyx pain: In many cases, the exact cause of the coccydynia

remains unknown. In these cases, the patient may not have any history of trauma

to the region, nor any associated medical conditions in the pelvis or rectum.


Symptoms

The primary symptom of coccydynia is pain. You may experience increased

sensitivity to pressure, especially when sitting and leaning backwards. The area

around your tailbone may ache. Coccydynia can cause pain that shoots down

the legs. It can also contribute to pain during sexual intercourse or bowel

movements. Certainly the classic, defining symptom for coccydynia is exquisite,

focal pain at the coccyx. The pain from the coccyx may travel (radiate) down into

the floor of the pelvis (e.g., into the lower genital region). Coccydynia is

frequently exacerbated by sitting, and especially by prolonged sitting or sitting on

a hard surface. Initial movement into the standing position (after sitting) may also

be painful. Most patients are able to locate their own coccyx bones, and will

indicate this spot as the primary focus of their pain. Patients will recognize the

coccyx location as being in the midline between the gluteal muscles (buttocks). A

patient wearing a belt would generally find their coccyx to be perhaps 4 to 7

inches below where the belt-line crosses the middle of their lower back. The

coccyx is located just slightly above the anus, and sometimes coccyx pain can be

exacerbated by defecation, especially if the bowel movement is particularly large

or hard. Unfortunately, coccydynia can be severe and persistent, and can

substantially decrease the quality of life for the affected patient.


Diagnosis

A doctor can diagnose coccydynia by reviewing your medical history and

examining you. You should tell your doctor if you have fallen or given birth

recently. Imaging tests, such as X-ray or MRI, may be used to rule out other

sources of pain. Electromyography (EMG) and nerve conduction studies may be

used to assess nerve function. Usually, an experienced physician can make the

diagnosis of coccydynia based upon a careful history and physical examination.

Additional diagnostic tests can include x-rays and other imaging studies.

Consultations with other physicians may be helpful if it is felt that the coccyx pain

is originating from medical conditions of the gastrointestinal tract (e.g., the

rectum), or originating from medical conditions of the reproductive organs

(uterus, ovaries, etc.).


Treatment

Coccydynia is typically first treated with non-steroidal anti-inflammatory

medications. Your doctor may recommend that you sit on a donut shaped pillow

to help relieve tailbone pressure. It may take several weeks or months for the

pain to decrease.


For persistent or severe pain, your doctor may prescribe pain medications. Local

medication injections are used to place numbing and anti-inflammatory

medications near the source (joint or bursa) of the pain. Nerve blocks are used

to interrupt a nerve’s ability to transmit pain signals.

Your doctor may gently move (manipulate) the coccyx after you receive a pain

relieving injection. You may be referred to physical therapy for gentle stretching.

Ultrasound therapy may be used, which soothes pain with warmth.

If treatments fail to relieve symptoms, surgery may be used to remove a portion

of the coccyx (coccygectomy). The short outpatient surgery is successful for

relieving symptoms for most people. However, surgery is very rarely used

There are a wide variety of treatments available for coccyx pain. Often, a

combination of treatment approaches is necessary in order to give adequate

relief.

Avoiding exacerbating factors: Patients can avoid exacerbating factors by

minimizing prolonged sitting and by avoiding sitting on hard surfaces.

Cushions: Sitting on cushions can be helpful, and especially sitting on "donut"

cushions (which have a hole cut out in the center, where the coccyx would

otherwise be pressing) or "wedge" cushions (which have a wedge-shaped

triangle cut out in the rear of the cushion, where the coccyx would otherwise be

pressing).


Medications taken by mouth: Pain may be decreased by the use of a variety of

medications taken orally. These include anti-inflammatory medications,

opioid/narcotic analgesics, medications used to treat nerve pain, and a variety of

other medications.


Medications given by local injection: In patients who are not receiving adequate

relief via cushions and oral medications, medications given by local injection may

provide substantial relief and may provide complete resolution of the pain. Unlike

caudal (epidural) steroid injections, nerve blocks for coccydynia may focus on

using a local anesthetic to block (temporarily shut-off) the nerves that carry

painful signals from the coccyx. These injections may especially target the

ganglion Impar, which is part of the sympathetic nervous system.


Coccyx surgery: Various surgeries of the coccyx have been considered

somewhat controversial, and may carry significant risks. Coccyx surgery would

generally only be considered in patients who have severe, persistent coccyx pain

despite non-surgical treatments, including the use of oral medications and focal

injections performed under the guidance of fluoroscopy. There are a small

percentage of patients with tailbone pain who may require surgical removal of the

coccyx (coccygectomy). Fortunately, most patients respond well enough to nonsurgical

treatments (especially including the injections) that they no longer need

to consider undergoing surgical treatment.