The Coccyx: The Small but Mighty Pain Generator

Lila Abbate, PT, DPT, MS, OCS, WCS, PRPC is a Board-Certified Specialist by the American Physical Therapy Association in Orthopedics (OCS) 2004 and Women’s Health (WCS) 2011. She has obtained the Certified Pelvic Rehabilitation Practitioner (PRPC) in 2014. She is a Diane Lee/LJ Lee, Integrated Systems Model (ISM) graduate and completed the New York series in 2012. Dr. Abbate is Senior Faculty with Herman & Wallace and can be found instructing the Pelvic Floor Series as well as her own courses Coccydynia and Painful Sitting and Bowel Pathology and Function.

Pain with sitting is a common complaint that patients may present to the clinic with. While excess sitting has been shown to be detrimental to the human body, sitting is part of our everyday culture ranging from sitting at a meal, traveling in the car, or doing work at a desk. Often, physical therapists disregard the coccyx or tailbone as the possible pain generator, simply because they are fearful of assessing it, have no idea where it is, or have never learned about it being a pain generator in their education.

Coccydynia is the general term for “pain over the coccyx.” Patients with coccydynia will complain of pain with sitting or transitioning from sitting to standing. Despite the coccyx being such a small bone at the end of the spine, it serves as a large attachment site for many important structures of interest that are important in pelvic floor support and continence:¹

• Anterior Tip: Iliococcygeus and pubococcygeus, Sacrococcygeal ligament
• Lateral: Coccygeal muscles which runs parallel with the sacrospinous ligament
• Posteriorly: Fibers of gluteus maximus and sacrotuberous ligament

Along with serving as a major attachment site for the above structures it provides support for weight bearing in the seated position and provides structural support for the anus. However, the coccyx is only 10% weightbearing, so what seems to go wrong that this bone is taking the brunt of the weightbearing? Women are five times more likely to develop coccydynia than men, with the most common cause being an external trauma like a fall or an internal trauma like a difficult childbirth.^1,2 In a study of 57 women suffering from postpartum coccydynia, most deliveries that resulted in coccyx pain were from the use of instruments such as forceps delivery or vacuum-assisted delivery. A BMI over 27 and having greater than or equal to 2 vaginal deliveries resulted in a higher rate of coccyx luxation during birth. ³ Other causes of coccyx pain can be non-traumatic such as rapid weight loss leading to loss of cushioning in sitting, hypermobility or hypomobility of the sacrococcygeal joint, infections like a pilonidal cyst, or pelvic floor muscle dysfunction.¹ When assessing a patient with coccyx pain, it is also of the utmost importance to rule out red flags, as there are multiple cases cited in the literature of tumors such as retro rectal tumors or cysts being the cause of coccyx pain. These masses must be examined by a doctor to determine if they are malignant or benign and if excision is necessary. Quite often, these masses can be felt as a bulge on rectal examination.^4,5

A multidisciplinary approach including physical therapy, ergonomic adaptations, medications, injections, and, possibly, psychotherapy leads to the greatest chance of success in patients with prolonged coccyx pain.¹ Special wedge-shaped sitting cushions can provide relief for patients in sitting and help return them to their social activities during treatment. Physical therapy includes manual manipulation and internal work to the pelvic floor muscles to alleviate internal spasms and ligament pain. Intrarectal coccyx manipulation can potentially realign a dislocated sacrococcygeal joint or coccyx.¹ Unique taping methods demonstrated in video by Dr. Abbate, can be used as a follow-up to coccyx manipulation to help hold the coccyx in the new position and allow for optimal healing. Often coccyx pain patients have concomitant pathologies such as pelvic floor muscle dysfunction, sacroiliac or lumbar spine pain, and various other orthopedic findings that are beneficial to address. When conservative treatments fail, injections or a possible coccygectomy may be considered.

Luckily conservative treatment is successful in about 90% of cases.¹ Join Lila Abbate in her upcoming Coccydynia and Painful Sitting remote course on March 31st. By learning how to treat coccyx pain appropriately, you will be a key provider in solving many unresolved sitting pain cases that are not resolved with traditional orthopedic physical therapy. 

References:

1. Lirette L, Chaiban G, Tolba R, et al. Coccydynia: An overview of the anatomy, etiology, and treatment of coccyx pain. The Ochsner Journal. 2014; 14:84-87.
2. Marinko L, Pecci M. Clinical Decision Making for the Evaluation and Management of Coccydynia: 2 Case Reports. JOSPT. 2014; 44(8): 615
3. Maigne JY, Rusakiewicz F, Diouf M. Postpartum coccydynia: a case series study of 57 women. Eur J Phys Rehabil Med. 2012; 48 (3): 387-392.
4. Levine R, Qu Z, Wasvary H. Retrorectal Teratoma. A rare cause of pain in the tailbone. Indian J Surg. 2013; 75(2): 147-148.
5. Suhani K, Ali S, Aggarwal L, et al. Retrorectal cystic hamartoma: A problematic tail. J Surg Tech Case Rep. 2104; 6(2): 56-60.

Coccydynia and Painful Sitting

Course Dates: March 31, June 17, September 22, and December 10  

Price: $175
Experience Level: Intermediate
Contact Hours: 5.5

Description: Coccyx pain is a common, frustrating condition for the patient who often has difficulty sitting, one of the most important tasks necessary for daily activity. Patients who find help from a pelvic rehabilitation provider have often experienced pain near the tailbone for long periods of time, leading to chronic pain in addition to neuromusculoskeletal dysfunctions. This one-day, remote continuing education course allows the therapist to focus on this vital, sensitive area to learn and refine skills in assessment and treatment. Anatomy, pathology, and palpation skills of the coccyx region are instructed. 

This course includes a video lab on both internal and external neuromuscular taping techniques which can immediately be applied in the clinic. This course also includes a review of seating options to reduce pain. 

Fun fact: Did you know that the pelvis fans and folds just like the hand and foot?
Ischial tuberosities change position and move medial to lateral and back based on the functional task. Pelvic floor muscles length and fascial integrity and its ability to conform to demands become an important factor in treating painful sitting.

The one-day course gives you a basic anatomy review and discusses the biomechanics of sitting and the difference of quadruped and its assessment. External coccyx treatments are explained and reviewed through video format along with a discussion to assist patients in making good decisions using sitting relief pillows. You will learn 5 basic tips to know if your patient has true coccydynia or if the pain is being driven from elsewhere up or down the chain. A review of the literature and how the medical community views basic coccydynia and which medical interventions can assist patients with long-standing sitting pain.