Coccydynia, commonly referred to as tailbone pain, can be a profoundly limiting and misunderstood condition. Although it affects a relatively small percentage of patients, its impact on function and quality of life is often disproportionate to its size. As pelvic rehabilitation therapists, we are uniquely positioned to assess and treat the biomechanical, musculoskeletal, and neuromuscular contributors to coccydynia, especially when sitting becomes painful or intolerable.

Coccydynia is typically defined as pain in the coccyx region, often exacerbated by sitting, transitioning from sit to stand, or activities that increase pressure on the tailbone (e.g., biking or prolonged driving). While trauma, like a fall onto the tailbone or childbirth, is a common cause, many cases are idiopathic or associated with repetitive strain, postural dysfunction, or referred pain from nearby structures.

Some key contributors we see in clinical practice include coccygeal hypermobility or hypomobility, myofascial dysfunction (in pelvic floor muscles, gluteal, obturator internus, or levator ani muscles), lumbar/sacral or SI joint dysfunction, scarring or adhesions from previous surgeries or trauma, central sensitization, and chronic pain responses.

We can identify coccygeal mobility restrictions, myofascial tension, or biomechanical contributors by performing a thorough assessment and a combination of internal and external examinations. Key assessment components may include observation of seated posture and pelvic alignment. Palpation of coccyx and surrounding tissues externally and when appropriate, and consented to, internally. Evaluation of coccygeal mobility via rectal or vaginal exam. Screening for lumbar and sacroiliac joint dysfunction. Muscle tone assessment of pelvic floor and adjacent muscles, and Functional sitting tests and aggravating movements analysis.

Treatment Considerations
A multimodal treatment plan for coccydynia should be tailored to the root cause(s), and sensitive to the often-overlooked emotional burden of persistent sitting pain.

1. Manual Therapy

• Internal coccyx mobilization: Often essential in addressing hypomobility or malalignment. Gentle ventral/dorsal glides can restore mobility.
• Myofascial release: Releasing obturator internus, coccygeus, piriformis, and other key muscles often alleviates referred pain.
• External techniques: Sacral mobilizations, soft tissue work to gluteal and lumbar areas.

2. Postural and Ergonomic Re-education

• Patients may develop rigid, guarded postures to avoid pain. Education and cueing for neutral spine and dynamic sitting strategies are key.
• Use of coccyx cut-out cushions can immediately reduce pressure and allow for healing.

3. Pelvic Floor Muscle Re-training

• Address overactivity or guarding in pelvic floor muscles.
• Down-training, biofeedback, and coordination exercises may be appropriate depending on the findings.

4. Addressing Central Sensitization

• For chronic or severe cases, central nervous system sensitization may amplify symptoms.
• Incorporate pain neuroscience education, graded exposure, and nervous system regulation techniques (e.g., breathwork, mindfulness, or autonomic retraining).

Painful sitting is more than an inconvenience—it can become a barrier to work, relationships, travel, and participation in daily life. As pelvic rehab specialists, we have the skills to bring validation, relief, and long-term strategies to people with coccydynia. By blending hands-on techniques with nervous system support, posture retraining, and education, we can help patients reclaim comfort and confidence in their bodies—one seat at a time.

If you're ready to deepen your clinical reasoning and expand your toolbox for treating coccydynia, we invite you to join Lila Abbate, PT, DPT, OCS, WCS, PRPC, for the remote course Coccydynia and Painful Sitting on August 2, 2025. Lila brings decades of pelvic health experience and a dynamic, practical approach to treating coccyx-related pain. Don’t miss this opportunity to sharpen your assessment and intervention skills for one of the most under-treated yet impactful pelvic pain conditions.

Register now to secure your spot and transform how you approach coccyx pain in your practice.

References:

1. Dufour, S., Vandyken, B., & Carter, M. (2018). Pelvic Girdle Pain and Dysfunction: A Clinical Guide. Handspring Publishing.
2. Hesch, J. (2015). The Hesch Method of Treating Coccyx Dysfunction. International Journal of Osteopathic Medicine, 18(1), 50–57. https://doi.org/10.1016/j.ijosm.2014.09.003
3. Bordoni, B., & Varacallo, M. (2024). Anatomy, Back, Coccygeal Muscles. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK538485/

“But nothing showed up on the MRI…”
If you’ve worked with people experiencing chronic pelvic pain, you’ve likely heard this line (or screamed it into the void yourself). Pelvic pain is complex. It’s layered. And when traditional diagnostic tools come up short, patients are left confused, discouraged, and often dismissed.

This is where pain science education becomes not just helpful—it becomes essential. Especially when we’re talking about central sensitization, a sneaky, brain-driven process that keeps the pain party going long after the tissue has healed.

Let’s dig into what this means for our pelvic pain population—and why it’s time every clinician added “pain science educator” to their superpower list.

What Is Central Sensitization?
Imagine your nervous system is like a home security system. Normally, it detects real threats—say, a break-in or fire. But in central sensitization, the system is so sensitive that it goes off when a leaf blows past the window. The brain and spinal cord amplify pain signals, misinterpreting non-threatening input (like gentle touch, muscle movement, or a full bladder) as dangerous.

In the pelvic floor world, this might look like:

• Burning with urination despite no infection
• Pain with penetration, even with no visible tissue damage
• A “tight” pelvic floor that resists every stretch and cue
• General pain or pressure that moves, shifts, or seems unprovoked

Central sensitization isn’t “in someone’s head.” It’s in their nervous system—and it’s very, very real.

Why Pain Education Matters
Pain science education helps patients reframe their experience. When someone understands that pain is a protective mechanism (not a damage report), the fear cycle begins to break.

This is huge in chronic pelvic pain. Patients often carry shame, confusion, and even trauma around their symptoms. By educating them about central sensitization, we:

• Reduce fear and catastrophizing
• Improve trust in the body
• Increase compliance with movement and manual therapy
• Promote neuroplastic healing (yes, the brain can change!)

Think of it this way: You wouldn’t start strength training a rotator cuff tear without explaining what’s happening first. The same rules apply here—except our “tear” is happening at the nervous system level.

How to Integrate Pain Science into Pelvic Floor Treatment
You don’t need to be a neuroscientist or TED Talker to do this well. Here’s how we incorporate pain education into every evaluation and treatment session:

1. Use Metaphors that Stick

The alarm system analogy is a go-to. Others include:

• “Your brain is trying to protect you, but it’s become a little overprotective.”
• “Your nervous system is on high alert like a smoke detector that’s too close to the toaster.”

2. Normalize Their Experience

Validate their symptoms without reinforcing fear. “Your body is reacting in a protective way. We can help it learn to feel safe again.”

3. Introduce the Concept of Graded Exposure

Reassure them that movement, intimacy, and bladder function can return—gradually, safely, and with support. We’re not rushing into the fire; we’re slowly turning down the alarm.

4. Keep Repeating the Message

It takes time for the nervous system—and the brain—to rewire. Repeat, reframe, and reinforce education at every visit.

The Future of Pelvic Health Is Brain-Based
Pelvic pain isn’t just a musculoskeletal issue—it’s a nervous system experience. And the more we understand central sensitization, the better we can support our patients.

Pain education isn’t fluff. It’s foundational. It’s empowering. And it may just be the first real explanation your patient has ever received.

So, let’s keep spreading the word, turning down alarms, and helping patients feel safe in their bodies again.

Because healing starts with understanding—and we’ve got a lot of explaining to do (in the best way possible).

Want to dive deeper into the why behind pain?
Learn how to distinguish between peripheral pain generators and central sensitization, understand how these mechanisms show up in the body, and gain practical strategies to address them in both pelvic pain and orthopedic patients.

Join us for our remote pain science course, Pain Science for the Chronic Pelvic Pain Population on June 21-22, where complex concepts meet clear, clinical application, even including verbatim script examples with real-life patients.

AUTHOR BIO
Tara Sullivan, PT, DPT, PRPC, WCS, IF

Dr. Tara Sullivan, PT, PRPC, WCS, IF (she/her) started in the healthcare field as a massage therapist practicing for over ten years, including three years of teaching massage and anatomy & physiology. During that time, she attended college at Oregon State University, earning her Bachelor of Science degree in Exercise and Sport Science, and she continued to earn her Master of Science in Human Movement and Doctorate in Physical Therapy from A.T. Still University. Dr. Tara has specialized in Pelvic Floor Dysfunction (PFD), treating bowel, bladder, sexual dysfunctions, and pelvic pain exclusively since 2012. She has earned her Pelvic Rehabilitation Practitioner Certification (PRPC), deeming her an expert in the field of pelvic rehabilitation, treating men, women, and children. Dr. Sullivan is also a board-certified clinical specialist in women’s health (WCS) through the APTA and a Fellow of the International Society for the Study of Women's Sexual Health (IF).

Dr. Tara established the pelvic health program at HonorHealth in Scottsdale and expanded the practice to 12 locations across the valley. She continues treating patients with her hands-on individualized approach, taking the time to listen and educate them, empowering them to return to a healthy and improved quality of life. Dr. Tara has developed and taught several pelvic health courses and lectures at local universities in Arizona, including Northern Arizona University, Franklin Pierce University, and Midwestern University. In 2019, she joined the faculty team at Herman and Wallace, teaching continuing education courses for rehab therapists and other health care providers interested in the pelvic health specialty, including a course she authored-Sexual Medicine in Pelvic Rehab, and co-author of Pain Science for the Chronic Pelvic Pain Population. Dr. Tara is very passionate about creating awareness of Pelvic Floor Dysfunction and launched her website pelvicfloorspecialist.com to continue educating the public and other healthcare professionals.

In March 2024, Dr. Tara left HonorHealth and founded her company, Mind to Body Healing (M2B), to continue spreading awareness on pelvic health, mentor other healthcare providers, and incorporate sexual counseling into her pelvic floor physical therapy practice. She has partnered with Co-Owner, Dr. Kylee Austin, PT.