Understanding Coccydynia

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/