Chiropractic Management of Coccydynia
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Coccydynia originates from various traumatic and non-traumatic factors. Many cases resolve spontaneously; others can lead to chronic and potentially debilitating pain syndromes. (1) Patients and providers often ignore the problem since management may involve intrarectal assessment and management.
Fortunately, your ChiroUp team has recently compiled an up-to-date, best practice protocol for managing this troublesome complaint. Check out our top clinical pearls:
Coccydynia Etiology
Coccydynia symptoms can arise from many etiologies, including bruised or broken coccygeal segments, chronic myofascial irritation, and sacrococcygeal joint dysfunction, degeneration, or dislocation. Traumatic etiologies are more common than insidious onsets and can have many triggers:
Acute external trauma from a backward fall onto the buttocks (7)
Acute internal trauma during childbirth.
Chronic external trauma from prolonged sitting on hard or narrow seats (15)
Chronic internal trauma from repetitive straining for bowel movements or intercourse (70)
Repeated impact exercise (73)
Coccydynia Presenting Complaints
The classic coccydynia presentation includes:
Localized "tailbone pain” provoked by activity.
A "constant deep ache" that becomes acute, sharp, or shooting upon movement.
Worse when sitting, particularly when reclining backward. (16,17)
Increased pain arising from a seated position due to contraction from the gluteus maximus. (16,17)
Sexual intercourse and defecation can sometimes intensify discomfort. (70)
Coccydynia General Assessment
The goal of chiropractic coccydynia assessment is first to rule out bony pathology (fracture, dislocation) and then identify any contributions from soft tissues (myofascial pain, sprain/ strain) and joints (hypermobility vs. hypomobility).
Tenderness to palpation is the hallmark clinical finding of coccydynia. (20-23)
Direct palpation can help differentiate local versus referred sources of coccydynia, which do not typically include coccygeal point tenderness or swelling. (1)
Radiographs may be appropriate to help identify degenerative changes and rule out dislocation or fracture, particularly following traumatic onsets. (34,35)
Coccydynia Orthopedic Tests
Coccydynia orthopedic evaluation aims to provoke coccygeal pain via compression or traction.
Foye's finger test is a simple assessment to help differentiate sacrococcygeal versus lumbosacral or sacroiliac pain. The patient is asked to use one finger to point to their most intense site of pain. Pointing to the midline of the tailbone suggests coccygeal involvement. (26)
The seated recline test begins with the patient sitting upright on a firm surface and then rolling backward 30 to 45 degrees to transition weight from the ischial tuberosities onto the coccyx; reproduction of tailbone pain suggests coccygeal involvement.
⚠️ Coccydynia Internal Assessment Concerns
Manual therapists should carefully consider whether they are the best-suited clinician for internal hands-on coccygeal assessment and treatment. Before embarking on any internal palpatory evaluation, examiners must weigh many factors, including:
Scope Of Practice Laws
Training
Informed Consent
Patient Expectations
Gender Preferences
Liability Issues
Experts advise extreme caution by obtaining a signed and witnessed informed consent that clearly outlines the procedure and rationale, utilizing a professional chaperone/ observer during treatment, plus offering the opportunity for the patient to have an additional family member with them during treatment. Providers should also document each aspect of care, including their clinical justification for the assessment or procedure. (72)
Coccydynia Internal Rectal Examination
Some clinicians choose to perform an internal rectal examination of the coccyx to assess for tenderness and hypermobility or hypomobility of the sacrococcygeal joint and myofascial involvement. (1,22,23,29,71)
To perform an internal sacrococcygeal joint assessment, the clinician pinches the patient's coccyx between their internal finger and external thumb, then assesses mobility in flexion and extension. Normal motion varies between 5 and 15 degrees in either direction. (30-32) Lateral flexion and rotation motion can also be assessed. (73) Acute presentations may have difficulty tolerating internal assessment. (23)
The internal coccygeal myofascial examination would typically include a trigger point assessment of the levator ani, coccygeus, and obturator internus muscles via a 360-degree clock-like sweep to identify areas of local sensitivity or hypertonicity. (19,29,33). Clinicians will frequently identify one or more internal trigger points that reproduce the patient’s specific complaint. (33)
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Other Joints and Muscles
Coccydynia evaluation should include careful consideration of referral from lumbosacral or sacroiliac contributors. (23,29)
Chronic leaning toward one side to unload the tender coccyx while sitting can shorten the quadratus lumborum, TFL, iliopsoas, or piriformis. (71)
Clinicians should screen for potential concurrent functional deficits, including dysfunctional breathing, pelvic floor dysfunction, hip abductor weakness, and foot hyperpronation.
Coccydynia Treatment Considerations
Coccydynia is a common condition that can prove challenging to treat. (1,34) Fortunately, 90% of coccydynia cases can be resolved via straightforward conservative management. (38-40) Chiropractic coccydynia management decisions are based on etiological factors.
Acute presentations may benefit from relative rest, inflatable cushions, stool softeners, and NSAIDs, while chronic cases may benefit from myofascial release techniques. (41)
Gentle repositioning may be appropriate for acute trauma, mobilization may be appropriate for hypomobility, and myofascial release is best suited for addressing soft tissue origins. (19,42)
Coccydynia External Manipulation
Various authors have reported success with external manual or instrument-assisted manipulation/mobilization of the coccyx and sacroiliac joints. (43-45) Spinal manipulation should be considered for joint mobility deficits in the spine or pelvis.
Coccydynia Internal Manipulation Techniques
Intrarectal manipulation of the sacrococcygeal joint has shown merit. (25,47-50) Internal coccygeal manipulation is performed by grasping the patient's coccyx between the clinician’s internal finger and external thumb, then applying a gentle posterior pull to move the coccyx and sacrococcygeal joint into extension. (19,25,29,50,51) Extension over-pressure may be maintained for several seconds. (25) Gentle mobilization/ repositioning is performed once to reduce unstable fractures or dislocations and up to three repetitions per treatment session for more chronic and stable hypomobile presentations. (29)
Internal myofascial release of the levator ani, coccygeal, and obturator internus can be performed via a slow, internal 360-degree clock-like sweep to identify areas of local sensitivity or hypertonicity. The release is performed by applying 15 to 20 seconds of tolerable sustained compression over any identified trigger points. (19,33,50,52) External massage of the pericoccygeal muscles may also be helpful. (50,69)
Coccydynia Rehab Exercises
Clinicians should address the external muscles that impact coccygeal function, including the gluteus maximus, hamstrings, iliopsoas, and piriformis. (53,54) Additional mobility exercises could include posterior pelvic tilt and knee to chest. Exercises including the dead bug, bird dog, side bridge, and modified planks (on hands and toes, lift knees) progressing to planks may help improve core stability.
Supine Piriformis Stretch
Posterior Pelvic Tilt Standing
Knee to Chest
Coccydynia Treatment Expectations
Manual therapy, including massage, stretching, mobilization, and manipulation, has demonstrated positive clinical outcomes. (25,34,41,47-49,55,56)
Three sessions of intrarectal coccygeal manual therapy have a reported long-term success rate between 24 to 43%. (25,49,57,58)
Appropriate manual therapy typically produces results within 1-3 visits. (19,29)
Positive treatment prognosticators for manual therapy include a recent post-traumatic onset with relatively normal coccygeal mobility. (25,49)
Patients with coccygeal instability or immobility have lower success rates. (58)
Coccydynia ADL Considerations
Patients should consider using a modified wedge-shaped cushion to relieve coccygeal pressure while sitting. Patients should choose a U-shaped pillow over circular varieties, which place undesired pressure on the coccyx. (1) Other home advice includes:
Minimize prolonged sitting, particularly on hard or narrow seats, i.e., bicycles, motorcycles, horses, canoes, etc. (15,23,61)
Avoid sit-ups that can place an excessive mechanical load on the coccyx. (53)
Sit leaning slightly forward, thereby transitioning weight from the coccyx onto the ischial tuberosities.
A standing desk is often desirable.
Walking, swimming, and yoga may provide benefits for coccydynia patients. (53)
Maintain an optimal weight while avoiding excessively rapid weight loss. (62)
Temporarily avoid sexual positions that provoke symptoms.
Adequate fiber and water intake may help mitigate problems associated with constipation.
Avoid overly tight clothing.
Coccydynia Patient Education
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*ChiroUp would like to thank Dr. James Lehman and Dr. Jeff Tucker who provided extensive content and professional direction for this protocol.
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