Coccydynia (Coccygodynia) - UpToDate

14/11/2018 Coccydynia (coccygodynia) - UpToDate
Official reprint from UpToDate®

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Coccydynia (coccygodynia)
Author: Patrick M Foye, MD

Section Editors: Patrice Eiff, MD, Mark D Aronson, MD
Deputy Editor: Lisa Kunins, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Oct 2018. | This topic last updated: Jan 25, 2018.
INTRODUCTION — Coccydynia is pain at the coccyx. It is also referred to as coccygodynia or tailbone pain.
Though coccydynia resolves with supportive care in the majority of patients, symptoms can persists for
months and years. Intractable coccydynia is relatively uncommon, but when it occurs it can dramatically
decrease a patient's quality of life. This topic will provide an overview of coccydynia, including diagnosis and
management.
ANATOMY — The coccyx is the lowest region of the vertebral spine, located inferior to the sacrum (figure 1).
Typically, the lower coccyx curves anteriorly, into the pelvis (figure 2 and figure 3). The coccyx, along with the
two ischial tuberosities, bears weight when a person is sitting, with an increased weight load on the coccyx
when a person leans back, partly reclining, in the sitting position (figure 4).
The coccyx typically has three to five vertebral segments, with fibrocartilaginous joints between the sacrum
and coccyx and between coccygeal segments. These joints are comparable with those seen in higher
intervertebral spaces but may be fused in the coccyx. Muscles and ligaments that insert on the sacrum and
coccyx (including the levator ani and its component parts) support the pelvic floor and participate in voluntary
control of the bowel.
PREVALENCE AND RISK FACTORS — The prevalence of coccydynia is unknown [1]. It most commonly
occurs in adolescents and adults [2,3], although children are sometimes affected.
Coccydynia is five times more prevalent in women than men [1,3]. The higher prevalence is thought to be
due to injuries that occur during childbirth as well as the coccyx being located more posteriorly in women
(figure 3) and thus more susceptible to external trauma [4].
Obesity is a risk factor [5,6]. It is hypothesized that obesity may lead to coccydynia by changing the way
people sit and/or by increasing the total weightbearing load.
ETIOLOGY — There are many etiologies for coccydynia, with the most common causes being related to
trauma [6,7]. Some cases may be idiopathic [5].
● External direct trauma – A common cause of coccydynia is direct external trauma from a fall
backwards into a sitting position, in which the coccyx is bruised, broken, or dislocated [1]. This may lead
to inflammation and spasm of the surrounding muscles.
● Repetitive minor trauma – Coccydynia may also occur in the setting of prolonged sitting from repetitive
minor trauma [1]. This occurs especially with poor posture, on a hard or ill-fitting surface (eg, during air or
car travel), or on a narrow surface (bicycle riding). This is also exacerbated by inflammation and muscle
spasm.
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● Maternal injury during childbirth – Injury is caused by pressure exerted on the coccyx during childbirth
(figure 5), especially during difficult delivery and with use of forceps [8,9].
● Posterior bone spicules/coccyx bone spurs – Coccydynia may be caused by a spicule or small bony
spur on the dorsal aspect of the lowest tip of the coccyx [5]. The spicule/bone spur irritates the coccygeal
region when the patient is sitting [7]. When sitting, the bone spur may pinch the underlying skin in
between the spur and the chair.
● Coccygeal instability – Both hyper- or hypomobility of the sacrococcygeal joint have been associated
with coccydynia [1,6]. Coccygeal dynamic instability (excessive mobility at the coccygeal joints) is
underappreciated and underdiagnosed, largely because sitting-versus-standing radiographs are rarely
performed. (See 'Imaging' below.)
● Osteoarthritis – Osteoarthritis may contribute to coccydynia [1]. However, though such changes are
commonly seen on radiographs, similar to findings on lumbar spine radiographs, it is not clear whether
radiograph findings correlate with symptoms of pain. (See "Evaluation of low back pain in adults", section
on 'Limited utility of imaging'.)
● Other – Somatization, particularly in the setting of known depression, has been reported as an etiology
of coccydynia [1,7]. However, psychological etiologies are not more common in coccydynia than in other
pain syndromes. (See "Somatic symptom disorder: Epidemiology and clinical presentation" and "Somatic
symptom disorder: Assessment and diagnosis".)
Patients may have coccydynia from complex regional pain syndrome. However, these patients may not
have the associated sensory changes, motor impairments, and autonomic symptoms. (See "Complex
regional pain syndrome in adults: Pathogenesis, clinical manifestations, and diagnosis", section on
'Clinical manifestations'.)
Rare causes include infection, metastatic cancer, calcium crystal deposits in the sacrococcygeal and
intercoccygeal joints, chordomas, benign notochordal cell tumors, avascular necrosis, arachnoiditis of
the sacral nerves, glomus tumor, and precoccygeal dermoid cyst [1,7,10-13]. (See "Spinal cord tumors",
section on 'Chordomas'.)
CLINICAL FEATURES
History — In patients with coccydynia, pain and tenderness are typically well-localized to the coccyx [1].
Patients complain of pain in the tailbone on sitting, especially when leaning back. Some patients have an
abrupt increase in pain during the transition from sitting to standing. Patients may also complain of pain with
defecation, sexual intercourse, and radiation of the pain to the floor of the pelvis from muscle spasms.
When evaluating a patient, we ask about the location of the pain, exacerbating positions/precipitants,
duration, severity, and any history of trauma. Asking the patient to point to the specific site of pain can usually
distinguish coccyx pain from typical lumbosacral sources of low back pain [14]. We also assess for specific
etiologies of coccydynia as well as other causes of pain in the same region by asking about:
● Pain associated with surrounding areas – Back, buttock, abdominal, rectal, or pelvic pain
● Symptoms of infection – Fever, chills, dysuria
● Symptoms of malignancy – Night sweats, weight loss, unexplained rectal or vaginal bleeding
● Symptoms of pelvic disease – Penile or vaginal discharge
Examination — In patients with coccydynia, focal external palpation of the coccyx that reproduces pain
symptoms but palpation of the surrounding area does not [1]. A focused external examination of the coccyx
should show pain and tenderness with focal external palpation and no surrounding erythema or swelling. In
patients where the diagnosis is uncertain with external palpation, internal palpation of the coccyx via rectal
examination can be helpful. The coccyx is grasped between the thumb and forefinger and is tender and
painful on movement, while adjacent structures are not tender. Other components of the physical
examination (eg, examination of the lumbosacral spine or pelvic exam) are performed based on concerns
from the history.
DIAGNOSIS
Clinical diagnosis — The diagnosis of coccydynia can be made on history and physical examination. In
patients with coccydynia, pain and tenderness are typically well-localized to the coccyx [1]. Patients complain
of pain in the tailbone on sitting, especially when leaning back. The diagnosis of coccydynia is confirmed by
focal external palpation of the coccyx that reproduces symptoms locally without pain in the surrounding area
[1]. If the diagnosis is uncertain based on external palpation, internal palpation of the coccyx via rectal
examination can be helpful. (See 'History' above and 'Examination' above.)
Additional evaluation — Most patients do not need imaging. Patients with mild or short-lived symptoms may
be managed without imaging studies. We obtain imaging for the following patients:
● Severe pain and history of blunt trauma – We obtain plain anterior-posterior and lateral radiographs in
patients with severe pain and a history of blunt trauma to assess for fracture. (See 'Management' below.)
● Symptoms concerning for infection or malignancy – We obtain imaging in patients with symptoms or
physical examination findings that suggest an underlying infection (eg, osteomyelitis, soft tissue
abscess) or malignancy (eg, chordoma, metastatic tumors). These patients include those with systemic
symptoms (eg, fevers, chills, night sweats, unexplained weight loss), concerning symptoms of nearby
organ systems (eg, unexplained rectal bleeding), or a concerning physical exam (eg, swelling, fistula, or
discharge around the coccyx or pain that is not localized to the coccyx).
We generally obtain magnetic resonance imaging (MRI) in these patients; however, other evaluation may
be appropriate if there is concern for a specific malignancy (eg, colonoscopy for rectal bleeding to
assess for colon cancer). When obtained, MRI should specifically include midline sagittal slices/images
in both T1 (to show bony details) and T2 or short tau inversion recovery (STIR) images (to show fluid
changes such as inflammation). (See "Clinical presentation, diagnosis, and staging of colorectal cancer",
section on 'Diagnosis' and "Principles of magnetic resonance imaging".)
● Persistent symptoms – Patients with persistent symptoms (>2 months) should have imaging. (See
'Imaging' below.)
DIFFERENTIAL DIAGNOSIS — The differential diagnosis for coccydynia includes disorders affecting
structures in the same region.
Pain may be referred to the coccyx from diseases of the spine. Spinal pathology, such as lumbar disc
disease, may coexist with coccydynia, so clinicians should pay close attention to the patient's specific site of
pain during both the patient history and physical examination [7]. Spinal disease alone does not cause
coccygeal tenderness to palpation, the hallmark of coccydynia. (See "Lumbar spinal stenosis:
Pathophysiology, clinical features, and diagnosis".)
If symptoms and tenderness on physical exam seem more localized to the pelvic floor muscles rather than
focal to the coccyx, disorders of the pelvic floor and pelvic organs (eg, prostatitis, pelvic inflammatory
disease, or other pelvic pain syndromes) should be considered. Patients with diseases of the pelvic organs
will generally have pain that is not localized to the coccyx and have other accompanying symptoms. (See
"Acute bacterial prostatitis" and "Pelvic inflammatory disease: Clinical manifestations and diagnosis" and
"Evaluation of acute pelvic pain in women" and "Causes of chronic pelvic pain in nonpregnant women".)
Other etiologies to consider include pilonidal sinus infection and proctalgia fugax. Pilonidal sinus infection
involves subcutaneous pain, redness, warmth, and swelling over the coccyx, often with a visible sinus and
purulent drainage. Proctalgia fugax refers to sudden attacks of fleeting rectal pain without gross pathology.
(See "Pilonidal disease" and "Proctalgia fugax".)
MANAGEMENT
Initial management — Patients found to have infection or malignancy should be treated accordingly. For
other patients with acute coccydynia, we start with conservative management with protection, analgesics,
and heat or ice rather than more invasive therapy [1]. Patients should also avoid exacerbating factors if
possible (eg, certain sitting surfaces).
Most cases of coccydynia (90 percent) will resolve either without medical care or with conservative
management [1]. Coccydynia associated with acute trauma is more likely to resolve than symptoms that
develop insidiously and without obvious cause. Most patients can expect symptom resolution over weeks to
months and should be managed conservatively for at least two months before considering other therapies.
● Protection – While it is not possible to put the injured part to complete rest, patients can protect their
coccyx while sitting by leaning forward so that weight is mainly borne on the ischial tuberosities and
posterior upper thighs (figure 4). "Donut" cushions (pillows with a hole in the center) or "wedge" cushions
(with a wedge-shaped section cut out of the back) distribute weight away from the coccyx. In our
experience, wedge cushions tend to be much more beneficial than donut cushions. Many styles of
cushions are sold in pharmacies or on the internet. Patients can also make a wedge cushion by cutting a
wedge out of a two- to four-inch foam rubber cushion.
● Analgesics – We start patients on nonsteroidal antiinflammatory drugs (NSAIDs) for pain relief unless
patients are diagnosed with an acute fracture. We avoid NSAIDs in patients with acute fracture as there
is some evidence to suggest that fracture healing may be impaired by NSAIDs. (See "Nonselective
NSAIDs: Overview of adverse effects", section on 'Possible effect on fracture healing'.)
In patients who have contraindications for NSAIDs, acetaminophen may be used. Opioid analgesics or
tramadol are options in patients with severe pain related to acute trauma and/or fracture.
There are no studies that have evaluated the effectiveness of analgesics in coccydynia [1]. However, as
NSAIDs are used to treat back pain and osteoarthritis, they are thought to be effective for coccydynia as
well. (See "Treatment of acute low back pain", section on 'Initial therapy' and "Overview of the
management of osteoarthritis", section on 'Overview of management'.)
● Heat or ice – Patients should try heat or cold based on their preference.
Intranasal calcitonin is being investigated as an option for therapy in patients with acute fracture, but there
are no randomized trials that have evaluated this treatment [15].
Persistent symptoms — A minority of patients develop chronic coccydynia, defined as symptoms persisting
for >2 months. Patients with persistent symptoms should be referred to a specialist with experience in
managing coccydynia for comprehensive care.
Imaging — We obtain imaging in patients with persistent symptoms. We generally start with plain
radiographs. If the patient has already had normal radiographs or the patient has developed symptoms
concerning for infection or malignancy, we obtain magnetic resonance imaging (MRI). (See 'Additional
evaluation' above.)
Coccygeal radiographs can evaluate for fractures, dislocations, hypermobility, bone spurs, and degenerative
changes [1]. When plain radiographs are performed, patients should have both anterior-posterior and
especially lateral radiographs. Specific types of radiographs are used to evaluate for particular etiologies of
coccydynia:
● Sitting-versus-standing films (coccygeal hypermobility) – To evaluate for coccygeal hypermobility

(dynamic instability), lateral radiographs are taken while standing (or supine) and while sitting in the most
painful position. Seated radiographs are also called coccygeal stress views, due to the weightbearing
stress upon the coccyx while sitting (figure 4). The alignment and angles of the coccygeal vertebral
bodies while standing and sitting are compared with evaluate for excessive mobility. Coccygeal
hypermobility is diagnosed when sitting causes the position of the coccyx to flex by ≥25 degrees, as
compared with the coccyx position while standing (or supine). Similarly, coccygeal hypermobility is also
diagnosed if sitting causes listhesis (subluxation) of more than 25 percent of the coccygeal vertebral
body, as compared with the coccyx position while standing (or supine) [5,16]. These seated images may
not be available at all institutions, as many radiology technicians and radiologists are not familiar with
this technique.
● Coned down lateral views (bone spurs) – To evaluate for distal coccygeal bone spurs, lateral
radiographs specifically using coned-down views are especially useful. For coned-down views, the
radiology technician attaches a collimator to the radiograph source to optimize the clarity of the
coccygeal images obtained.
Local injection — For patients with persistent symptoms, we suggest management with a series of
coccygeal injections containing local anesthetic or local anesthetic plus glucocorticoid. Local injection may be
most effective for patients with coccygeal instability or bone spurs. Ideally, prior to injection, an accurate
anatomic diagnosis should be made via imaging. Injections may be directed at the sacrococcygeal junction,
individual coccygeal joints, a coccygeal bone spur, the caudal epidural space, or the ganglion impar. Injection
of coccygeal structures, guided by fluoroscopy, with either local anesthetic or local anesthetic plus
corticosteroids, relieves or alleviates symptoms in many patients [1,7,17].
Case series have found positive results from injection at the ganglion impar, a midline sympathetic ganglion
located just anterior to the upper coccyx [18-22]. As an example, a series of 22 patients with persistent
coccydynia that failed to respond to initial conservative treatments found that ganglion impar injection
successfully provided >50 percent relief in 82 percent of patients, with a mean duration of relief of six months
[20]. The study also showed that a repeat ganglion impar injection typically provided an even longer effect,
with a median duration of relief of 17 months.
Other treatments — Many treatments have been advocated for persistent coccydynia, but the evidence
of effectiveness is variable. Pelvic floor physical therapy and manipulation are adjunctive treatments that may
be beneficial for specific patients.
● Pelvic floor physical therapy – Pelvic floor physical therapy is most helpful in patients with significant
pain within the muscles, tendons, and ligaments of the pelvic floor [1]. These patients often report pain
that is inferior and anterior to the coccyx, rather than pain that is strictly localized to the coccyx. They
may also have other pelvic floor symptoms, such as pain during sex or difficulties with bowel or bladder
function. A retrospective study of pelvic floor physical therapy in 79 patients with coccydynia found that
86 percent had a good outcome, defined as least a 40 percent improvement in average pain score, and
62 percent had an excellent outcome, defined as at least a 60 percent improvement in the average pain
score [23]. (See "Pelvic floor physical therapy for management of myofascial pelvic pain syndrome in
women".)
● Manipulation – We find manipulation most helpful in patients with pain from muscle spasms in proximity
to the sacrococcygeal region [1]. However, in patients with coccygeal hypermobility, fractures, and bone
spurs, manipulation may worsen symptoms. Manipulation via the rectum is done to massage muscles
attached to the coccyx that might be in spasm and to mobilize fascia and the coccyx [24]. This may
include levator ani massage/stretching.
In a randomized trial of 102 patients with chronic (>2 months) coccydynia, scores for pain and functional
impact improved over the six months for both the manipulation and placebo groups. The group that
received manipulation were more likely to improve compared with the placebo group (36 versus 20
percent), but neither group had a large improvement [25]. Also, manipulation was least likely to help
those with coccygeal hypermobility.
● Medications for chronic pain – Patients with persistent symptoms may respond to therapeutic
regimens that are used for patients with chronic pain of any etiology. Such regimens may include tricyclic
antidepressants or antiepileptic medications. However, there are no studies on use of these medications
in coccydynia. (See "Overview of the treatment of chronic non-cancer pain".)
● Other – Interventions that have advocates but no evidence of effectiveness include ultrasound, short-
wave diathermy, and transcutaneous nerve stimulation.
Intractable coccydynia — Surgical excision of the coccyx is generally a last resort reserved for patients with
intractable coccydynia who have undergone a full trial of nonsurgical treatments without relief. Complete
coccygectomy removes the coccyx at or just proximal to the sacrococcygeal junction, avoiding the rectum
(which is immediately anterior), and ideally leaving the periosteum and ligamentous attachments intact.
Partial coccygectomy leaves the upper coccygeal vertebral bone(s) in place.
Case series of patients undergoing coccygectomy report relief in most patients, although there is
disagreement about the magnitude of effectiveness, perhaps due to patient selection [26-30]. A 2011 review
of the surgical treatment of coccydynia excluding patients with malignancy found 24 articles, most
retrospective case series, reporting on 671 patients [31]. Seventy-five percent were reported to have
excellent/good outcomes. The complication rate was 11 percent, and complications were mostly infections
but also included hematomas, delayed wound healing, and wound dehiscence. Subsequent studies have
been consistent with the review. In a consecutive series of coccygectomies at an academic medical center in
California, 26 of 61 patients were followed for a median follow-up of 37 months, with 85 percent reporting
excellent/good outcomes [32]. In another prospective study, including 98 patients with chronic coccydynia
who had failed conservative management, 70 percent had improvement in patient reported pain and disability
at two years [33]. Thirty percent were classified as failures, including up to 6 percent with disability scores
worse than pre-surgery. In the absence of a randomized trial, it is not possible to know the extent to which
recovery was related to factors other than surgery.
SUMMARY AND RECOMMENDATIONS
● Coccydynia is pain in the coccyx. It is more common in women than men. Obesity is a risk factor. It is
most often related to trauma. (See 'Prevalence and risk factors' above and 'Etiology' above.)
● Diagnosis can be made by history and physical examination. Pain and tenderness are typically well-
localized to the coccyx, and symptoms are reproduced with direct pressure on the coccyx during a
physical examination. Unless acute fracture, infection, or malignancy is suspected, imaging is not
immediately necessary for most patients with acute coccydynia. (See 'Diagnosis' above.)
● For acute coccydynia (≤2 months) that is not caused by infection or malignancy, we start with
conservative management rather than more invasive therapy. Conservative treatments include protection
with wedge pillows, analgesics, and heat or cold applications. (See 'Management' above.)
Most patients can expect symptom resolution over weeks to months and should be managed
conservatively for at least two months before more aggressive management is tried.
● Patients with persistent symptoms (>2 months) should be referred to a specialist with experience in
managing coccydynia. We obtain imaging in these patients. (See 'Imaging' above.)
In the absence of randomized trials of effectiveness, we suggest management with a series of coccygeal
injections containing local anesthetic or local anesthetic plus glucocorticoid (Grade 2C). (See 'Local
injection' above.)
● We suggest that coccygectomy be performed only as a last resort for intractable cases (Grade 2C).
Results of effectiveness from randomized trials are not available and there is a risk of serious
complications, including infection and hematoma. (See 'Intractable coccydynia' above.)
ACKNOWLEDGMENT — The editorial staff at UpToDate would like to acknowledge Robert H Fletcher, MD,
MSc, who contributed to an earlier version of this topic review.
Use of UpToDate is subject to the Subscription and License Agreement.
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18. Foye PM. Ganglion impar injection techniques for coccydynia (coccyx pain) and pelvic pain.
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19. Foye PM, Buttaci CJ, Stitik TP, Yonclas PP. Successful injection for coccyx pain. Am J Phys Med
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20. Gunduz OH, Sencan S, Kenis-Coskun O. Pain Relief due to Transsacrococcygeal Ganglion Impar
Block in Chronic Coccygodynia: A Pilot Study. Pain Med 2015; 16:1278.
21. Gonnade N, Mehta N, Khera PS, et al. Ganglion impar block in patients with chronic coccydynia. Indian
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Topic 7772 Version 27.0
GRAPHICS
Anatomy of the sacrum and coccyx
Graphic 52932 Version 3.0
Superior view of female pelvis
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Anatomy of coccyx
Seating position and coccydynia (pain in the coccyx)
Pressure on coccyx during vaginal delivery (childbirth)
During a vaginal delivery, injury from pressure exerted on the coccyx, especially
during forceps delivery, can lead to coccydynia.
Reproduced from: U.S. Department of Health and Human Services Office on Women's
Health. Pregnancy: Labor and birth. Available at:
http://www.womenshealth.gov/pregnancy/childbirth-beyond/labor-
birth.html (Accessed on July 23, 2015).
Contributor Disclosures
Patrick M Foye, MD Nothing to disclose Patrice Eiff, MD Nothing to disclose Mark D Aronson,
MD Nothing to disclose Lisa Kunins, MD Nothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must conform
to UpToDate standards of evidence.
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14/11/2018 Coccydynia (coccygodynia) - UpToDate

Official reprint from UpToDate®

Author: Patrick M Foye, MD

● Symptoms of infection – Fever, chills, dysuria

● Symptoms of pelvic disease – Penile or vaginal discharge

● Sitting-versus-standing films (coccygeal hypermobility) – To evaluate for coccygeal hypermobility

SUMMARY AND RECOMMENDATIONS

Use of UpToDate is subject to the Subscription and License Agreement.

Topic 7772 Version 27.0

Anatomy of the sacrum and coccyx

Graphic 52932 Version 3.0

Superior view of female pelvis

Graphic 60078 Version 3.0

Graphic 101138 Version 1.0

Seating position and coccydynia (pain in the coccyx)

Graphic 59325 Version 3.0

Pressure on coccyx during vaginal delivery (childbirth)

Graphic 102921 Version 1.0

Conflict of interest policy

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