Cuckoo Over the Coccyx: Is Tailbone Pain Driving You Insane?
Tailbone pain which is also known as coccydynia, classically presents as pain over the region of your tailbone and can be quite literally a pain in the ass. The overall incidence is unknown, but women are five times more likely than men to have this problem (1).
First, lets give a brief overview of the anatomy of the spine. Your spine consists of your cervical spine (your neck), your thoracic spine (your midback), your lumbar spine (your low back), and then finally your sacrum and then coccyx, or tailbone, which is located at the very end of your spine. "Coccyx" was derived from the Greek word for the beak of a cuckoo bird because if you look from the side, it looks like the beak of a cuckoo bird. It is comprised of 3 to 5 fused vertebrae and it is triangular in shape (see the below images) and connects to the sacrum to make the sacrococcygeal joint (2).
Like the rest of the spine, the tailbone should have some movement in the joint in order for everything to function properly. I give the example of a rudder of a ship, small changes in the rudder create big changes in direction of the ship - imagine if your tailbone is out of alignment, the entire rest of the spine, up to your neck can be effected and possibly contribute to other types of neck and back pain. As I will discuss later, the coccyx can be either too stiff (hypomobile) or too mobile (hypermobile), both of which can cause problems.
What is the job of the coccyx?
The coccyx has many roles in the body including (1,2):
Insertion site for the pelvic floor muscles and pelvic ligaments in order to provide support to your internal organs
Helps to have healthy bowel movements
Provides weight bearing support when seated
Helps to maintain the position of the anus
Basically, if the tailbone can't move, or moves too much, this can not only be painful, but you may notice other issues like difficulty going to the bathroom, incontinence (leaking pee or poop), and pain when you sit, or other areas of pain in addition, like neck or lower back pain.
Common symptoms of coccydynia (1,2)
Pain over the coccyx
Worse with prolonged sitting or leaning back when sitting
Worse with prolonged standing
Worse when going from a seated position to standing
Pain with intercourse
Pain with bowel movements
Causes of tailbone pain
The most common cause of tailbone pain is due to external or internal trauma. External trauma is usually due to a backwards fall, which is common in ice skaters, snowboarders, and horseback riders (2). An example of internal trauma would be childbirth, especially if it is a difficult delivery or there is instrumentation used.
Minor trauma and repetitive stress is also a common cause of tailbone pain. Today, many of us sit at desks for hours on end and tend to slump, if you drive often, the carseat may cause you to adopt this slumped position and what that does is causes increased pressure on the tailbone especially on hard or narrow surfaces (2).
Other causes can be from degenerative joint or disc disease, hyper- or hypomobility of the sacrococcygeal joint, infections as well as anatomical variations can also lead to pain in this area (2).
First line treatments
Conservative treatment can help 90% of cases of tailbone pain (Lirette). This consists of pelvic floor physical therapy, rest, as well as lifestyle and behavioral modifications such as cushions if you sit for a prolonged time, limiting prolonged sitting or standing throughout your day, proper posture while sitting and standing, as well as modalities like heat/ice and NSAIDs (1-3).
What happens in a pelvic floor physical therapy treatment session?
Pelvic floor physical therapy is a first-line treatment for coccyx pain. Pelvic floor physical therapists have specialized training in evaluating and treating conditions of the pelvis.
In a typical session, your pelvic floor PT should take a thorough history of your pain in order to help determine the cause as well as any other issues that may be related to your injury or symptoms. After taking a thorough history, your pelvic floor PT should provide you with education regarding anatomy of the spine and pelvic floor, to help give you a clearer picture of what is going on and why you are having pain.
After this part comes the examination. Because the coccyx is part of the spine, your PT should do a screen of your posture in sitting and standing as well as check your alignment in standing, sitting, as well as lying down. Your PT will also palpate (feel) your muscles around the pelvis and assess the joint mobility in your spine - including the sacrum and coccyx (externally).
The last part of the examination is internal palpation of the pelvic floor muscles, this can be done vaginally with a gloved finger, but it is necessary in cases of coccyx pain that an internal rectal exam is performed to check the alignment of the coccyx, the muscles directly attaching to the coccyx, as well as identify the mobility status of the coccyx by using the index finger internally and thumb externally simultaneously.
Based on the patient's history and objective findings your therapist will come up with a treatment plan and likely send you home with some exercises or suggestions for home and work to help alleviate your pain. Treatment techniques will vary based on findings, but will almost always include manual therapy. If you have a hypomobile (stuck) coccyx, your therapist will need to mobilize it, if it is too loose, you will need to work with your therapist to stabilize it and your therapist will look beyond the coccyx to figure out the other contributing factors like muscle imbalances or trigger points in the muscles surrounding the pelvis. Treatment will often include massage, myofascial release, and muscle trigger point release to the internal pelvic floor muscles, especially if muscle spasm is present (3).
Additionally, your therapist can help identify if there are any other providers you may need to see (see second line treatments below) as coccyx pain can require more than just manual therapy.
Second line treatments
For those that don't respond to conservative treatments, interventional procedures like guided injections at the site of the coccyx, neurolysis, radiofrequency ablation, and ganglion impar blocks and can be in conjunction with physical therapy; however, there is a lack of evidence-based literature to support these techniques, empirically, these can be beneficial (1-3).
If all else fails, surgical removal of the tailbone is a treatment option for patients who do not respond to conservative and one study reported that at 1 year post-operatively, 80% of patients had reported excellent results; however, this study only had 10 patients in it which limits its usefulness (1).
How do I find a pelvic floor physical therapist?
You may already be working with a physical therapist or other health care provider, they can also be great resources in finding a qualified provider to help you, so ask!
There are a few websites that you can check out to find a provider in your area, click on the link to be redirected:
Elkhashab Y, Ng A. A Review of Current Treatment Options for Coccygodynia. Current Pain And Headache Reports. 2018;22(4):28. doi:10.1007/s11916-018-0683-7.
Lirette LS, Chaiban G, Tolba R, Eissa H. Coccydynia: An Overview of the Anatomy, Etiology, and Treatment of Coccyx Pain. Ochsner Journal. 2014;14(1):84-87. https://0-search-ebscohost-com.sclcatalog.muih.edu/login.aspx direct=true&db=aph&AN=103073658&site=ehost-live. Accessed September 9, 2019.
Maigne JY, Chatellier G. Comparison of three manual coccydynia treatments: a pilot study. Spine. 2001;26(20):E479. https://0-search-ebscohost-com.sclcatalog.muih.edu/login.aspx?direct=true&db=cmedm&AN=11598528&site=ehost-live. Accessed September 9, 2019.