Tailbone pain can make everyday tasks uncomfortable at best, and unbearable at worst. The coccyx, a small triangular bone at the bottom of the spinal column, can get bruised and even fractured. Coccygodynia, sometimes referred to as coccydynia, coccalgia, coccygeal neuralgia or tailbone pain, is the term used to describe the symptoms of pain that occur in the region of the coccyx.

The pain is most commonly triggered in a sitting position, but may also occur when the individual changes from a sitting to standing position. Most cases will resolve within a few weeks to months, however for some patients the pain can become chronic, having negative impacts on quality of life. For these individuals, management can be difficult due to the complex nature of coccygeal pain.

Sign and Symptoms

• Achy or piercing pain in the tailbone.
• More severe pain when changing from sitting to standing up.
• More severe pain when sitting for long periods of time.
• Pain during bowel movements.
• Pain during sex.

Other related symptoms that may occur with coccydynia include:

• Depression.
• Anxiety.
• Poor sleep.
• Painful buttocks.
• Back pain.

• Local trauma. A direct injury to the coccyx is probably the most common cause of coccydynia. A fall on the tailbone can inflame the ligaments and injure the coccyx or the coccygeal attachment to the sacrum. Coccygeal trauma usually results in a bruised bone, but may also result in a fracture or dislocation either in the front or back of the coccyx.
• Repetitive stress. Activities that put prolonged pressure on the tailbone, such as horseback riding and sitting on hard surfaces for long periods of time, may cause the onset of coccyx pain. Tailbone pain from these causes usually is not permanent, but if inflammation and symptoms are not managed, the pain may become chronic and cause long-term altered mobility of the sacrococcygeal joint.
• Childbirth. During delivery, the baby’s head passes over the top of the coccyx, and the pressure against the coccyx can sometimes result in injury to the coccygeal structures (the disc, ligaments, and bones). While uncommon, the pressure can also cause a fracture in the coccyx.
• Tumor or infection. Rarely, coccydynia can be caused by a nearby tumor or infection that puts pressure on the coccyx.
• Referred coccyx pain. In rare cases pain will be referred to the coccyx from elsewhere in the spine or pelvis, such as a lumbar herniated disc or degenerative lumbar disc.

Certain factors may increase the chance of coccygeal pain developing. Risk factors for coccydynia include:

• Obesity. Pelvic rotation, including movement of the coccyx, is usually lessened in individuals who are overweight, leading to more continual stress being placed on the coccyx and increasing the chances of developing coccyx pain. One study found that a Body Mass Index (BMI) of more than 27.4 in women and 29.4 in men increases the risk for coccydynia following repetitive stress or a one-time injury.¹
• Gender. Women have a higher chance of developing coccydynia than men, due to a wider pelvic angle as well as trauma to the coccyx endured during childbirth.

Diagnosis

Coccydynia is typically diagnosed by gathering a thorough medical history and completing a physical exam.

• Palpation to check for local tenderness. A doctor will feel by hand (called palpation) to identify swelling and tenderness around the coccyx. Palpation may also be used to identify potential coccygeal spicules (bone spurs), cysts, or tumors.

• Intrarectal exam and manipulation. In some cases, a doctor may choose to manipulate the coccyx manually through the rectum, in order to assess limited or excessive mobility of the sacrococcygeal joint. Intrarectal manipulation may also be used to assess any muscle tension in the pelvis connecting to the coccyx.

Tests for Coccydynia

• Dynamic X-ray imaging tests. While there is some debate over the efficacy of imaging tests for diagnosing coccydynia, it is generally agreed that dynamic x-ray imaging is helpful. A dynamic X-ray produces two images—one of the patient sitting and another of the patient standing. A doctor will compare the images and measure the angle of pelvic rotation as well as the coccyx’s change in position from sitting to standing. If these measurements are outside of the normal range (between 5 and 25 degrees), too much or too little coccygeal movement can be identified as the cause of pain.
• Coccygeal discogram. Similar to the same procedure done on the lumbar spine, a coccygeal discogram consists of an injection of local anesthesia in the sacrococcygeal region. The injection targets a specific area in the spine, such as an intervertebral joint or disc, to identify the precise location where pain is being caused.
• CT or MRI scans. A static image of the coccyx taken by MRI or CT scan (one that does not illustrate pelvic rotation or movement) may be used if the suspected cause of pain is a fracture, tumor, or abnormal mobility of the sacrococcygeal joint. Static images, however, are usually not helpful for diagnosing coccydynia and are used sparingly when a source of coccydynia cannot be clearly identified using other means.

Treatment

• Non-steroidal anti-inflammatory drugs (NSAIDs). Common NSAIDs, such as ibuprofen (Advil), naproxen (Aleve), or COX-2 inhibitors (Celebrex), help reduce the inflammation around the coccyx that is usually a cause of the pain.
• Ice or cold pack. Applying ice or a cold pack to the area several times a day for the first few days after pain starts can help reduce inflammation, which typically occurs after injury and adds to pain.
• Heat or heating pad. Applying heat to the bottom of the spine after the first few days of pain may help relieve muscle tension, which may accompany or exacerbate coccyx pain. Common heat sources include a hot water bottle, chemical heat pack, long-lasting adhesive heat strip, or hot bath (as long as weight is kept off the tailbone in the bathtub).

• Activity modification. Alterations to everyday activities can help take cumulative pressure off of the tailbone and alleviate pain. These activity modifications may include using a standing desk to avoid prolonged sitting, using a pillow to take the weight off the coccyx, or adjusting posture so weight is taken off the tailbone when sitting.
• Supportive pillows. A custom pillow that takes pressure off the coccyx when sitting may be used. Pillows for alleviating coccydynia may include U- or V-shaped pillows, or wedge-shaped pillows with a cutout or hole where the tailbone is. Any type of pillow or sitting arrangement that keeps pressure off the coccyx is ideal and largely a matter of personal preference. A supportive cushion can be useful in the car, as well as in an office, classroom, or at home.
• Dietary changes. If tailbone pain is caused by or worsened with bowel movements or constipation, increased fiber and water intake, as well as stool softeners, is recommended.
• Surgery. During a procedure known as a coccygectomy, the coccyx is surgically removed. This option is typically only recommended when all other treatments fail.

If tailbone pain is persistent or severe, additional non-surgical treatment options for coccydynia may include:

• Injection. An injection of a numbing agent (lidocaine) and steroid (to decrease inflammation) in the area surrounding the coccyx may provide pain relief. The physician uses imaging guidance to ensure that the injection is administered to the correct area. Pain relief can last from 1 week up to several years. If the first injection is effective, patients may receive up to 3 injections in a year.

Physical Therapy. Some patients find pain relief through manual manipulation of the coccyx. Through manual manipulation, the joint between the sacrum and the coccyx can be adjusted, potentially reducing pain caused by inadequate coccyx mobility. Coccydynia may be reduced or alleviated by massaging tense pelvic floor muscles that attach to the coccyx. Tense muscles in this region can place added strain on the ligaments and sacrococcygeal joint, limiting its mobility or pulling on the coccyx.

• Stretching. Gently stretching the ligaments attached to the coccyx can be helpful in reducing muscle tension in the coccygeal area. A physical therapist, chiropractor, physiatrist, or other appropriately trained healthcare practitioner can provide instruction on appropriate stretches for relieving coccyx pain.
• TENS unit. Transcutaneous Electrical Nerve Stimulator (TENS) units apply electric stimulation that interferes with the transmission of pain signals from the coccyx to the brain. These devices can be good option for patients who wish to keep their intake of medications to a minimum. There are many varieties of TENS units, with some using high-frequency stimulation that are worn for short periods of time, and others using low-frequency stimulation that may be worn longer.

Prevention and Self care

• Avoid sitting down for long periods of time. When seated, avoid sitting on hard surfaces and alternate sitting on each side of the buttocks. Also, lean forward and direct your weight away from the tailbone.
• When moving to a sitting or standing position, lean forward as this helps alleviate pressure.
• Physical therapy can be beneficial in teaching pelvic floor relaxation techniques (reverse Kegels) which help get the coccyx into better alignment and can relieve the pain experienced when urinating or defecating.
• For traumatic injuries, apply ice to the tailbone area for 15-20 minutes, four times a day, for the first few days after the injury.
• Take non steroidal anti-inflammatory drugs (NSAIDS) such as aspirin or ibuprofen to reduce pain and improve your ability to move around. Do not take NSAIDS if you have kidney disease, a history of gastrointestinal bleeding, or are also taking a blood thinner — such as Coumadin — without first talking with your doctor. In that case, it is safer to take acetaminophen, which helps lessen pain but does not reduce inflammation.
• You can purchase a “doughnut” cushion or pillow to sit on. This cushion has a hole in the middle to prevent the tailbone from contacting the flat surface.
• Eat foods high in fiber to soften stools and avoid constipation.

 References

https://my.clevelandclinic.org/health/diseases/10436-coccydynia-tailbone-pain

https://www.physio-pedia.com/Coccygodynia_(Coccydynia,_Coccalgia,_Tailbone_Pain)

https://www.mayoclinic.org/tailbone-pain/expert-answers/faq-20058211

https://www.spine-health.com/conditions/lower-back-pain/coccydynia-tailbone-pain

https://www.webmd.com/cancer/tailbone-pain-coccydynia