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Coccyx Pain

  • Author: Patrick M Foye, MD; Chief Editor: Consuelo T Lorenzo, MD  more...
 
Updated: May 26, 2016
 

Background

Coccyx pain (tailbone pain) can frustrate patients and significantly impair quality of life, but relief is possible.[1] (See Treatment and Medication.)

Coccyx pain was first documented in 1588, and the term coccygodynia was coined by Simpson in 1859.[2] Currently, the term coccydynia is used somewhat more commonly than coccygodynia. The 2 terms are interchangeable, however, and indicate pain localized to the coccyx. Neither term specifies the underlying etiology. Coccyx pain can occur from local trauma or a tumor, but many cases are idiopathic, with no identifiable cause. (See Etiology.)[3, 4]

Patients with coccyx pain often report that their physicians minimize, dismiss, or belittle their symptoms.[3] Indeed, many physicians may have a bias against patients with coccyx pain, which has been referred to as the “lowest” form of “low back pain.”[5] Tailbone pain is often relatively severe and persistent, causing significant compromise of the patient's ability to perform or endure various activities. Physicians who understand coccydynia and the available treatment options can provide a great service to this otherwise neglected patient population. (See Presentation, Workup, Treatment, and Medication.)

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Anatomy

The coccyx is the terminal end of the spine, just inferior to the sacrum. The human coccyx is often considered a vestigial remnant or corollary of a tail; thus, the coccyx is colloquially referred to as the tailbone. The word coccyx comes from the Greek word for cuckoo, the name apparently having been derived from the tailbone’s shape, which resembles that of a cuckoo’s beak.[2]

The human coccyx is composed of 3-5 individual segments (coccygeal vertebrae), with variations occurring with regard to the number of segments, the overall angulation (curve) of the coccyx, and the degree of articulation versus fusion between the individual segments. In 80% of patients, the coccyx is made up of 4 coccygeal vertebrae. Typically, the coccyx is concave anteriorly and convex posteriorly.

The base of the coccyx articulates with the sacral apex via the sacrococcygeal junction. The sacrococcygeal articulation and intracoccygeal articulations contain fibrocartilaginous discs, somewhat comparable to the intervertebral discs present at other spinal levels. The apex (distal tip) of the coccyx is typically rounded, but may be bifid. (See the image below.)

Lateral view of the pelvis and coccyx. The bracket Lateral view of the pelvis and coccyx. The bracket shows the area of focus for radiographs that would provide a coned-down view of mainly the coccyx and distal sacrum. A more common lateral view would often also include larger bony structures, such as the lumbar spine and femur, all of which would make it difficult to optimize visualization of the small bones of the coccyx. In patients with coccyx pain, these coned-down, lateral views of the coccyx can provide important diagnostic information. Coned-down images obtained in the weight-bearing (seated) position can be compared with those obtained in a non–weight-bearing position (eg, side lying), thus allowing assessment for dynamic instability (eg, dislocations that occur only while seated).

Muscles and ligaments

In humans, the coccyx serves important functions, including as an attachment site for various muscles, tendons, and ligaments. Physicians and patients should remember the importance of these attachments when considering surgical removal of the coccyx.

Muscles inserting on the anterior coccyx include the levator ani, which is sometimes considered as several separate muscle parts, including the coccygeus, iliococcygeus, and pubococcygeus muscles. This important muscle group supports the pelvic floor (preventing inferior sagging of the intrapelvic contents) and plays a role in maintaining fecal continence. A midline component is the anococcygeal raphe, by which the coccyx supports the position of the anus.[2] Muscles originating on the posterior coccyx include the gluteus maximus, which is the largest of the gluteal (buttock) muscles and which functions to extend the thigh during ambulation.

Multiple important ligaments attach to the coccyx.[2] The anterior and posterior sacrococcygeal ligaments attach the sacrum to the coccyx (similar to the functions of the anterior and posterior longitudinal ligaments spanning cervical, thoracic, and lumbosacral spinal segments). Laterally, the transverse process of the coccyx serves as an attachment site for the lateral sacrococcygeal ligaments (arising from the inferolateral sacrum), as well as for fibers from the sacrospinous ligament (arising laterally from the spine of the ischium) and the sacrotuberous ligament (connecting the sacrum with the ischial tuberosity, but with fibers attaching to the coccyx as well).

Function

The coccyx serves somewhat as a weight-bearing structure when a person is seated, thus completing the tripod of weight bearing composed of the coccyx and the bilateral ischium. The ischial weight-bearing surfaces are, more specifically, at the ischial tuberosities and inferior rami of the ischium.

The coccyx bears more weight when the seated person is leaning backward; therefore, many patients with coccydynia sit leaning forward (flexing at the lumbosacral and hip regions), which shifts more of the weight to the bilateral ischium rather than the coccyx (see the images below). Alternatively, patients with coccydynia may sit leaning toward one side so that the body weight is exerted mainly on one ischial tuberosity or the other, with less pressure on the coccyx. Such side leaning may lead to concomitant ischial bursitis in addition to the antecedent coccydynia.

Coccyx pain (coccydynia, or tailbone pain) is typi Coccyx pain (coccydynia, or tailbone pain) is typically worse when the patient is sitting. Often, the pain is even worse when sitting leaning slightly backward, since this increases the weight bearing on the coccyx, as shown in this image. Dynamic radiographs of the coccyx involve obtaining coned-down (focused) views of the coccyx while the patient is seated (eg, in his or her most painful position). Often, this involves having the patient lean backward 0-40°, depending on the symptoms. Radiographs obtained in this position are compared with those obtained in a non–weight-bearing position (eg, side lying) to assess for instability or dislocations in the seated position.
Patients with a painful coccyx often find it more Patients with a painful coccyx often find it more comfortable to sit leaning slightly forward, as shown in this image. This forward-leaning position minimizes any weight bearing on the coccyx itself and thus minimizes the exacerbation of coccyx pain. As shown, when a patient sits leaning forward, most of the weight bearing occurs bilaterally through the inferior ischial regions of the pelvis and the posterior thigh (femur) regions.
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Etiology

Causes of coccyx pain include trauma, fractures, dislocations, and primary or metastatic malignancies.[6, 7, 8] (A retrospective study by Dang et al of primary spinal tumors [438 patients] indicated that those of the sacrum or coccyx are more likely to be malignant.[9] ) Sources of acute, abrupt trauma include internal trauma (eg, giving birth) and external trauma (eg, falling onto the coccyx). Nonabrupt trauma may include prolonged sitting. Tailbone pain may begin after certain medical procedures, such as colonoscopy.[10] Some cases of coccydynia are idiopathic, without any identified etiology.

One risk factor for coccyx pain is aging; degenerative changes of the sacrococcygeal junction and the intracoccygeal junctions, as well as fusion at these sites, seem to increase with age.

A gender-specific risk factor in females is trauma related to giving birth; substantial pressure may be placed on the coccyx as the baby descends through the mother's pelvis.

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Epidemiology

Coccydynia is considered to be relatively uncommon, but data are lacking on the exact incidence and prevalence of the condition.

Coccydynia is seen in males and females; however, women seem to be affected more frequently than men.[3] As previously mentioned, one gender-specific risk factor in females is trauma related to giving birth; the coccyx may endure substantial pressure as the baby descends through the mother's pelvis.

Coccydynia can occur in children and adults. Degenerative changes of the sacrococcygeal junction and the intracoccygeal junctions, as well as fusion at these sites, seem to increase with age.

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Prognosis

While some patients with coccydynia have complete relief via natural recovery over time, others develop a persistent, chronic pain syndrome at the coccyx region.

One proposed reason why coccyx pain seems to be more chronic than other injury sites is the inability to immobilize or brace the site (eg, as compared with bracing and casting that is available for injuries at the wrist, ankle, or others, but is not available for similar immobilization at the coccyx). This may contribute to delayed or prolonged recovery as well as the development of chronic, persistent, intractable pain syndromes.

Once the coccyx pain has become chronic (persisting for more than 3-6 mo), it may be less likely to resolve by natural recovery alone, more likely to continue indefinitely, more likely to be resistant to treatment, and more likely to require a multimodal treatment approach (eg, oral medications combined with local injections).

Early interventions (eg, oral medications, injections, physical therapy) are presumed to decrease the chance that acute coccydynia will develop into chronic coccydynia. This may be considered a reason for aggressive nonsurgical treatment early on, to potentially decrease the chances of lifelong pain and disability.

Although coccydynia is generally not associated with increased mortality, it is often associated with substantial morbidity. Patients with coccydynia often report severe and persistent pain that compromises functional activities requiring sitting and diminishes their quality of life.

One case series indicated that a positive coccygeal discogram is correlated with better outcome from surgery, but these results were based on small numbers, including just 2 surgical patients who had positive preoperative discograms and 2 surgical patients who had negative preoperative discograms.[11] Further, the usefulness of a positive discogram at predicting surgical outcome intuitively seems to be contraindicated by a separate, histologic study showing that disc degeneration at the sacrococcygeal joint in 5 patients was associated with poor surgical outcome in all 5 cases.[12]

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Patient Education

The author of this Medscape Reference article (Dr. Foye) has provided further information on the topic of tailbone pain at the following websites:

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Contributor Information and Disclosures
Author

Patrick M Foye, MD Director of Coccyx Pain Center, Professor and Interim Chair of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School; Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, University Hospital

Patrick M Foye, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, International Spine Intervention Society, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists

Disclosure: Nothing to disclose.

Coauthor(s)

Charles J Buttaci, DO, PT Pain Management, Northeast Orthopedics

Charles J Buttaci, DO, PT is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Osteopathic College of Physical Medicine and Rehabilitation, International Spine Intervention Society

Disclosure: Nothing to disclose.

Leia Rispoli Rutgers New Jersey Medical School

Disclosure: Nothing to disclose.

Chief Editor

Consuelo T Lorenzo, MD Medical Director, Senior Products, Central North Region, Humana, Inc

Consuelo T Lorenzo, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.

Acknowledgements

Michael T Andary, MD, MS Professor, Residency Program Director, Department of Physical Medicine and Rehabilitation, Michigan State University College of Osteopathic Medicine

Michael T Andary, MD, MS is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, and Association of Academic Physiatrists

Disclosure: Allergan Honoraria Speaking and teaching; Pfizer Honoraria Speaking and teaching

Debra Ibrahim New York College of Osteopathic Medicine

Disclosure: Nothing to disclose.

Evish Kamrava St George's University School of Medicine

Disclosure: Nothing to disclose.

Robert L Sheridan, MD Assistant Chief of Staff, Chief of Burn Surgery, Shriners Burns Hospital; Associate Professor of Surgery, Department of Surgery, Division of Trauma and Burns, Massachusetts General Hospital and Harvard Medical School

Robert L Sheridan, MD is a member of the following medical societies: American Academy of Pediatrics, American Association for the Surgery of Trauma, American Burn Association, and American College of Surgeons

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Dev Sinha, MD Resident Physician, Department of Physical Medicine and Rehabilitation, University of Pennsylvania Health Systems

Disclosure: Nothing to disclose.

Matthew Kirk Sorensen Rutgers New Jersey Medical School

Disclosure: Nothing to disclose.

Acknowledgments

Dr. Foye acknowledges and appreciates the numerous patients with coccyx pain who have traveled—often substantial distances—to see him over the years. Much has been learned by listening to descriptions of their symptoms and to their stories, by discovering how suffering from coccyx pain impacts the quality of their lives, and by analyzing their favorable responses to nonsurgical treatment. Their substantial contributions to the coccydynia knowledge base have helped in the treatment of many subsequent patients with coccyx pain, not only in Dr. Foye's practice, but (through his publications in this area) elsewhere as well. Dr. Foye finds it to be a gratifying privilege to help so many of these patients find relief.

References
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Lateral view of the pelvis and coccyx. The bracket shows the area of focus for radiographs that would provide a coned-down view of mainly the coccyx and distal sacrum. A more common lateral view would often also include larger bony structures, such as the lumbar spine and femur, all of which would make it difficult to optimize visualization of the small bones of the coccyx. In patients with coccyx pain, these coned-down, lateral views of the coccyx can provide important diagnostic information. Coned-down images obtained in the weight-bearing (seated) position can be compared with those obtained in a non–weight-bearing position (eg, side lying), thus allowing assessment for dynamic instability (eg, dislocations that occur only while seated).
Coccyx pain (coccydynia, or tailbone pain) is typically worse when the patient is sitting. Often, the pain is even worse when sitting leaning slightly backward, since this increases the weight bearing on the coccyx, as shown in this image. Dynamic radiographs of the coccyx involve obtaining coned-down (focused) views of the coccyx while the patient is seated (eg, in his or her most painful position). Often, this involves having the patient lean backward 0-40°, depending on the symptoms. Radiographs obtained in this position are compared with those obtained in a non–weight-bearing position (eg, side lying) to assess for instability or dislocations in the seated position.
Patients with a painful coccyx often find it more comfortable to sit leaning slightly forward, as shown in this image. This forward-leaning position minimizes any weight bearing on the coccyx itself and thus minimizes the exacerbation of coccyx pain. As shown, when a patient sits leaning forward, most of the weight bearing occurs bilaterally through the inferior ischial regions of the pelvis and the posterior thigh (femur) regions.
 
 
 
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