eMedicine Specialties > Physical Medicine and Rehabilitation > Lower Limb Musculoskeletal Conditions

Coccyx Pain

Author: Patrick M Foye, MD, FAAPMR, FAAEM, Associate Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, Director of Coccyx Pain (Tailbone Pain, Coccydynia) Service (www.TailboneDoctor.com), University of Medicine and Dentistry of New Jersey, New Jersey Medical School
Coauthor(s): Charles J Buttaci, DO, PT, Pain Management, Northeast Orthopedics; Matthew Kirk Sorensen, EMT-B, Kean University
Contributor Information and Disclosures

Updated: Jan 29, 2009

Introduction

Background

Coccyx pain (tailbone pain) can frustrate patients and significantly impair quality of life, but relief is possible.

Coccyx pain was first documented in 1588, and the term coccygodynia was coined by Simpson in 1859.¹ Currently, the term coccydynia is used somewhat more commonly than coccygodynia. The 2 terms are interchangeable and indicate pain localized to the coccyx. Neither term specifies the underlying etiology. Coccyx pain can occur from local trauma or a tumor, but most cases are idiopathic and have no identifiable cause.²

Patients with coccyx pain often report that their physicians minimize, dismiss, or belittle their symptoms.² 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.

Related eMedicine topic:
Coccygodynia

Pathophysiology

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.¹ The coccyx is the terminal end of the spine, just inferior to the sacrum. 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 human coccyx is often considered a vestigial remnant or corollary of a tail; thus, the coccyx is colloquially referred to as the tailbone.

Anatomy and function of the coccyx

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, whereby the coccyx supports the position of the anus.¹ 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.¹ 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).

The coccyx serves as somewhat of 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 images below and Images 1-2). 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.

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

Frequency

United States

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

Mortality/Morbidity

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.

Race

No specific racial differences have been reported for coccydynia.

Sex

Coccydynia is seen in males and females; however, women seem to be affected more frequently than men.² One 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.

Age

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.

Clinical

History

The history obtained from a patient with coccydynia involves details regarding the coccydynia itself and other underlying conditions that may refer pain to the coccyx region.

• Localization of pain - The patient should be asked to indicate or point to the painful site or sites.
• Severity of coccyx pain - The patient should be asked to rate the level of coccygeal pain (0-10 scale) when it is at its best and at its worst and to indicate overall pain severity.
• Duration and onset date of coccydynia - The patient should be asked whether any identifiable traumatic incident, recent or remote, occurred.
• Exacerbating factors - The patient should be asked whether there is pain associated with, for example, prolonged sitting or sitting on hard versus soft surfaces, as well as with sexual intercourse, standing up after sitting, or bowel movements.
• Sitting tolerance - The patient should be asked to quantify how many minutes of sitting can be tolerated before the pain mandates changing position.

Other elements of the patient's history that should be obtained include the following:

• Cushions tried - Such as donut cushions, which have a circular hole in the middle, or wedge cushions, which have a triangular wedge cut out posteriorly
• Oral medications tried and response to these
• Interventional pain management procedures and response to these - Such as caudal or other epidurals, local anesthetic blocks, and steroid injections, as well as whether these were administered blindly or guided fluoroscopically
• Gastrointestinal (GI) symptoms - Constipation; diarrhea; bright-red blood per rectum; melena (black, tarry stool); and fecal incontinence
  • GI workup - Such as GI consult, colonoscopy, or rectal exam
• Urinary symptoms - For instance, urinary incontinence, or dysuria
  
  
  • Urinary diagnostic workup - Such as urology consult or urinalysis
• Female intrapelvic history - Such as uterine fibroids or ovarian cysts
• Female obstetric history - Childbirth, vaginal or cesarean delivery, and any associated difficulties at the time
• Female menopausal status - Premenopausal, perimenopausal, or postmenopausal
• Lower limb neurologic symptoms - Such as radicular pain or lower limb numbness or weakness
• Concomitant ischial bursitis - Such as unilateral or bilateral ischial buttock pain due to leaning to either side to avoid sitting with pressure on the midline/coccyx region
• Body weight - Such as any significant increase or decrease in body weight preceding the onset of the symptoms.
• History of cancer - Especially colon, prostate, ovarian, cervical, testicular, or other intrapelvic malignancies.
• Risk factors for cancer - Blood per rectum, abnormal vaginal bleeding, unexplained weight loss, fevers, or chills

Physical

• Palpation
  • Sacrococcygeal palpation involves identifying and exerting pressure onto the sacrococcygeal junction and the coccyx, noting whether the presenting symptoms localize well to that site (ie, exquisite tenderness at the coccyx and/or sacrococcygeal junction, with only mild or absent tenderness at adjacent structures).
  • Some clinicians palpate the coccyx via an internal/external approach; using a gloved hand, they place 1 or 2 fingers inside the rectum (anterior to the coccyx) and, with another 1 or 2 fingers, palpate externally (posterior to the coccyx). In this way, some clinicians also attempt to assess for increased or decreased sacrococcygeal mobility. Patients with severe coccydynia may have difficulty tolerating this examination.
  • Palpation of other (noncoccygeal) lumbosacral structures is an important aid in ruling out pain generators from the ischial bursae, sacroiliac joints, lumbosacral facet joints, and lumbosacral or gluteal muscles.
  • In one study, 25 out of 30 (83%) patients with a bone spicule at the distal coccyx had a "pit" noted in the overlying skin.³
• Neurologic examination - Strength, sensation, and muscle-stretch reflexes can be assessed throughout the bilateral lower limbs to assess for any lumbosacral radiculopathy.
• Lumbosacral range of motion - This can be assessed in multiple planes, including documentation of pain with these motions, particularly if the presenting symptoms are reproduced.
• GI and gynecologic physical examination - Depending on the patient's history and the clinician's expertise, abdominal and gynecologic physical examinations may be performed. Manual digital rectal examination can assess for hemorrhoids or other intrarectal masses.

Causes

• Some causes⁴ of coccyx pain include trauma, fractures, dislocations, and malignancies (either primary or metastatic).
• Sources of trauma include childbirth, falls, and prolonged sitting.
• Tailbone pain may begin after certain medical procedures, such as colonoscopy.⁵
• Some cases of coccydynia are idiopathic, without any identified etiology.

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