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. Questions relate to the following:
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Localization of pain - The patient should be asked to indicate or point to the painful site or sites
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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
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Duration and onset date of coccydynia - The patient should be asked whether any identifiable traumatic incident, recent or remote, occurred
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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
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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:
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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
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Oral medications tried and response to these
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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
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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)
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Urinary symptoms - For instance, urinary incontinence or dysuria (urinary diagnostic workup, such as urology consult or urinalysis)
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Female intrapelvic history - Such as uterine fibroids or ovarian cysts
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Female obstetric history - Childbirth, vaginal or cesarean delivery, and any associated difficulties at the time
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Female menopausal status - Premenopausal, perimenopausal, or postmenopausal
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Lower limb neurologic symptoms - Such as radicular pain or lower limb numbness or weakness
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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
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Body weight - Such as any significant increase or decrease in body weight preceding the onset of the symptoms
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History of cancer - Especially colon, prostate, ovarian, cervical, testicular, or other intrapelvic malignancies.
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Risk factors for cancer - Blood per rectum, abnormal vaginal bleeding, unexplained weight loss, fevers, or chills
Physical Examination
Palpation
Sacrococcygeal palpation involves identifying and exerting pressure onto the sacrococcygeal junction and the coccyx and 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. [22]
Additional assessments
Other aspects of the physical examination include the following:
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Skin inspection – Direct visual inspection of the skin over the coccygeal region is important. An underlying pilonidal cyst may produce visible discharge, local rash, or a visible skin opening (fistula). In addition, inspecting for a local dimple/divot may be relevant, because in one study, as noted above, 25 (83%) of 30 patients with a bone spicule at the distal coccyx had a "pit" noted in the overlying skin. [22]
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Neurologic examination - Strength, sensation, and muscle-stretch reflexes can be assessed throughout the bilateral lower limbs to evaluate for any lumbosacral radiculopathy
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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
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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
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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).
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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.
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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.
