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This pain is usually provoked by sitting or by rising from a seated to a standing position. It is also known as coccydynia or coccygeal neuralgia[2]. The pain caused by coccygodynia is disabling and has a significant impact on the patient's quality of life. The pain can be described as "pulling" or "lancinating," and may also radiate to the sacrum, lumbar spine, and buttocks, or more rarely to the thighs[2]. The coccyx is the most distal aspect of the vertebral column. It consists of three to five rudimentary vertebral units that are typically fused. The ventral part of the coccyx is concave, and the dorsal aspect is convex and features coccygeal articular processes[3]. The coccyx articulates with the sacral cornu of the inferior sacral apex at S5[3]. The anterior aspect of the coccyx serves as the attachment site of ligaments and muscles important for many functions of the pelvic floor. The levator ani muscle includes m. coccygeus, m. pubococcygeus and m. iliococcygeus. The coccyx supports the position of the anus.
Attached to the posterior side of the coccyx is m. gluteus maximus. Muscle weakness, disturbed tonus or damage to muscles or ligaments can cause abnormal positions of the coccyx[3]. The prevalence for coccygodynia is five times greater in women than in men[3]. This may be related to increased pressure during pregnancy or delivery (post-partum coccygodynia)[4].The pain in the coccyx can be caused by radiation from a lumbosacral segment, a direct trauma or an overcharge[5]. Congenital deviations can also cause complaints during long sitting[5]. Coccygodynia may be classified as posttraumatic or idiopathic. Posttraumatic coccygodynia may be due to a fall onto the buttocks, or due to a difficult childbirth[2]. Some studies question the possibility that coccygodynia could be caused by a direct trauma, because of protection by the ischiadic bones. Often, a positional change of the coccyx is caused by overtension of the anal levator muscle[6]. In more than one third of cases, coccygodynia has an idiopathic cause[2].
The patient may complain of pain in the coccyx region during, going into, or coming out of a seated position - this is a first indication of coccygodynia. Tenderness over the coccyx is likely present, and the location of tenderness may help to discern between different forms of coccygodynia[4][5]: Local coccygodynia presents as pain felt in the coccyx during sitting, and does not spread in any direction. The pain can be relieved by sitting on a hard surface or with the buttocks over the border of the chair. Only pressure point pain is present. Depending on the exact location of the pain, walking, stair walking or getting up from sitting can be painful. Other movements are painless and examination of lumbar spine and sacroiliac joints and hips are normal. Trauma or overtension of the levator ani muscle can shift the coccyx into an abnormal position. These contributing factors can be distinguished based on the affected tissues[4][5].Psychogenic coccydynia features a less specific pain location, and usually a vague and radiating pain in various directions.
Lumbar and hip movements are painful[4]. Coccygodynia can be diagnosed during a physical examination. Patients may take a guarding seated position, in which one buttock is elevated to shift weight from the coccyx and to prevent and/or minimize discomfort and pain. With referred or radiated pain, the pain will also arise during lumbar movements. Physical examination will show an increased pain during a straight leg raise test. There may be radiating pain around the buttocks and going to the back of the thighs. Women may have pain during menstruation[4][5]. Palpation at the sacrococcygeal junction will elicit a tender point and will be painful[2]. There is growing evidence that supports the efficacy of coccygectomy as treatment for coccygodynia. Coccygectomy showed a high percentage of patients with good results, and this outcome is durable over time[2]. Patients with coccygodynia are initially advised to avoid provocative factors. Initial treatment includes ergonomic adjustments such as using a donut-shaped pillow or gel cushion when sitting for a long period of time.
This reduces local pressure and improves the patient's posture. There is however no significant evidence that these minor changes reduce the patient's complaints[7]. Mobilizations can be used to help realign the position of the coccyx. The first choice for mobilization is postero-anterior central vertebral pressure (first gently oscillating). Given that there is tenderness to palpation, it might be best to start with rotation mobilization. It is advised to begin mobilizing only one side at one treatment[8].Another option for manual therapy is to apply deep transverse frictions (DTF) to the affected ligaments. The patient lies in prone position with a pillow under the pelvis and the legs in slight abduction and internal rotation. The therapist places his thumb on the affected spot, and, depending on the location of the lesion (direction DTF), the DTF are administered. Manipulation of the coccyx can be performed intrarectal with the patient in lateral position. With the index finger, the coccyx is repeatedly flexed and extended.