Coccydynia

Coccydynia or Coccygodynia
Classification and external resources
Specialty rheumatology
ICD-10 M53.3
ICD-9-CM 724.79
DiseasesDB 32571
eMedicine pmr/242

Coccydynia is a medical term meaning pain in the coccyx or tailbone area,[1] usually brought on by sitting too abruptly.

Synonyms

Coccydynia is also known as coccygodynia, coccygeal pain, coccyx pain, or coccalgia.[1]

Anatomy

Structure

Coccydynia occurs in the lowest part of the spine, the coccyx, which is believed to be a vestigial tail, or in other words the “tail bone”. The name coccyx is derived from the Greek word for cuckoo due to its beak like appearance. The coccyx itself is made up of 3 to 5 vertebrae, some of which may be fused together. The ventral side of the coccyx is slightly concave whereas the dorsal aspect is slightly convex. Both of these sides have transverse grooves that show where the vestigial coccygeal units had previously fused. The coccyx attaches the sacrum, from the dorsal grooves with the attachment being either a symphysis or as a true synovial joint, and also to the gluteus maximus muscle, the coccygeal muscle, and the anococcygeal ligament.

Orientations of the coccyx

There are four different orientations for the coccyx, as described by Postacchini and Massobrio. In type I the coccyx is curved anteriorly with its apex facing downward and caudally. In type II this forward curvature is more dramatic and the apex extends forward. Type III is where the coccyx angles forward sharply. Lastly, type IV is characterized by the coccyx being subluxated at the sacrococcygeal joint.

Pathophysiology

There are common pathophysiological ways that a person may develop coccydynia. The two main causes for this condition are sudden impact due to fall, and coccydynia caused by childbirth pressure in women.[2] Other ways that coccydynia develops are partial dislocation of the sacrococcygeal synchondrosis that can possibly result in abnormal movement of the coccyx from excessive sitting, and repetitive trauma of the surrounding ligaments and muscles, resulting in inflammation of tissues and pain.

Diagnosis

A number of different conditions can cause pain in the general area of the coccyx, but not all involve the coccyx and the muscles attached to it. The first task of diagnosis is to determine whether the pain is related to the coccyx. Physical rectal examination, high resolution x-rays and MRI scans can rule out various causes unrelated to the coccyx, such as Tarlov cysts and pain referred from higher up the spine. Note that, contrary to most anatomical textbooks, most coccyxes consist of several segments: 'fractured coccyx' is often diagnosed when the coccyx is in fact normal or just dislocated at an intercoccygeal joint.[3][4]

A simple test to determine whether the coccyx is involved is injection of local anesthetic into the area. If the pain relates to the coccyx, this should produce immediate relief.[5]

If the anesthetic test proves positive, then a dynamic (sit/stand) x-ray or MRI scan may show whether the coccyx dislocates when the patient sits.[6]

Use of dynamic x-rays on 208 patients who gave positive results with the anesthetic test showed:

This study found that the pattern of lesions was different depending on the obesity of the patients: obese patients were most likely to have posterior luxation of the coccyx, while thin patients were most likely to have coccygeal spicules.

Angle of incidence

Sagittal coccygeal movement is measured using the angle of incidence—or the angle at which the coccyx strikes the seat when an individual sits down.[7] A smaller angle indicates the coccyx being more parallel to the seat, resulting in flexion (or “normal” movement) of the coccyx.[7] A larger angle indicates the coccyx being more perpendicular to the seat, causing posterior subluxation (or “backward” movement) of the coccyx.[7]

Sagittal view of coccyx in standing and sitting position

Causes

One way of classifying coccydynia is whether the onset was traumatic versus non-traumatic. In many cases the exact cause is unknown and is referred to as idiopathic coccydynia.

Coccydynia is a fairly common injury which can often result from falls, particularly in leisure activities such as cycling and skateboarding. Coccydynia is often reported following a fall or after childbirth. In some cases, persistent pressure from activities like bicycling may cause the onset of coccyx pain.[8] Coccydynia due to these causes usually is not permanent, but it may become very persistent and chronic if not controlled. Coccydynia may also be caused by sitting improperly thereby straining the coccyx.

Rarely, coccydynia is due to the undiagnosed presence of a sacrococcygeal teratoma or other tumor in the vicinity of the coccyx.[1] In these cases, appropriate treatment usually involves surgery and/or chemotherapy.

Prevalence

A study of 2000 cases of back pain referred to hospital found that 2.7% were diagnosed as coccydynia.[9] This type of pain occurs five times more frequently in women than in men. It can occur at any age, the mean age of onset being around 40.[1] There are no ethnicity or race associations with coccydnia.

Clinical features

Activities that put pressure on the affected area are bicycling, horseback riding, and other activities such as increased sitting that put direct stress on the coccyx. The medical condition is often characterized by pain that worsens with constipation and may be relieved with bowel movement. Rarely, even sexual intercourse can aggravate symptoms.

Non-surgical treatment

Since sitting on the affected area may aggravate the condition, a cushion with a cutout at the back under the coccyx is recommended. If there is tailbone pain with bowel movements, then stool softeners and increased fiber in the diet may help. For prolonged cases, anti-inflammatory medications such as NSAIDS or pain-relieving drugs may be prescribed.[1] The use of anti-depressants such as Elavil (amitriptyline) may help alleviate constant pain. Tailbone pain physicians specializing in Physical Medicine and Rehabilitation at New Jersey Medical School have published that sometimes even just a single local nerve block injection at the ganglion impar can give 100% relief of coccydynia when performed under fluoroscopic guidance.[8]

Additionally if the pain is caused by a malignment of the coccyx, manipulation by a chiropractor, osteopathic physician (D.O.) or physical therapist can offer relief.[10]

Surgical treatment

In rare cases, surgery to remove the coccyx (coccygectomy) may be required. Typically, surgery is reserved for patients with cancer (malignancy) or those whose tailbone pain has failed to respond to non-surgical treatment (such as medications by mouth, use of seat cushions, and medications given by local injections done under fluoroscopic guidance, as noted above).[11]

Prevention or to ease coccyx pain

Body positioning and alignment is significant for producing less stress in the coccyx region. Bad posture can influence coccyx pain. People may not realize that they are over stressing their coccyx while doing daily activities. Pain in the coccyx can be caused from many incidents like falling, horseback riding, or even sitting on hard surfaces for a long period of time. The main focus is to prevent coccyx pain from occurring, by correcting everyday activities that contribute to tailbone pain.

Proper equipment used to preventing coccyx pain

There is no definite way to fully prevent coccyx pain because an accident can occur at any given time. However, people who are obese are at a higher risk for developing coccyx pain. Carrying excessive weight contributes to more stress on the coccyx while sitting down causing increased chances of pain.[12] Prevention of carrying excessive weight gain can help reduce the tension and pressure on the coccyx. In other words, the coccyx for obese people may be more posteriorly outward when they are sitting down.[12] Avoidance of contact sports like basketball, football, and or hockey can decrease the risks of coccyx pain, because it can help reduce the chances of falling. Another method is proper safety equipment for sports is to prevent coccyx pain. For example, there are hockey pants that provide extra cushion that protect the thigh, coccyx, and buttocks. These results will lead to less falls that can cause trauma to the coccyx.

Stretches & strengthening exercises for prevention

A kneeling groin stretch can help prevent coccyx pain from occurring after long periods of sitting. The adductor magnus is involved in the kneeling groin stretch, and when it is tight it can contribute to tailbone pain, so stretching can help prevent tailbone pain. Other stretches like piriformis stretch, and hands to feet stretch, can relieve stress off the muscles around the coccyx, after sitting for a long time. These release tension built up around the muscles in the coccyx.

See also

References

  1. 1 2 3 4 5 Patel, R; Appannagari, A; Whang, P.G. (May 2008). "Coccydynia". Current Reviews in Musculoskeletal Medicine. 1 (3-4): 223–226. doi:10.1007/s12178-008-9028-1. PMID 19468909.
  2. ↑ Patel, Ravi, Anoop Appannagari, and Peter G. Whang. "Abstract." National Center for Biotechnology Information. U.S. National Library of Medicine, 07 May 2008. Web. 21 May 2013.
  3. ↑ Postacchini F, Massobrio M (October 1983). "Idiopathic coccygodynia. Analysis of fifty-one operative cases and a radiographic study of the normal coccyx". J Bone Joint Surg Am. 65 (8): 1116–24. PMID 6226668.
  4. ↑ Kim NH, Suk KS (June 1999). "Clinical and radiological differences between traumatic and idiopathic coccygodynia.". 40 (3). Yonsei Medical Journal: 215–20.
  5. ↑ Marx, Fred A. (1996). "Coccydynia/Levator Syndrome, A Therapeutic Test". Techniques in Coloproctology. 4 (1).
  6. ↑ Maigne JY, Doursounian L, Chatellier G (December 2000). "Causes and mechanisms of common coccydynia: role of body mass index and coccygeal trauma". Spine. 25 (23): 3072–9. doi:10.1097/00007632-200012010-00015. PMID 11145819.
  7. 1 2 3 Maigne, J., Doursounian, L., & Chatellier, G. (2000). Causes and mechanisms of common coccydynia: role of body mass index and coccygeal trauma. SPINE, 25(23), 3072-3079.
  8. 1 2 Foye P, Buttaci C, Stitik T, Yonclas P (2006). "Successful injection for coccyx pain". Am J Phys Med Rehabil. 85 (9): 783–4. doi:10.1097/01.phm.0000233174.86070.63. PMID 16924191.
  9. ↑ Ghormley, RK. 1958. An Etiologic Study of Back Pain. Radiology, Volume 70, Issue 5, pages 649-653.
  10. ↑ Comparison of Three Manual Coccydynia Treatments: A Pilot Study Spine 2001 Volume 26, number 20, pages E479-E484 JeanYves Maigne, MD,* and Gilles Chatellier, MD
  11. ↑ Foye, P.M. (2007). "Reasons to delay or avoid coccygectomy for coccyx pain". Injury. 38 (11): 1328. doi:10.1016/j.injury.2007.06.022. PMID 17884057.
  12. 1 2 Maigne, Jean-Yves, and Doursounian Levon. "Causes and Mechanisms of Common Coccydynia: Role of Body Mass Index and Coccygeal Trauma." Spine Journal 2.5.23 (2000): 3072-3079.
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