The marvellous strength and flexibility of the lower back increase the stability of the body. However, it is this same spectacular feature that makes it very susceptible to developing many health problems.
Also, because of the many nerves that run through the lower part of the spine to other body parts, pain on this part can be quite devastating. One of these problems that can occur is tailbone pain, also known as coccydynia. In this article, we will give you facts about coccydynia, its causes, signs and symptoms, diagnosis, treatment and prevention.
What is coccydynia?
Coccydynia is an inflammation that is localized to the coccyx. The coccyx is the bottom portion of the spine that lies below the sacrum. It is triangular in shape and is made up of three to five bones fused or semi-fused by disc-like ligaments. (1)
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Although the coccyx is largely considered to be vestigial (meaning that it became functionless in the course of evolution), it has some critical roles to play, and injury to it may be a constant source of misery.
For instance, the coccyx forms the connection point of several pelvic floor muscles that support defecation, the vagina in females and assist in movement. Also, it is one of the three parts that support a person when in the sitting position.
Coccydynia is also known as coccygodynia, coccygeal pain, coccalgia or coccyx pain.
What causes coccydynia?
Injury to the tailbone is one of the commonest causes of coccydynia. (2) It usually leads to inflammation, which contributes to pain and discomfort. The trauma may be caused by:
- Direct injury that may be due to a fall especially in leisure activities such as cycling, can be due to a crash or after childbirth. These situations may cause direct damage to the ligaments or bones, resulting in a fracture or dislocation.
- Excessive movement, which puts extra stress on the sacrum and coccyx
- Limited mobility that causes the coccyx to protrude outward, putting pressure on the sacrum and coccyx joint
- Persistent pressure from activities such as skateboarding and horse riding
- Adapting the wrong sitting posture for prolonged periods
Although rarely, the pain may be due to a nearby tumor or infection that puts pressure on the tailbone. The pain may also be referred from a different part of the spine or other pelvic structures.
Who is at a higher risk of suffering from coccydynia?
Between women and men, women are five times more likely to develop coccydynia. (3)
This is because women have a broader pelvic structure, which lowers the level of pelvic rotation, leaving the coccyx more exposed to injury. Women also tend to place more weight on the pelvis when seated and due to childbirth, the coccyx may be damaged as the fetus moves through the birth canal.
Being overweight or obese is another significant predisposing factor for coccydynia. (4) The excessive weight causes continual stress on the coccyx, increasing the chances of coccygeal pain.
What are the signs and symptoms of coccydynia?
- Pain and tenderness that is localized to the tailbone. The pain does not radiate to the pelvis or the legs. Most people describe the pain as dull and achy. The pain may also worsen when coccyx bears more weight such as when walking, during a bowel movement, sexual intercourse, when seated on a hard surface or leaning backwards.
- Tightness or general discomfort on the lower back
- Some women may experience pain or discomfort during sexual intercourse
How is it diagnosed?
A diagnosis of coccydynia is typically made by gathering information through history taking, physical examination and possibly radiographic images. (5)
For history taking, the doctor chiefly asks about the current symptoms and how they developed. It may as well yield information on recent trauma with acute onset of pain or onset of pain that has no clear inciting factor and environmental or lifestyle factors that may have contributed to the pain.
During the physical exam, the healthcare provider palpates the lower back area to elicit tenderness and look out for any swelling around the coccyx. The doctor may also do a rectal examination to grasp the coccyx with the forefinger and thumb. Manipulation of the coccyx in this way elicits pain and excessive or limited mobility of the sacrococcygeal joint, in case of coccydynia. If the coccyx is not tender upon palpation, then there is a high likelihood that the pain is referred from another body part.
Diagnostic imaging tests are not generally needed for diagnosing tailbone pain. Nevertheless, in case of unrelenting pain whose history and physical examination are not adequate for a diagnosis, the doctor may order radiographic studies such as X-rays and magnetic resonance imaging to evaluate the possibility of tumors, fractures, or degenerative changes.
- Dynamic X-ray is done when one is seated and standing, to produce two images. The images are then compared to measure the angle of pelvic rotation and to see how the coccyx changes position from sitting to standing. Too much or too little coccyx movement is then identified as the cause of pain.
- Coccygeal discogram involves giving an injection of local anaesthesia that targets the specific area of the coccyx such as an intervertebral disc. If there is immediate pain relief, then definitely the origin of the pain is from the coccyx.
- Computed Tomography (CT) scan or Magnetic Resonance Imaging (MRI) to illustrate a detailed image of the of the coccyx, sacrococcygeal joint and other nearby structures. These scans are used when a fracture or tumor is suspected.
Routine blood tests may also be obtained to rule out infections, tumors or autoimmune disorders.
How is coccydynia treated?
Despite the fact that coccydynia was formally introduced in the 16th century, its treatment is still a problematic issue, because of the multifactorial nature of the coccygeal pain. For most people, the pain resolves on itself within weeks or months. However, for some, it can be chronic and debilitating. A combination of physical therapy, medications, and psychotherapy has the highest successful treatment chances.
When the cause of coccydynia is from an acute injury, medical treatment is necessary. Most other cases require conservative treatment.
Some of the medications that may be indicated include:
- Non-steroidal anti-inflammatory drugs (NSAIDS) drugs such as ibuprofen. They reduce inflammation and pain around the coccyx, which is what mainly causes the discomfort in coccydynia.
- Opioids are recommended for severe pain that is not responsive to other analgesics
More aggressive medical measures include (6)
Injections of a numbing agent such as lignocaine or a corticosteroid to provide pain relief and help to clear the inflammation. The doctor uses ultrasound or X-ray to get guidance to the specific area that is experiencing pain. The injections are given up to three times in a year since if they work, they provide relief for a period of a week to several years.
Manual manipulation of the coccyx to adjust the joint between the coccyx and sacrum. It helps to correct inadequate mobility by relaxing tense muscles that pull the coccyx. It should be done by a skilled practitioner such as a physical therapist or chiropractor for the reason that if anything is done wrong, it worsens the pain.
Pelvic floor rehabilitation is necessary especially if the coccygeal pain is as a result of childbirth. It uses the principles of physical therapy that improve the strength and function of the pelvic muscles that support not only the coccyx but also the bladder, vagina and anus. Therapists use Kegels exercises, breathing techniques, manual manipulation and electrical stimulation for pelvic rehabilitation.
Transcutaneous electrical nerve stimulation (TENS) uses low-voltage electrical currents to interfere with nerve transmission of pain from the coccyx to the central nervous system. It can be done in the hospital, doctor’s office or one can have a battery-operated TENS machine to use at home.
Coccygectomy is indicated as a last resort. This is because the procedure is associated with more complications and may even fail to relieve pain. It involves removal of the entire coccyx or only part of it. The surgeon makes a small incision on the area above the coccyx, dissects the cartilage covering the bony part then the coccyx is removed. Coccygectomy may take about 30 to 45 minutes and can therefore, be done on an outpatient basis. The most challenging bit about coccygectomy is that it takes longer to heal, sitting becomes difficult throughout the healing process and it can take up to a year before one notices any relief from the symptoms.
Most non-medical treatment approaches are noninvasive, mostly involve activity modification and do not require the assistance of a medical professional. They include:
Coccygeal cushions (also known as supportive coccyx pillows or donut cushions), relieve pressure from the coccyx when seated. The pillows are made of gel or heavy-duty foam and are U, V or wedge-shaped with a cut-out where the coccyx is. They can be used in the car, office, class, home or anywhere else that one may need to sit down.
Application of heat compressions relieves muscle tension by improving blood flow and helping muscles to relax. One can use a hot water bottle, hot bath, or microwavable heating pads. Alternating heat compressions with cold massages is particularly helpful for exercise-induced coccygeal pain.
Ice or cold packs reduce blood flow to the muscles surrounding the coccyx. It also numbs the sore tissues and slows down relaying of pain messages. Cold compressions are applied to the coccyx area for 20 minutes. Note that the ice packs should not be used directly on the skin and bony portions of the spine to avoid ice burns. Instead, fill a plastic bag with the ice packs then wrap with a dry cloth.
Massages relieve muscle spasms and ligament pain. Tense muscles on the coccygeal region place additional strain on the coccyx, its joints and ligaments, thus limiting its mobility. A massage of the lower back should be done gently to avoid hurting the coccyx further.
Gentle stretching is also helpful in lowering muscle tension. It can be done at home or hospital with the assistance of a caregiver, a physiotherapist, chiropractor or physiatrist.
Low-impact aerobic activities that raise the heart rate without jarring the spine may be considered after sufficient pain relief has been achieved and one can tolerate some level of movement. Walking, elliptical training and stationary bicycling are some of the activities to consider. These activities are beneficial in that they increase blood flow to the coccygeal area, improve oxygen, nutrient and inflammation-fighting bio-compounds supply. Exercise also promotes the release of endorphins, which then interact with opiate receptors in the brain to reduce the perception of pain. Endorphins work in the same way as opioids.
Also, very important are dietary modifications to include adequate water and fiber intake, to ensure smooth bowel movement. Constipation worsens coccydynia especially an hour before defecating and several hours afterwards. (7)
Can it be prevented?
There are many things that can be done to lower the risk of injury or prevent recurrence of coccydynia. Most of them boil down to adopting healthy lifestyle habits. Here are some of the tips to keep tailbone pain away.
- Adopting a proper sitting posture. Poor posture places the pressure on the coccyx and interferes with the natural curve of the spine. Preferably, use an ergonomic chair, get up and walk after every 30 to 45 minutes, and at times, opt for a stand-up desk.
- Regular physical activity that incorporates flexibility, strength, stretching (especially the hamstrings) and cardio workouts.
- Maintaining a healthy weight
- Avoid sitting on an overstuffed wallet
- Eating anti-inflammatory foods like omega-3 foods, fresh raw vegetables and fruits
- Use the right technique to lift up objects by bending at the hips (not back), keeping the chest forward and keeping the load close to the body.
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