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Sunday, August 17, 2025

Tailbone (coccyx) pain


Introduction

Tailbone pain, medically known as coccydynia, refers to discomfort localized at the coccyx, a small triangular bone at the bottom of the spine. It serves as an attachment site for muscles, ligaments, and tendons, and supports body weight when sitting. Pain in this area can be mild and self-limiting or severe and chronic, interfering with daily activities such as sitting, standing, and bowel movements.

Coccydynia is more common in women (due to differences in pelvic anatomy and childbirth), but it can affect anyone. The condition may result from trauma, repetitive strain, degenerative changes, or, rarely, underlying systemic disease.

Anatomy of the Coccyx

  • Composed of 3–5 fused vertebrae.

  • Connected to the sacrum via the sacrococcygeal joint.

  • Surrounded by ligaments and the gluteal muscles.

  • Bears significant weight when sitting, particularly when leaning back.

Causes of Tailbone Pain

1. Trauma and Injury

  • Direct trauma: falling backward onto a hard surface.

  • Childbirth: pressure and stretching of pelvic structures can injure or dislocate the coccyx.

  • Repetitive strain: cycling, rowing, or prolonged sitting on hard surfaces.

2. Degenerative and Mechanical Causes

  • Degenerative joint disease (osteoarthritis of the sacrococcygeal joint).

  • Hypermobile or dislocated coccyx.

  • Abnormal curvature of coccyx.

3. Infections and Inflammation

  • Pilonidal cyst (abscess near tailbone).

  • Sacrococcygeal joint infection (rare).

4. Neoplastic Causes (Rare)

  • Primary tumors (chordoma, osteosarcoma).

  • Metastatic cancers (e.g., rectal, prostate).

5. Other

  • Idiopathic (no identifiable cause).

  • Psychogenic pain (functional component).

Clinical Features

  • Localized pain at the base of the spine.

  • Worse when sitting, leaning back, or rising from seated position.

  • Pain on bowel movements or sexual intercourse (in severe cases).

  • Tenderness on palpation of coccyx.

  • Swelling, redness, or drainage may suggest infection.

Diagnostic Evaluation

History

  • Trauma history (falls, childbirth).

  • Duration and severity of pain.

  • Aggravating and relieving factors.

  • Associated symptoms: fever, weight loss, neurological signs.

Examination

  • Inspection for swelling, deformity, infection signs.

  • Palpation: localized tenderness over coccyx.

  • Rectal examination: assess coccyx mobility and rule out masses.

Investigations

  • X-ray (sitting vs standing views): detects dislocation, fracture, abnormal curvature.

  • MRI: if infection, tumor, or soft tissue cause suspected.

  • CT scan: for detailed bony anatomy.

Treatment

1. General Measures

  • Avoid prolonged sitting.

  • Use a coccygeal cushion (donut pillow) to relieve pressure.

  • Warm compresses or ice packs.

  • Weight management to reduce pressure.

2. Pharmacological Treatment

Analgesics

  • Paracetamol (acetaminophen): 500–1000 mg every 6 hours as needed (max 4 g/day).

  • NSAIDs:

    • Ibuprofen: 200–400 mg every 6–8 hours (max 2400 mg/day).

    • Naproxen: 250–500 mg twice daily.

    • Diclofenac: 50 mg two–three times daily.

Muscle Relaxants (for spasm-related pain)

  • Cyclobenzaprine: 5–10 mg at night.

  • Diazepam: 2–5 mg orally at night (short-term use only).

Local Injections

  • Corticosteroid injections:

    • Triamcinolone acetonide 20–40 mg mixed with local anesthetic (lidocaine 1%) into sacrococcygeal joint.

    • Provides weeks to months of pain relief.

3. Physical Therapy and Non-Drug Therapies

  • Pelvic floor physiotherapy: relaxation and strengthening exercises.

  • Manual manipulation of coccyx: by trained physiotherapist.

  • Transcutaneous electrical nerve stimulation (TENS): for chronic pain.

4. Surgical Management (for Refractory Cases)

  • Coccygectomy: surgical removal of coccyx.

  • Reserved for severe, chronic cases unresponsive to conservative and injection therapy.

  • Risks: infection, poor wound healing.

Red Flags (Urgent Referral)

  • Severe pain after trauma with inability to sit or walk.

  • Signs of infection: fever, abscess, drainage near coccyx.

  • Neurological symptoms: weakness, numbness, bowel/bladder dysfunction.

  • Unexplained weight loss or persistent pain (rule out malignancy).

Prognosis

  • Most cases improve within weeks to months with conservative care.

  • Chronic cases may persist but often respond to physiotherapy and injections.

  • Surgical outcomes are variable but may help selected patients.

Summary of Key Treatments with Doses

  • Paracetamol: 500–1000 mg PO q6h (max 4 g/day).

  • Ibuprofen: 200–400 mg PO q6–8h.

  • Naproxen: 250–500 mg PO BID.

  • Diclofenac: 50 mg PO BID–TID.

  • Cyclobenzaprine: 5–10 mg PO nightly.

  • Diazepam: 2–5 mg PO nightly (short-term).

  • Triamcinolone acetonide: 20–40 mg intra-articular injection with lidocaine.




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