What is the management plan for a coccygeal (tailbone) injury?

Management Plan for Coccygeal (Tailbone) Injury

Conservative management is the first-line approach for most coccygeal injuries, with surgical intervention reserved only for refractory cases with abnormal mobility or spicules that fail to respond to conservative measures.

Initial Assessment and Diagnosis

• Key symptoms to identify:

  • Midline pain located below the sacrum and above the anus
  • Pain worsening with sitting or during transitions from sitting to standing
  • Focal tenderness during palpation of the coccyx

• Diagnostic imaging:

  • Lateral radiographs in both standing and sitting positions to assess for abnormal mobility (present in 70% of patients with coccygodynia) 1
  • Consider MRI or CT for suspected fractures, tumors, or other pathology 2
  • Dynamic imaging studies are particularly important for patients with water slide injuries or other trauma 3

Conservative Management Algorithm

First-line interventions (0-4 weeks):

1. Rest and activity modification:

   • Use specialized coccyx cushion with cutout for the tailbone
   • Avoid prolonged sitting
   • Avoid activities that aggravate pain (cycling, rowing, horseback riding)

2. Pain management:

   • Oral NSAIDs and acetaminophen for pain control
   • Topical analgesics may provide additional relief

Second-line interventions (4-8 weeks if no improvement):

1. Physical therapy:

   • Pelvic floor physical therapy
   • Manual therapy including massage and stretching of the levator ani muscle
   • Mobilization techniques for the coccyx 1

2. Interventional procedures:

   • Local anesthetic and corticosteroid injections into painful structures (sacrococcygeal joint, first intercoccygeal disc)
   • Consider injections into Walther's ganglion for persistent pain 1

Surgical Management

Surgical intervention (coccygectomy) should be considered only when:

• Conservative measures have failed after at least 6 months
• Patient has documented abnormal mobility of the coccyx or coccygeal spicules
• Pain significantly impacts quality of life 1, 4

Surgical approach considerations:

• Total or partial coccygectomy using a longitudinal incision is recommended for carefully selected patients 4
• Potential complications include infection (both superficial and deep) 4
• Success rates are high (good to excellent results in most patients) when proper patient selection is applied 4

Special Considerations

Postpartum Coccygodynia

• Higher risk in women with:
  • Instrumental deliveries
  • Multiparity
  • Higher BMI
  • Short perineum
  • Advanced maternal age 5

Trauma-Related Coccygodynia

• Common causes include:
  • Falls directly onto the tailbone
  • Water slide injuries 3
  • Sports injuries

Follow-up Recommendations

• Regular follow-up at 2-4 week intervals during conservative management
• Monitor for:
  • Pain improvement
  • Functional improvement (ability to sit comfortably)
  • Development of complications (infection, persistent pain)
• If symptoms persist beyond 6 months despite appropriate conservative management, consider surgical consultation

Common Pitfalls to Avoid

1. Failure to obtain dynamic imaging (standing vs. sitting radiographs)
2. Overlooking extracoccygeal causes of pain (pilonidal cyst, perianal abscess, hemorrhoids)
3. Premature surgical intervention before adequate trial of conservative measures
4. Inadequate pain management leading to chronic pain syndrome
5. Incomplete coccygectomy leaving painful proximal segments 4