What are the treatment options for sacral (tailbone) pain?

Treatment Options for Sacral (Tailbone) Pain

For sacral/tailbone pain (coccydynia), initial management should focus on conservative measures including cushion use, NSAIDs or acetaminophen, activity modification, and pelvic floor physical therapy, with image-guided corticosteroid injections reserved for refractory cases after 1-2 months of failed conservative treatment. 1

Initial Conservative Management (First-Line Treatment)

• Advise patients to remain active within pain limits rather than prescribing bed rest 2
• Use specialized cushions (wedge-shaped or donut cushions) to reduce direct pressure on the coccyx while sitting 1
• First-line medications include acetaminophen or NSAIDs based on individual patient risk factors 2
• Consider short-term muscle relaxants for severe muscle spasm 2
• Recommend gradual return to normal activities as tolerated 2

Physical Therapy Interventions

• Pelvic floor physical therapy is a key conservative treatment modality for coccydynia 1
• For persistent symptoms beyond 4 weeks, consider structured exercise therapy 2
• Massage therapy may provide benefit for chronic symptoms 2

Diagnostic Imaging Considerations

Important caveat: Routine imaging is generally not indicated for uncomplicated tailbone pain in the first 4-6 weeks unless red flags are present 2. However, when imaging is warranted:

• Plain radiographs of the coccyx are the initial diagnostic test when imaging is needed 1
• MRI, CT, or nuclear medicine bone scans are advanced studies reserved for specific clinical scenarios 1
• A quality improvement study found that sacral MRI for low back/tailbone pain was positive for major findings in only 2% of cases and rarely changed management, suggesting imaging should be highly selective 3

Red Flags Requiring Immediate Evaluation

Obtain imaging promptly if any of the following are present:

• History of cancer (positive likelihood ratio 14.7) 2
• Unexplained weight loss (positive likelihood ratio 2.7) 2
• Failure to improve after 1 month (positive likelihood ratio 3.0) 2
• Severe or progressive neurologic deficits 2
• Suspected infection or cauda equina syndrome 2

Interventional Pain Management

For patients who fail conservative management after 1-2 months:

• Image-guided corticosteroid injections into the coccygeal region can be considered 1
• Topical medications may provide adjunctive benefit 1
• For limited severe pain, short-term opioids may be considered, but only for brief duration due to dependence risk 2

Surgical Consideration

• Coccygectomy (surgical removal of the coccyx) is reserved for rare, refractory cases that have failed all conservative and interventional treatments 1

Special Diagnostic Considerations

In younger patients with chronic sacral pain and morning stiffness, consider inflammatory causes:

• Inflammatory sacroiliitis or axial spondyloarthropathy should be suspected in patients younger than 45 years with pain duration >3 months and inflammatory symptoms 4
• Initial imaging for suspected inflammatory disease should include X-rays of the sacroiliac joints (rated 9/9 appropriateness) and spine (rated 9/9) 4
• If X-rays are negative or equivocal, MRI of the sacroiliac joints without contrast (rated 8/9) is the next appropriate step 4

Common Pitfalls to Avoid

• Do not routinely order sacral MRI for simple tailbone pain without red flags—it has extremely low yield (2% positive rate) and high cost without patient benefit 3
• Do not confuse sacroiliac joint pain with coccyx pain—they require different diagnostic and treatment approaches 5, 6
• Do not overlook serious pathology: While rare, sacral pain can be caused by tumors (giant cell tumor, chordoma, Ewing sarcoma), infection, or insufficiency fractures requiring multimodality imaging assessment 7
• Physical examination should include focal palpation of the coccyx—tenderness during direct palpation is the classic finding in coccydynia 1