What can be done to relieve coccyx pain when lying on my back?

Management of Coccyx Pain When Lying Supine

For coccyx pain when lying on your back, avoid supine positioning and instead use side-lying or prone positions with pillow support, combined with conservative measures including specialized cushions for sitting, NSAIDs, and physical therapy targeting the pelvic floor muscles. 1, 2

Immediate Positional Modifications

• Avoid lying flat on your back as this position increases direct pressure on the coccyx and exacerbates pain 1
• Sleep on your side with a pillow between your knees to maintain spinal alignment and reduce coccygeal pressure 2
• If you must lie supine, place a small pillow or rolled towel under your knees to reduce lumbar lordosis and decrease coccygeal tension 3
• Consider prone (stomach) positioning if tolerable, as this completely eliminates posterior pressure on the coccyx 1

Conservative Treatment Measures

Conservative therapy is successful in 90% of coccydynia cases, making it the appropriate first-line approach 2:

• Use a coccyx cushion (donut-shaped or wedge cushion with coccygeal cutout) for all sitting activities to reduce direct pressure 1, 2
• Apply heat therapy using heating pads to the coccygeal region for short-term pain relief 4
• Take NSAIDs or acetaminophen for pain management; acetaminophen is preferred initially given general safety profile 4, 2
• Maintain activity and avoid prolonged bed rest, as remaining active improves outcomes 4

Physical Therapy and Manual Interventions

• Pelvic floor physical therapy is essential, focusing on massage and stretching of the levator ani muscle and manual mobilization of the coccyx 1, 2
• Manual manipulation and massage of the coccygeal region can provide significant relief 1, 2
• Transcutaneous electrical nerve stimulation (TENS) may be beneficial for refractory cases 2

When to Escalate Care

If conservative measures fail after 8-12 weeks, consider:

• Local corticosteroid injections into the sacrococcygeal or intercoccygeal discs, or around muscle attachments at the coccyx 1, 2
• Diagnostic imaging with sitting/standing lateral radiographs to assess for abnormal coccygeal mobility (hypermobility or subluxation), which is present in 70% of coccydynia cases 1, 3
• If plain radiographs are inconclusive but clinical suspicion remains high, MRI or CT imaging can reveal coccygeal pathology not visible on x-rays 5

Important Clinical Considerations

Abnormal coccygeal mobility is the most common pathological finding (70% of cases) and can be confirmed with dynamic radiographs comparing standing versus sitting positions 1. This finding is crucial because patients with documented hypermobility respond best to treatment.

Red flags requiring further evaluation include:

• Progressive neurological symptoms suggesting cauda equina involvement 4
• Fever or constitutional symptoms suggesting infection 4
• History of cancer or unexplained weight loss 4
• Failure to improve with 3-6 months of comprehensive conservative therapy 2

Surgical Consideration

Coccygectomy (partial or total removal) is reserved for refractory cases after exhausting conservative options, with best outcomes in patients with documented abnormal mobility or bony spicules 1, 2. Success rates are high when patient selection is appropriate, but surgery should only be considered after 6-12 months of failed conservative management 2.

Multidisciplinary Approach

A combination of physical therapy, ergonomic adaptations (including sleep positioning), medications, and potentially injections provides the greatest chance of success in managing coccyx pain 2. Many cases resolve without medical intervention, but active management accelerates recovery 2.