What is the initial work-up and treatment for chronic coccydynia (tailbone pain)?

Chronic Tailbone Pain (Coccydynia) Work-Up

Begin with a focused clinical assessment including sitting/standing lateral radiographs, followed by conservative management with cushions, NSAIDs, and physical therapy—reserving advanced imaging (MRI or CT) only when initial X-rays are negative but clinical suspicion remains high. 1, 2, 3

Initial Clinical Assessment

History and Physical Examination:

• Document midline pain below the sacrum and above the anus that worsens with sitting or sit-to-stand transitions 2
• Identify precipitating factors: trauma (fall, childbirth), chronic overload (obesity, prolonged sitting, cycling, rowing), or idiopathic onset 1, 4
• Perform focal palpation of the coccyx to reproduce symptoms 2
• Consider intrarectal mobility testing to assess sacrococcygeal joint hypomobility and pain provocation 4

Essential Diagnostic Imaging:

• Obtain dynamic lateral radiographs (sitting and standing positions) as the initial imaging study 1, 3
• These X-rays identify abnormal coccyx mobility (hypermobility, subluxation, luxation), fractures, or bony spicules—present in 70% of coccydynia cases 1
• Plain radiographs alone may miss pathology in up to 30% of cases 1, 3

When Initial X-Rays Are Negative

Advanced Imaging Indications:

• If clinical suspicion remains high despite negative plain films, proceed to MRI or CT 3
• MRI without contrast reveals disc degeneration at sacrococcygeal/intercoccygeal segments, occult fractures, tumors, or soft tissue pathology 3
• CT better demonstrates bony spicules and subtle fractures not visible on plain films 3

Exclude Alternative Diagnoses

Rule out extracoccygeal sources before confirming coccydynia 1:

• Pilonidal cyst, perianal abscess, hemorrhoids
• Pelvic organ pathology
• Lumbosacral spine disorders, sacroiliac joint dysfunction, piriformis syndrome

First-Line Conservative Management

Conservative therapy succeeds in 90% of cases 5:

Non-Pharmacological Interventions:

• Coccyx cushion (donut or wedge-shaped) to reduce sitting pressure 2, 5
• Pelvic floor physical therapy with manual manipulation and massage of levator ani muscle 1, 5
• Ergonomic modifications: avoid prolonged sitting, use standing desks 5

Pharmacological Treatment:

• Oral NSAIDs for pain control 2, 3
• Topical analgesics as adjunct therapy 2

Interventional Options for Refractory Cases:

• Local anesthetic and corticosteroid injections into sacrococcygeal disc, intercoccygeal disc, or Walther's ganglion 1, 5
• Nerve blocks for diagnostic confirmation and therapeutic benefit 5
• Radiofrequency ablation of coccygeal discs or Walther's ganglion 1

Reassessment Timeline

• Review treatment response within 6 months 6
• If no improvement with conservative measures after adequate trial (typically 3-6 months), consider escalation 4, 5

Surgical Intervention

Coccygectomy (partial or total) is reserved for refractory cases 1, 4:

• Best outcomes in patients with documented abnormal coccyx mobility and bony spicules 1
• Consider only after failure of comprehensive conservative management 4, 5
• Success rates are high when patient selection is appropriate 5, 3

Critical Pitfalls to Avoid

• Do not pursue continuous imaging cycles without therapeutic trials between studies 6
• Do not overlook psychosocial factors that may amplify pain and disability—obesity, occupational sitting demands, and psychological distress significantly impact outcomes 6, 1
• Do not rush to surgery—30% of coccydynia cases are idiopathic and many resolve spontaneously with time and conservative care 1, 5
• Do not assume negative X-rays exclude coccydynia—proceed to MRI/CT when clinical presentation is classic 3