What is the recommended treatment for chronic coccydynia (tail bone pain)?

Treatment of Chronic Coccydynia (Tailbone Pain)

Conservative management with NSAIDs, cushions, and physical therapy should be the first-line approach for chronic coccydynia, as 90% of cases resolve with non-surgical treatment, reserving coccygectomy only for refractory cases after failed conservative therapy including local steroid injections. 1

Initial Conservative Management (First 6-12 Weeks)

Non-Pharmacologic Interventions

• Use specialized cushions (donut or wedge-shaped) to reduce direct pressure on the coccyx while sitting 2, 1
• Avoid prolonged sitting and minimize transitions from sitting to standing, which typically worsen symptoms 2, 3
• Initiate pelvic floor physical therapy including manual manipulation and massage of the sacrococcygeal joint 1, 3
• Consider ergonomic adaptations to reduce sitting time and pressure 1

Pharmacologic Treatment

• Start NSAIDs at maximum tolerated doses as first-line pharmacologic therapy 4
• Acetaminophen can be used as an alternative or adjunct for patients with NSAID contraindications 5
• Topical analgesics may be considered for localized pain relief 5, 2

Important caveat: NSAIDs carry risks of GI bleeding, renal toxicity, and cardiovascular events, particularly in elderly patients or those with prolonged use 5

Second-Line Treatment (If No Improvement After 6 Weeks)

Local Steroid Injections

• Proceed to local corticosteroid injections into the sacrococcygeal region if NSAIDs and conservative measures fail 4, 1
• Patients often require repeat injections over time for sustained benefit 4
• 53% of patients in one series required this escalation of therapy 4

Additional Conservative Measures

• Continue pelvic floor physical therapy with manual manipulation 1, 3
• Consider transcutaneous electrical nerve stimulation (TENS) as part of multimodal pain management 5, 1
• Psychotherapy may be beneficial for patients with chronic, refractory pain 1

Advanced Imaging Considerations

If clinical suspicion remains high but initial plain radiographs are negative, obtain MRI or CT imaging to identify occult fractures, mobile fragments, or other pathology not visible on standard sitting/standing lateral films 6. This is particularly important before considering surgical intervention.

Surgical Management (Reserved for Refractory Cases)

Indications for Coccygectomy

• Failure of conservative treatment including NSAIDs and multiple steroid injections over 3-6 months 4, 1
• Patients with higher pretreatment pain scores (VAS >8) are more likely to require surgery 4
• Radiographic evidence of coccygeal pathology on advanced imaging 6

Surgical Outcomes and Complications

• 82% of surgical patients report marked improvement in pain and function 4
• High infection risk: 27% develop wound infections and 9% experience wound dehiscence 4
• All infections typically resolve with irrigation, debridement, and short-course oral antibiotics 4
• Patients must be counseled about these significant complication rates before proceeding 4

Clinical Pearls and Pitfalls

Key diagnostic features to confirm:

• Midline pain below the sacrum and above the anus 2
• Focal tenderness on direct palpation of the coccyx 2
• Pain worse with sitting and sit-to-stand transitions 2, 3
• Hypomobility or abnormal mobility on intrarectal examination (when performed) 3

Common pitfall: Proceeding to surgery without adequate trial of conservative therapy. The evidence strongly supports that 90% of cases resolve without surgical intervention 1, and even patients requiring surgery should have failed both NSAIDs and local injections before coccygectomy is considered 4.

Risk factors to identify: Obesity and female gender are associated with increased risk of developing coccydynia 1, which may influence treatment intensity and duration.