What is the recommended treatment for a patient with coccyx pain lasting 6 months, including medication dosages?

Treatment of Chronic Coccyx Pain (6 Months Duration)

For coccyx pain persisting 6 months, initiate NSAIDs (ibuprofen 400 mg every 4-6 hours, maximum 3200 mg daily) combined with local corticosteroid injection into the painful coccygeal segment, followed by manual therapy if injection fails. 1, 2

First-Line Pharmacologic Management

• Start with NSAIDs as the primary analgesic: Ibuprofen 400 mg every 4-6 hours as needed, not exceeding 3200 mg total daily dose 1
• Take with meals or milk to minimize gastrointestinal complaints 1
• Use the lowest effective dose for the shortest duration consistent with pain control 1
• If NSAIDs alone are insufficient, acetaminophen or small doses of narcotics can be added 3

Interventional Treatment Algorithm

Step 1: Local Corticosteroid Injection

• Inject local anesthetic plus corticosteroid directly into the painful coccygeal segment (sacrococcygeal or intercoccygeal disc, Walther's ganglion, or muscle attachments) 4, 2
• This is recommended as first-choice treatment for severe chronic pain (2C+ evidence) 2
• Mean pain reduction of -1.5 points at 6 months and -2.8 points at 36 months can be expected 5
• If no response after first injection, a second injection may be attempted 6

Step 2: Manual Therapy (If Injection Fails)

• Perform bimanual coccyx manipulation and manual therapy including massage and stretching of the levator ani muscle 4, 7
• This is particularly effective for patients with abnormal coccygeal mobility (hypermobility, subluxation) 4
• Manual therapy should be combined with physical therapy 4

Step 3: Diagnostic Imaging

• Obtain dynamic lateral radiographs (standing and sitting positions) to assess for abnormal coccygeal mobility, which is present in 70% of coccygodynia cases 4
• Consider MRI if neurological causes (lumbar disc herniation) are suspected, particularly if pain is not provoked by prolonged sitting 2

Adjunctive Conservative Measures

• Prescribe a coccyx cushion to reduce pressure during sitting 4
• Recommend activity modification: avoid prolonged sitting, bicycling, rowing, and riding 4
• Physical therapy and acupuncture may provide additional benefit 4

Surgical Consideration

• Reserve coccygectomy for refractory cases after conservative management fails for at least 36 months 7, 5
• Patients with posterior coccyx dislocation and abnormal mobility respond best to surgical treatment 4, 5
• At 36 months, 51% of patients have persistent significant pain (>3/10) despite conservative treatment, indicating potential surgical candidates 5
• Coccygectomy provides effective pain relief in properly selected patients, with superficial wound infection being the most common complication 7

Important Caveats

• Longer duration of symptoms predicts worse outcomes: Each additional month of symptom duration increases odds of treatment failure by 4% 5
• Exclude secondary causes: Rule out pilonidal cyst, perianal abscess, hemorrhoids, pelvic organ disease, lumbosacral spine disorders, and sacroiliac joint pathology before diagnosing primary coccygodynia 4
• Confirm coccygeal origin: Pain should be reproducible with manual palpation of the coccyx and provoked by prolonged sitting 4, 2
• Avoid interventions with insufficient evidence: Intradiscal injections, ganglion impar block, radiofrequency treatment, and caudal blocks should only be used in research settings (0 level recommendation) 2
• In 30% of cases, no cause is identified (idiopathic coccygodynia), but treatment approach remains the same 4