Treatment Options for Coccyx (Tailbone) Pain
For coccydynia (tailbone pain), begin with conservative management including NSAIDs, specialized cushions, and activity modification, which successfully resolves symptoms in 90% of cases. 1
Initial Conservative Treatment (First-Line)
Conservative therapy should be attempted for at least 6-8 weeks before considering advanced interventions:
- NSAIDs for pain control: Ibuprofen 400 mg every 4-6 hours as needed (maximum 3200 mg daily), taken with food to minimize gastrointestinal side effects 2
- Specialized seating cushions: Donut-shaped or wedge cushions that reduce direct pressure on the coccyx during sitting 3, 1
- Activity modification: Limit prolonged sitting and use proper ergonomic positioning 1
- Pelvic floor physical therapy: Manual manipulation and massage of the sacrococcygeal joint, particularly effective for hypomobility 4, 1
Diagnostic Evaluation
Physical examination should focus on:
- Focal midline tenderness during direct palpation of the coccyx below the sacrum and above the anus 3
- Pain reproduction with intrarectal mobility testing of the sacrococcygeal joint 4
- Worsening pain with sitting and transitions from sitting to standing 3, 4
Imaging approach:
- Initial sitting/standing lateral radiographs to assess coccyx mobility and fracture 3, 4
- If radiographs are negative but clinical suspicion remains high, obtain MRI or CT to identify subtle pathology not visible on plain films 5
Interventional Treatments (Second-Line)
When conservative management fails after 6-8 weeks, consider:
- Local corticosteroid injections: 2 mL dexamethasone with 2 mL bupivacaine 0.5% injected at the coccygeal region 6
- Critical caveat: Avoid injections near the Achilles tendon if posterior heel structures are involved 7
- Ultrasound-guided radiofrequency ablation (RFA) of coccygeal nerve: Combined with steroid injection, this 2024 study showed 54% of patients achieved >50% pain reduction at 12 weeks with minimal adverse events 6
- Transcutaneous electrical nerve stimulation (TENS) 1
- Nerve blocks for diagnostic and therapeutic purposes 1
Surgical Management (Last Resort)
Coccygectomy (surgical removal of the coccyx) should be reserved for refractory cases unresponsive to all conservative and interventional treatments, with high success rates for pain reduction when appropriately selected 3, 5, 1
Surgical referral is indicated when:
- No improvement after 6-8 weeks of appropriate conservative treatment 7
- Persistent symptoms despite interventional procedures 5
- Radiographic evidence of mobile coccygeal fragment or significant pathology 5
Common Pitfalls to Avoid
- Do not overlook traumatic versus non-traumatic etiology: Traumatic onset may respond better to conservative physical therapy, while non-traumatic cases may require earlier interventional or surgical management 4
- Do not rely solely on plain radiographs: Advanced imaging (MRI/CT) can reveal pathology missed on x-rays in patients with high clinical suspicion 5
- Recognize gender and obesity as risk factors: Female patients and those with obesity have higher incidence of coccydynia 1
- Avoid premature surgical intervention: 90% of cases resolve with conservative treatment alone 1