What is the management approach for coccydynia with normal X-ray results?

Management of Coccydynia with Normal X-ray

For tailbone pain with normal X-rays, begin with conservative management including NSAIDs, specialized cushions, and physical therapy for at least 3 months; if symptoms persist despite conservative measures, obtain advanced imaging (MRI or CT) to identify occult pathology before considering surgical intervention.

Initial Conservative Management (First-Line)

Conservative treatment successfully resolves 90% of coccydynia cases and should be the initial approach 1:

• NSAIDs for pain control and anti-inflammatory effects 2
• Specialized seating cushions (donut or wedge-shaped) to reduce pressure on the coccyx during sitting 1, 3
• Limit prolonged sitting and use ergonomic adaptations 1
• Physical therapy including:
  • Pelvic floor rehabilitation 1
  • Manual manipulation and massage of the sacrococcygeal joint 4, 1
  • Stretching exercises 3

When Conservative Treatment Fails (After 3+ Months)

If symptoms persist after 3 months of conservative management 4:

• Local corticosteroid injections into the sacrococcygeal region 1, 3, 2
  • Patients often require repeat injections over time 2
  • Provides temporary relief in many cases 4

Advanced Imaging for Persistent Cases

Normal plain X-rays do not rule out coccydynia 5. When clinical suspicion remains high despite negative X-rays:

• Obtain MRI or CT imaging to identify:
  • Mobile coccygeal fragments not visible on plain films 5
  • Subtle fractures or bone spurs 3
  • Soft tissue pathology 5
  • Advanced coccygeal instability 3

This is critical because dynamic radiographs may miss pathology that advanced imaging can reveal 3, 5.

Surgical Consideration (Last Resort)

Coccygectomy should be reserved for patients who:

• Fail conservative treatment including NSAIDs and injections 3, 2
• Have evidence on advanced imaging of:
  • Advanced coccygeal instability (subluxation or hypermobility) 3
  • Spicule formation 3
  • Mobile fragments causing symptoms 5

Surgical outcomes:

• 82% of patients report marked improvement 2
• High infection risk: 27% develop wound infections requiring irrigation/debridement 2
• Patients must be counseled about infection risk before proceeding 2

Clinical Assessment Approach

Even with normal X-rays, perform targeted examination 4:

• Intrarectal mobility testing of the sacrococcygeal joint (reproduces symptoms in true coccydynia) 4
• Pain provocation testing during palpation 4
• Assess for hypomobility of the sacrococcygeal joint 4
• Rule out lumbar spine pathology as alternative pain source 4

Common Pitfalls to Avoid

• Don't dismiss the diagnosis based solely on normal X-rays—plain radiographs have low sensitivity for coccydynia 5
• Don't rush to surgery without exhausting conservative options and obtaining advanced imaging 3, 2
• Don't forget multidisciplinary approach combining physical therapy, medications, and injections leads to greatest success 1
• Consider psychotherapy for refractory cases as part of comprehensive management 1

Additional Treatment Options for Refractory Cases

Before surgery, consider 1:

• Transcutaneous electrical nerve stimulation (TENS)
• Nerve blocks
• Spinal cord stimulation (rare cases)