What is the recommended treatment for coccydynia?

Treatment of Coccydynia

Conservative management with NSAIDs and local corticosteroid injections should be the initial treatment approach for coccydynia, with coccygectomy reserved only for patients who fail conservative therapy after adequate trial. 1

Initial Conservative Management

First-Line Treatment

• Begin with NSAIDs alone for patients with mild to moderate pain (VAS <6), as 13% of patients respond to this intervention without requiring additional treatment 1
• NSAIDs such as ibuprofen or naproxen address both pain and inflammation in the sacrococcygeal region 1

Second-Line: Local Corticosteroid Injections

• Proceed to local corticosteroid injections when NSAIDs alone provide inadequate relief, as approximately 53% of patients require this escalation 1
• Inject local anesthetic combined with corticosteroid directly into the painful coccygeal segment 2
• Patients often require repeat injections over time for sustained symptom control 1
• Dynamic standing and seated radiographs should be obtained to identify abnormal coccygeal mobility, as this predicts better surgical outcomes if conservative treatment fails 2

Adjunctive Physical Therapy

• Pelvic floor physical therapy targeting muscle relaxation is highly effective, reducing average pain from 5.08 to 1.91 with mean global improvement of 71.9% 3
• Treatment includes coccygeal massage and stretching of the levator ani muscle 2
• An average of 9 physical therapy sessions achieves optimal results 3
• Consider baclofen (19% of patients), ganglion impar blocks (8%), or coccygeus trigger point injections (17%) as secondary interventions alongside physical therapy 3

Surgical Management

Indications for Coccygectomy

• Reserve surgery only for patients failing conservative treatment including NSAIDs, injections, and physical therapy 1, 2
• Surgical candidates typically present with significantly higher pretreatment pain scores (VAS 8.3 vs 5.4 in conservative group) 1
• Best surgical outcomes occur in patients with radiographically demonstrated abnormalities of coccygeal mobility on dynamic films 2

Surgical Outcomes and Complications

• 82% of surgical patients report marked improvement in pain and function 1
• High infection risk: 27% develop wound infections and 9% experience wound dehiscence 1
• All infections resolve with irrigation, debridement, and short-course oral antibiotics 1
• Patients must be counseled about the high infection rate before proceeding with surgery 1

Postcoccygectomy Pain Management

• For the 18% who continue experiencing pain after coccygectomy, pelvic floor physical therapy remains effective, reducing average pain from 6.64 to 3.27 3
• This demonstrates that physical therapy can salvage outcomes even in surgical failures 3

Diagnostic Considerations

Clinical Assessment

• Confirm diagnosis through intrarectal mobility testing of the sacrococcygeal joint, which should reproduce symptoms and demonstrate hypomobility 4
• Pain characteristically increases with prolonged sitting and intensifies during sit-to-stand transitions 4
• Lumbar spine examination should be negative to exclude referred pain 4

Advanced Imaging

• When clinical suspicion is high but plain radiographs are inconclusive, obtain MRI or CT to reveal coccygeal pathology 5
• MRI and CT can demonstrate inflammation, edema, and mobile fragments not visible on plain films 5, 2
• Bone scans may show inflammation but are less accurate than dynamic radiography 2

Treatment Algorithm

Step 1: Initiate NSAIDs for all patients with coccydynia 1

Step 2: Add local corticosteroid injections if NSAIDs fail after 4-6 weeks 1, 2

Step 3: Refer for pelvic floor physical therapy (9 sessions average) with consideration of adjunctive baclofen, ganglion impar blocks, or trigger point injections 3

Step 4: Obtain dynamic standing/seated radiographs to assess coccygeal mobility if considering surgery 2

Step 5: Proceed to coccygectomy only after documented failure of all conservative measures, with patient counseled regarding 27% infection risk 1

Important Caveats

• Pain duration and history of trauma do not predict treatment outcomes, so all patients deserve aggressive conservative trial regardless of chronicity 3
• Greater initial pain scores correlate with higher final pain scores, but this should not deter treatment as absolute improvement remains substantial 3
• Patients with traumatic onset may respond more rapidly to manual therapy than those with insidious onset, though both can achieve successful outcomes 4