What is the recommended treatment for chronic coccygeal pain without trauma?

Management of Chronic Coccygeal Pain Without Trauma

Start with conservative therapy including NSAIDs, specialized cushions, and pelvic floor physical therapy, as these achieve satisfactory results in the majority of patients with coccygodynia. 1, 2

Initial Conservative Management (First-Line)

• NSAIDs are the first-choice treatment for coccygeal pain, particularly in the acute phase but also applicable to chronic presentations 2
• Specialized coccyx cushions (donut-shaped or wedge cushions with coccygeal cutout) reduce direct pressure during sitting 3
• Pelvic floor physical therapy including levator ani muscle massage and stretching should be initiated early, as muscle tension and spasm contribute to pain perpetuation 1, 3, 4
• Manual therapy with coccyx mobilization can address abnormal mobility, which is the most common pathological finding (70% of patients with coccygodynia) 1

Diagnostic Imaging Considerations

• Lateral radiographs of the coccyx in both standing and sitting positions (dynamic imaging) are always indicated to identify abnormal mobility, subluxation, or bony spicules 1, 2
• MRI or CT scanning should be obtained if plain radiographs are inconclusive but clinical suspicion remains high, as these can reveal fractures, disc degeneration, or other pathology not visible on X-ray 5
• Physical examination must include manual palpation of the coccyx to reproduce pain and confirm coccygeal origin 2

Interventional Treatments (Second-Line)

When conservative measures fail after 2-3 months:

• Local injection of local anesthetic and corticosteroid into the painful coccygeal segment is the primary interventional option (Grade 2C+ evidence) 1, 2, 4
• Injections can target the sacrococcygeal disc, first intercoccygeal disc, Walther's ganglion, or muscle attachments around the coccyx 1
• Pulsed radiofrequency ablation of coccygeal discs and Walther's ganglion may be considered, though evidence is limited and should ideally be performed under study conditions 1, 2, 4
• Extracorporeal shock wave therapy has emerging evidence for pain relief in refractory cases 4

Important Caveat: Radiofrequency for Coccygeal Pain

RF targeting coccygeal pain was rated as inconclusive in the 2023 synthesis of interventional pain management guidelines, indicating insufficient evidence to strongly recommend this approach 6

Surgical Consideration (Last Resort)

• Coccygectomy (partial or total) is reserved only for refractory cases that have failed all conservative and interventional therapies 1, 2, 4
• Patients with abnormal mobility of the coccyx and bony spicules respond best to surgical treatment 1
• Coccygectomy is not routinely recommended due to moderate long-term results and risk of major complications, but has high success rates for pain reduction in carefully selected patients who have failed all other treatments 2, 4

Exclusion of Other Causes

Before attributing pain solely to the coccyx, exclude:

• Pilonidal cyst, perianal abscess, hemorrhoids (local anorectal pathology) 1
• Pelvic organ disorders (urogenital or colorectal disease) 1, 2
• Lumbosacral spine pathology, sacroiliac joint dysfunction, or piriformis syndrome (referred pain) 1
• Infections or tumors must be ruled out in idiopathic presentations 2
• If pain is not provoked by prolonged sitting or manual examination, consider neurological causes such as lumbar disc herniation 2

Treatment Algorithm

1. Weeks 0-8: NSAIDs + coccyx cushion + activity modification (avoid prolonged sitting, cycling, rowing)
2. Weeks 8-12: Add pelvic floor physical therapy and manual coccyx mobilization
3. Month 3+: If no improvement, proceed to local corticosteroid injection
4. Month 6+: Consider pulsed radiofrequency or extracorporeal shock wave therapy
5. Only after 12+ months of failed conservative/interventional therapy: Evaluate for coccygectomy in patients with documented abnormal mobility or spicules

Common Pitfalls

• Do not proceed directly to interventional treatments without adequate trial of conservative therapy, as most patients respond to non-invasive measures 1
• Do not rely solely on static X-rays—dynamic sitting/standing views are essential to detect abnormal mobility 1
• Avoid opioids for chronic coccygeal pain, as they do not address the underlying pathology and carry significant risks of dependence and narcotic bowel syndrome 6, 7