What are the treatment options for intermittent coccyx (tailbone) pain?

Treatment of Intermittent Coccyx Pain

For intermittent coccyx pain, begin with conservative management using NSAIDs, a coccyx cushion with central cutout, and activity modification; if symptoms persist beyond 6 months despite conservative measures, consider local corticosteroid injections, and reserve coccygectomy only for refractory cases after exhausting all conservative options.

Initial Conservative Management (First-Line)

• NSAIDs should be the first-line pharmacological treatment for acute and chronic coccygodynia, given their demonstrated effectiveness for musculoskeletal pain 1, 2.
• Acetaminophen (650 mg every 4-6 hours, maximum 4 g/24 hours) is an alternative first-line option with excellent safety profile, particularly for patients with contraindications to NSAIDs 1.
• A coccyx cushion with a central recess (donut cushion) should be prescribed immediately to reduce direct pressure on the coccyx while sitting 3, 4.
• Avoid prolonged sitting, cycling, and rowing activities that increase mechanical stress on the coccyx 3.
• Apply local heat or cold therapy to the coccyx region for symptomatic relief 5.

Physical Examination and Diagnosis

• Confirm coccygeal origin by reproducing pain with direct palpation of the coccyx during rectal or external examination 3, 6, 7.
• Obtain dynamic lateral radiographs of the coccyx in both standing and sitting positions to identify abnormal mobility (hypermobility, subluxation), which is present in 70% of coccygodynia cases 3, 4.
• Pain that is not provoked by prolonged sitting or manual palpation suggests alternative diagnoses such as lumbar disc herniation or referred visceral pain 2.

Second-Line Interventional Treatment

• If conservative measures fail after 3-6 months, proceed to local injection of corticosteroid plus local anesthetic directly into the painful coccygeal segment 3, 2, 4.
• Manual therapy including massage and stretching of the levator ani muscle, plus mobilization of the coccyx, can be beneficial 3, 6.
• Pelvic floor physical therapy focusing on muscle relaxation (not strengthening) may help address associated muscle spasm 5, 6.

Surgical Consideration

• Coccygectomy should only be considered if symptoms persist beyond 6 months despite comprehensive conservative treatment, with success rates of 80-90% when properly indicated 3, 6, 4.
• Patients with abnormal coccygeal mobility on dynamic radiographs and bony spicules respond best to surgical treatment 3, 4.
• Coccygectomy carries risk of major complications and should be reserved as a last resort 2.

Critical Pitfalls to Avoid

• Do not overlook alternative diagnoses: pilonidal cyst, perianal abscess, hemorrhoids, pelvic organ pathology, sacroiliac joint dysfunction, or lumbosacral spine disorders can all present as "coccyx pain" 3, 2.
• In 30% of cases, no specific cause is identified (idiopathic coccygodynia), but this should be a diagnosis of exclusion 3.
• Women and obese patients are at higher risk for developing coccygodynia 6.
• Avoid premature surgical intervention—90% of cases resolve with conservative treatment alone 6.
• When using NSAIDs in older patients, assess cardiovascular, gastrointestinal, and renal risks, and consider gastroprotection with proton pump inhibitors 1.