What is the management for a fractured coccyx (tailbone)?

Management of Coccyx Fracture

Conservative management is the gold standard treatment for coccyx fractures, with most patients achieving satisfactory results through a combination of activity modification, pain control, physical therapy, and supportive measures. 1, 2

Initial Assessment and Diagnosis

• Obtain dynamic lateral radiographs of the coccyx in both standing and sitting positions to evaluate for abnormal mobility (hypermobility >25° flexion or >25% posterior subluxation while sitting) and identify fracture patterns 3
• Look specifically for Type II coccyx morphology, intercoccygeal joint subluxation, and bony spicules, which are associated with persistent pain 3
• Consider MRI if clinical suspicion remains high despite negative plain films, as it can detect fractures and soft tissue pathology more effectively 4

Conservative Treatment (First-Line)

Conservative therapy should be implemented for all patients initially and typically provides relief in the majority of cases. 1, 2

Pain Management

• Prescribe NSAIDs and analgesics for acute pain control, with cautious use of opioids only for severe cases 1
• Recommend decreased sitting time and use of a coccyx cushion (donut pillow) to reduce pressure on the injured area 1, 2

Physical Interventions

• Initiate physical therapy including coccygeal massage, stretching of the levator ani muscle, and manual mobilization of the coccyx 1
• Implement postural adjustments to minimize stress on the coccyx during daily activities 2

Advanced Conservative Options (If Initial Measures Fail)

• Local injection of corticosteroids and/or local anesthetic into painful structures (sacrococcygeal disc, intercoccygeal disc, or muscle attachments) 1
• Consider ganglion impar block for refractory pain 3
• Pulsed radiofrequency ablation of coccygeal discs and Walther's ganglion may provide relief 1, 5
• Extracorporeal shockwave therapy has shown efficacy in some cases 4, 5, 3

Surgical Management

Coccygectomy (partial or total) is reserved for refractory cases after failure of conservative treatment, particularly in patients with documented advanced coccygeal instability (subluxation or hypermobility) or spicule formation. 1, 2

Indications for Surgery

• Persistent pain despite at least 6-12 months of comprehensive conservative therapy 1
• Evidence of significant hypermobility (>35° posterior subluxation) on dynamic radiographs 3
• Presence of bony spicules causing mechanical irritation 1, 2
• Patients with these specific findings demonstrate the greatest improvement postoperatively 2

Common Pitfalls

• Do not dismiss persistent postpartum coccyx pain as normal inflammation—maintain high suspicion for fracture, especially after difficult or instrument-assisted deliveries 4
• Avoid delaying dynamic radiographs—static films may miss the abnormal mobility that is present in 70% of coccydynia cases 1
• Do not rush to surgery—approximately 30% of cases are idiopathic, and most patients respond to conservative measures 1
• Be aware that one-third of patients may have no identifiable cause (idiopathic coccydynia), requiring a trial of empiric conservative treatment 1

Expected Outcomes

• Most patients recover well with conservative management, though some may experience prolonged discomfort requiring 1-2 years of treatment 4, 2
• Patients with documented instability or spicules respond best to surgical intervention when conservative measures fail 1, 2