What are the treatment options for constant hip movement due to lower spine/tailbone (coccyx) pain?

Treatment of Constant Hip Movement Due to Lower Spine/Tailbone Pain

For patients with tailbone (coccyx) pain causing compensatory hip movement, conservative treatment including physical therapy, NSAIDs, and coccygeal cushions should be initiated first, with interventional procedures (steroid injections or radiofrequency ablation) reserved for cases unresponsive to 6 months of conservative care, and coccygectomy considered only after all other treatments have failed. 1, 2, 3

Initial Diagnostic Approach

Rule out referred pain from the lumbar spine first, as lower back pathology commonly presents with hip symptoms and may be the primary pain generator rather than the coccyx itself. 4, 5

• Obtain plain radiographs of the pelvis, hip, and lumbosacral spine as the initial imaging study to screen for structural abnormalities, arthritis, or fractures 4
• Dynamic lateral radiographs of the coccyx (standing and sitting positions) should be obtained specifically to assess for abnormal coccygeal mobility, which is present in 70% of coccygodynia cases 1
• Look for hypermobility, anterior/posterior subluxation, fractures, or bony spicules on these dynamic films 1

Conservative Treatment (First-Line for 6+ Months)

All patients should begin with conservative management, as satisfactory results are achieved in the majority of coccygodynia cases with non-surgical approaches. 1

• NSAIDs or acetaminophen for pain control 6
• Coccygeal cushion (donut-shaped or wedge cushion) to reduce pressure on the tailbone during sitting 1
• Physical therapy including manual therapy with massage and stretching of the levator ani muscle, and mobilization of the coccyx 1
• Activity modification: avoid prolonged sitting, bicycling, rowing, and other activities that increase coccygeal load 1
• Maintain physical activity rather than bed rest, as activity is more effective for spinal pain 6

Interventional Treatment (After 6 Months of Failed Conservative Care)

For patients unresponsive to conservative treatment, ultrasound-guided interventional procedures provide significant pain relief without the risks of surgery. 2

• Ultrasound-guided steroid injection and radiofrequency ablation (RFA) of the coccygeal nerve is highly effective, with 54% of patients achieving >50% pain reduction at 12 weeks 2
• The procedure involves: visualizing coccygeal nerves at the level of coccygeal cornua, injecting 1 mL lidocaine 2%, performing RFA at 90°C for 60 seconds, then injecting 2 mL dexamethasone and 2 mL bupivacaine 0.5% 2
• Diagnostic/therapeutic injections of local anesthetic with corticosteroid into the sacrococcygeal disc, first intercoccygeal disc, or Walther's ganglion can confirm coccygeal origin of pain and provide relief 1

Surgical Treatment (Last Resort)

Coccygectomy should only be considered after failure of all conservative and interventional treatments, typically after 6-7 months of unsuccessful non-surgical management. 3

• Best surgical candidates are patients with documented abnormal coccygeal mobility on dynamic radiographs or bony spicules 1, 3
• Surgical outcomes: 71.4% of patients achieve excellent results, though wound infections occur in 14.2% of cases 3
• Partial or total coccygectomy can be performed depending on the pathology 1

Addressing the Hip Movement Component

The constant hip movement is likely a compensatory mechanism to avoid coccygeal pressure, so treatment should focus on the primary coccygeal pathology rather than the hip itself. 1

• Screen for true hip pathology with physical examination including FADIR test, range of motion assessment, and evaluation for trochanteric bursitis or abductor tendinopathy 4, 5
• If hip radiographs are normal and hip examination is non-contributory, the hip movement is secondary to coccyx pain avoidance 4, 5
• MRI of the hip is only indicated if there are specific findings suggesting intra-articular hip pathology (positive FADIR test, mechanical symptoms, limited range of motion) 4

Critical Pitfalls to Avoid

• Do not perform coccygectomy as first-line treatment - it should only be considered after 6+ months of failed conservative and interventional therapies 1, 3
• Do not assume all hip movement is from hip pathology - referred pain from the spine or compensatory movement from coccyx pain is common 4, 5
• Do not obtain MRI without first getting plain radiographs - radiographs are the appropriate initial imaging study 4
• 30% of coccygodynia cases are idiopathic with no identifiable cause, so extensive workup may not reveal a specific etiology 1