What is the treatment for coccydynia (pain on the tailbone) when sitting down?

Treatment of Coccydynia (Tailbone Pain When Sitting)

Start with conservative management including NSAIDs, seat cushioning, and manual therapy, as this successfully resolves symptoms in the majority of patients; reserve coccygectomy only for refractory cases with documented abnormal coccygeal mobility or spicule formation. 1, 2, 3

Initial Conservative Treatment Approach

First-Line Interventions

• Begin NSAIDs at maximum tolerated doses as the primary pharmacologic treatment for acute and chronic coccygeal pain 2
• Implement activity modifications including decreased sitting time, use of a coccyx cushion (donut-shaped or wedge cushion with coccygeal cutout), and avoiding prolonged sitting, cycling, or rowing 1, 4
• Initiate manual therapy consisting of massage and stretching of the levator ani muscle and mobilization of the coccyx, typically over 3 treatment sessions 1, 5

Diagnostic Confirmation During Treatment

• Obtain lateral radiographs in both standing and sitting positions (dynamic imaging) to assess for abnormal coccygeal mobility, which is present in 70% of coccydynia cases 1
• Perform manual examination with direct palpation of the coccyx to reproduce symptoms and confirm coccygeal origin of pain 2, 5
• Consider intrarectal mobility testing to assess sacrococcygeal joint hypomobility or hypermobility 5

Second-Line Interventions for Persistent Pain

Therapeutic Injections

• Administer local anesthetic and corticosteroid injections into painful structures (sacrococcygeal disc, first intercoccygeal disc, Walther's ganglion, or muscle attachments around the coccyx apex) 1, 2
• These injections serve dual purposes: diagnostic confirmation of coccygeal pain origin and therapeutic relief 1
• Expect temporary relief in many patients, though some may require repeated injections 5

Additional Conservative Modalities

• Consider pelvic floor physical therapy for comprehensive management 4
• Trial acupuncture as an adjunctive treatment option 1
• Apply topical medications for localized pain relief 4

Surgical Intervention: Coccygectomy

Indications for Surgery

Reserve coccygectomy exclusively for patients who:

• Have failed comprehensive conservative management over an adequate trial period 2, 3
• Demonstrate abnormal coccygeal mobility (hypermobility, subluxation, or luxation) on dynamic radiographs 1, 3
• Have coccygeal spicules (bony excrescences) identified on imaging 1, 3

Important Surgical Considerations

• Patients with documented instability or spicules respond best to surgical treatment 1, 3
• Coccygectomy carries risk of major complications and produces only moderate long-term results in many cases 2
• Surgical intervention should be considered a last resort after exhausting conservative options 2, 3

Exclusion of Alternative Diagnoses

Rule Out Extracoccygeal Causes

Before committing to coccydynia-specific treatment, exclude these conditions that can mimic coccygeal pain:

• Pilonidal cyst, perianal abscess, or hemorrhoids 1
• Pelvic organ disorders (rectum, sigmoid colon, urogenital system) 1, 2
• Lumbosacral spine pathology including disc herniation, which may refer pain to the coccygeal region 2, 5
• Sacroiliac joint dysfunction or piriformis muscle disorders 1

Red Flag Assessment

• If pain is NOT provoked by prolonged sitting or manual examination, consider neurological causes such as lumbar disc herniation rather than true coccydynia 2
• In 30% of cases, no specific cause is identified (idiopathic coccydynia), but these patients still respond to conservative management 1

Common Pitfalls to Avoid

• Do not rush to surgery without documenting abnormal coccygeal mobility or spicule formation on imaging, as outcomes are poor in patients without these findings 1, 3
• Do not overlook referred pain from visceral structures or lumbar spine pathology that can present identically to coccydynia 1, 2
• Do not abandon conservative therapy prematurely—the majority of patients achieve satisfactory results with multimodal conservative treatment 1
• Do not skip dynamic radiographs when considering surgical intervention, as static images may miss the abnormal mobility that predicts surgical success 1, 3