What is the best treatment approach for a patient with Coccydynia (tailbone pain)?

Treatment of Coccydynia (Tailbone Pain)

Conservative therapy should be the first-line approach for all patients with coccydynia, including NSAIDs, physical therapy with manual manipulation, and local steroid injections, with coccygectomy reserved only for refractory cases after at least 2-3 months of failed conservative management.

Initial Conservative Management (First-Line Treatment)

All patients with coccydynia should begin with conservative therapy, which achieves satisfactory results in the majority of cases 1:

• NSAIDs are the cornerstone of initial pharmacologic management 2, 3
• If NSAIDs alone are insufficient, acetaminophen or small doses of narcotics can be added 2
• Coccyx cushion (donut pillow) to reduce pressure while sitting 1
• Activity modification: avoid prolonged sitting, bicycling, rowing, and other activities that increase coccygeal pressure 1

Physical Therapy and Manual Interventions

Physical therapy should be incorporated early in the treatment algorithm 1, 4:

• Manual therapy including massage and stretching of the levator ani muscle 1
• Mobilization of the coccyx through intrarectal manipulation for patients with hypomobility 1, 4
• Acupuncture or laser acupuncture may provide analgesic effects 1, 5

One case report demonstrated complete resolution of refractory coccydynia after traumatic fracture using low-level laser therapy once weekly for 24 weeks 5. Manual therapy to the sacrococcygeal joint over 3 treatment sessions achieved near-complete resolution in patients with traumatic onset 4.

Interventional Procedures (Second-Line)

If conservative measures fail after 4-8 weeks, proceed to interventional techniques 1, 6:

• Local injections of anesthetic and corticosteroid into painful structures (sacrococcygeal disc, intercoccygeal disc, muscle attachments) 1, 6, 3
• Patients often require repeat injections over time for sustained benefit 3
• Extracorporeal shock wave therapy has demonstrated significant pain relief in some studies 6
• Pulsed radiofrequency ablation of coccygeal discs, Walther's ganglion, or ganglion impar 1, 6

Seventeen of 32 patients (53%) in one series were successfully managed with NSAIDs followed by local injections 3.

Surgical Management (Last Resort)

Coccygectomy should only be considered after at least 2-3 months of failed conservative and interventional therapy 1, 5, 6:

• Best candidates: patients with abnormal coccyx mobility (hypermobility, subluxation) on dynamic radiographs and those with coccygeal spicules 1
• Success rate: 82% of surgical patients report marked improvement 3
• Complication warning: High infection rate (27% wound infections, 9% dehiscence in one series) 3
• All infections resolved with irrigation, debridement, and oral antibiotics 3

Patients with traumatic onset who fail manual therapy may require diagnostic imaging and surgical excision, whereas those with non-traumatic onset may respond better to conservative approaches 4.

Diagnostic Considerations

Before proceeding with treatment, confirm coccygeal origin of pain 1:

• Dynamic radiographs (lateral X-rays in standing and sitting positions) to assess abnormal mobility—the most common pathological finding in 70% of patients 1
• Diagnostic injections of local anesthetic into suspected pain generators to confirm coccygeal source 1
• Exclude extracoccygeal causes: pilonidal cyst, perianal abscess, hemorrhoids, pelvic organ disease, lumbosacral spine disorders, sacroiliac joint dysfunction 1
• Note that 30% of cases are idiopathic with no identifiable cause 1

Treatment Algorithm Summary

1. Weeks 0-4: NSAIDs + activity modification + coccyx cushion 2, 1, 3
2. Weeks 4-8: Add physical therapy with manual manipulation 1, 4
3. Weeks 8-12: Local steroid injections if inadequate response 1, 6, 3
4. After 2-3 months: Consider coccygectomy only for refractory cases with confirmed abnormal mobility 1, 5, 6, 3

Critical Pitfalls to Avoid

• Do not rush to surgery: Conservative therapy succeeds in the majority of patients, and surgery carries significant infection risk 1, 3
• Do not overlook non-coccygeal causes: Always exclude lumbosacral, sacroiliac, and pelvic pathology before attributing pain solely to the coccyx 1
• Warn surgical candidates about complications: Patients must understand the 27% infection rate before proceeding with coccygectomy 3
• Obtain dynamic imaging: Static X-rays may miss abnormal mobility that is only apparent with positional changes 1