What is the diagnosis and treatment for coccydynia (tailbone pain)?

Coccydynia: Diagnosis and Treatment

Diagnosis

Coccydynia is diagnosed clinically by midline pain below the sacrum and above the anus that worsens with sitting or sit-to-stand transitions, confirmed by focal tenderness on direct palpation of the coccyx. 1

Key Diagnostic Features

• Pain characteristics: Localized to the tailbone region, exacerbated by sitting and transitioning from sitting to standing 1
• Physical examination: Direct palpation of the coccyx reproduces the pain 1
• Imaging studies:
  • Start with plain radiographs (lateral views in both standing and sitting positions) to assess coccygeal mobility 2
  • Abnormal coccygeal mobility (hypermobility, subluxation, or luxation) is found in 70% of patients with coccydynia 2
  • Advanced imaging (MRI, CT, or bone scan) is reserved for cases where infection, tumor, or other pathology is suspected 1

Diagnostic Confirmation

• Local anesthetic injection into the sacrococcygeal disc, first intercoccygeal disc, or Walther's ganglion can confirm coccygeal origin of pain 2
• Intrarectal mobility testing can assess sacrococcygeal joint hypomobility and reproduce symptoms 3

Differential Diagnosis to Exclude

• Pilonidal cyst, perianal abscess, hemorrhoids 2
• Pelvic organ pathology 2
• Lumbosacral spine disorders, sacroiliac joint dysfunction, piriformis syndrome 2
• Note: 30% of cases are idiopathic with no identifiable cause 2

Treatment Algorithm

Conservative management is the gold standard and should be exhausted before considering surgery, as most patients achieve satisfactory results with non-operative treatment. 2, 4

First-Line Conservative Treatment (Weeks 1-12)

• Activity modification: Decrease sitting time, use coccyx cushion (donut-shaped or wedge) 1, 4
• Oral medications: NSAIDs and analgesics 1
• Physical therapy:
  • Pelvic floor physical therapy 1
  • Manual therapy including coccygeal massage and stretching of levator ani muscle 2
  • Mobilization of the coccyx 2, 3
• Postural adjustments to reduce coccygeal pressure 4

Second-Line Interventional Treatment (If Conservative Fails After 3+ Months)

• Local corticosteroid and anesthetic injections into painful structures (sacrococcygeal disc, intercoccygeal disc, or periarticular tissues) 2, 4
• Ultrasound-guided radiofrequency ablation (RFA) with steroid injection:
  • Target the coccygeal nerve at the level of coccygeal cornua 5
  • Technique: 1 mL lidocaine 2% injection, followed by RFA at 90°C for 60 seconds, then 2 mL dexamethasone and 2 mL bupivacaine 0.5% 5
  • Results show 54% of patients achieve >50% pain reduction at 12 weeks 5
  • Lower adverse event rate compared to other interventions 5

Surgical Treatment (Reserved for Refractory Cases)

Coccygectomy (partial or total) is indicated only after failed conservative management, particularly in patients with documented abnormal coccygeal mobility or spicule formation, as these patients respond best to surgery. 2, 4

• Surgical candidates: Patients with advanced coccygeal instability (subluxation, hypermobility) or bony spicules who have failed 6-12 months of conservative treatment 4, 3
• Not surgical candidates: Patients without demonstrable structural abnormality have poorer surgical outcomes 4

Common Pitfalls to Avoid

• Do not skip dynamic radiographs (sitting and standing views) as static films miss 70% of pathology 2
• Do not rush to surgery without exhausting conservative options, as most patients improve without surgery 2, 4
• Do not perform coccygectomy in patients without documented instability or spicules, as outcomes are significantly worse 4
• Do not forget to evaluate for referred pain from lumbar spine, sacroiliac joints, or pelvic organs before attributing all symptoms to the coccyx 2, 3