Treatment of Coccydynia
Conservative management with NSAIDs, cushions, physical therapy including manual manipulation, and local corticosteroid injections should be the first-line approach for coccydynia, with coccygectomy reserved only for refractory cases after exhausting all conservative options.
Initial Conservative Management
The foundation of coccydynia treatment is conservative therapy, which successfully manages the majority of patients 1.
Pharmacologic Interventions
- NSAIDs (ibuprofen or naproxen) serve as first-line pharmacologic treatment for pain and inflammation 2
- Acetaminophen can be added if NSAIDs alone are insufficient 3
- Small doses of narcotics may be considered when NSAIDs and acetaminophen provide inadequate relief 3
Non-Pharmacologic Conservative Measures
- Coccyx cushions (donut-shaped or wedge cushions) to reduce pressure while sitting 1, 4
- Activity modification including avoiding prolonged sitting and limiting activities that aggravate symptoms 1
- Physical therapy with specific manual techniques 1, 5:
Clinical Pearl: Abnormal coccyx mobility (hypermobility, subluxation) is the most common pathological finding in coccydynia patients (70% of cases) and can be confirmed with dynamic lateral radiographs in standing and sitting positions 1.
Interventional Therapies for Refractory Cases
When conservative management fails after 2-3 months, escalate to interventional approaches 5.
Local Injection Therapy
- Corticosteroid with local anesthetic injections into painful structures (sacrococcygeal disc, intercoccygeal disc, muscle attachments) 1, 5
- These injections serve both diagnostic (confirming coccygeal origin of pain) and therapeutic purposes 1
- May provide temporary relief but symptoms can recur 6
Advanced Interventional Techniques
- Pulsed radiofrequency ablation of coccygeal discs and ganglion impar 1, 5
- Ganglion impar block 5
- Extracorporeal shock wave therapy 5
- Laser acupuncture has shown promise in case reports for refractory traumatic coccydynia 7
Important Caveat: Patients with hypomobility on intrarectal mobility testing may respond well to manual therapy, while those with persistent symptoms despite manual therapy may require surgical intervention 6.
Surgical Management
Indications for Coccygectomy
Surgery should be considered only after failure of conservative and interventional therapies 1, 5.
Best surgical candidates 1:
- Patients with abnormal coccyx mobility (hypermobility, subluxation)
- Patients with coccygeal spicules (bony excrescences)
- Refractory cases with debilitating pain affecting quality of life 5
Surgical Options
Surgical Considerations: While coccygectomy demonstrates effectiveness in refractory cases, it carries a high complication rate, making thorough conservative treatment essential before proceeding 7, 5.
Diagnostic Workup
Essential Evaluations
- Dynamic radiographs (lateral X-rays in standing and sitting positions) to assess coccyx mobility 1
- Physical examination with focal palpation of the coccyx reproducing pain 4
- Intrarectal mobility testing to assess sacrococcygeal joint mobility and reproduce symptoms 6
Advanced Imaging
- MRI, CT, or bone scans for cases where diagnosis remains unclear or to rule out other pathology 4
Rule Out Alternative Diagnoses
Exclude extracoccygeal causes that can mimic coccydynia 1:
- Pilonidal cyst, perianal abscess, hemorrhoids
- Pelvic organ pathology
- Lumbosacral spine disorders, sacroiliac joint dysfunction
- Piriformis muscle syndrome
Note: In 30% of patients, no specific cause can be identified (idiopathic coccydynia), but treatment approach remains the same 1.
Treatment Algorithm
- First 2-3 months: NSAIDs + cushions + activity modification + physical therapy with manual techniques 1, 5
- If inadequate response: Add local corticosteroid/anesthetic injections 1, 5
- If temporary relief only: Consider advanced interventional techniques (pulsed radiofrequency, ganglion impar block) 5
- If refractory after 6+ months of comprehensive conservative care: Surgical consultation for coccygectomy 1, 5