What is the best treatment approach for a patient with coccydynia (tailbone pain), considering their medical history, including any previous trauma or childbirth?

Coccydynia (Tailbone Pain): Treatment Approach

Conservative therapy successfully manages 90% of coccydynia cases and should be the initial treatment approach, incorporating cushions, NSAIDs, physical therapy, and local injections before considering surgical intervention. 1

Initial Assessment and Diagnosis

Confirm coccygeal origin of pain through:

• Focal tenderness on direct palpation of the coccyx during physical examination 2
• Pain worse with sitting and during sit-to-stand transitions 2
• Midline pain located below the sacrum and above the anus 2

Obtain sitting and standing lateral radiographs to evaluate for abnormal coccygeal mobility (hypermobility, subluxation, or luxation), which is the most common pathological finding in 70% of patients with coccydynia 3. If initial radiographs are inconclusive but clinical suspicion remains high, obtain MRI or CT to reveal coccygeal pathology not visible on plain films 4.

Conservative Treatment Algorithm (First-Line)

Implement the following conservative measures sequentially or in combination:

1. Mechanical modifications 1

   • Specialized coccyx cushion (donut or wedge-shaped) to reduce direct pressure while sitting
   • Ergonomic adaptations at work and home
   • Activity modification to avoid prolonged sitting, bicycling, and rowing 3

2. Pharmacologic management 1

   • NSAIDs for pain and inflammation (when not contraindicated) 5
   • Topical analgesics 2

3. Physical therapy interventions 1

   • Pelvic floor rehabilitation
   • Manual therapy including massage and stretching of the levator ani muscle 3
   • Manual mobilization of the coccyx 3

4. Weight management if obesity is present 5, 3

Interventional Treatment (Second-Line for Refractory Cases)

If conservative therapy fails after 6-8 weeks, proceed with interventional procedures:

• Local anesthetic and corticosteroid injections into painful structures (sacrococcygeal disc, first intercoccygeal disc, Walther's ganglion, or muscle attachments) to confirm coccygeal origin and provide therapeutic benefit 3, 2

• Ultrasound-guided radiofrequency ablation (RFA) combined with steroid injection of the coccygeal nerve demonstrates significant pain reduction, with 54% of patients achieving >50% reduction in pain scores at 12 weeks 6. This represents a newer, less invasive alternative with lower adverse event rates 6.

Surgical Treatment (Reserved for Refractory Cases)

Coccygectomy (partial or total) is indicated only when:

• Conservative and interventional treatments have failed 3, 1
• Abnormal coccygeal mobility or bony spicules are documented on imaging 3
• Patients with these specific findings respond best to surgical treatment 3

Coccygectomy has a high success rate for pain reduction in appropriately selected patients 4, but should be considered only after exhausting conservative options given the 90% success rate of non-surgical management 1.

Critical Pitfalls to Avoid

Rule out extracoccygeal causes that can mimic coccydynia, including pilonidal cyst, perianal abscess, hemorrhoids, pelvic organ disease, lumbosacral spine disorders, sacroiliac joint dysfunction, and piriformis muscle disorders 3. These require fundamentally different management approaches.

Recognize that 30% of cases are idiopathic with no identifiable cause despite thorough evaluation 3. These patients still benefit from the conservative treatment algorithm outlined above.

Consider multidisciplinary approach employing physical therapy, ergonomic adaptations, medications, injections, and psychotherapy when initial conservative measures fail, as this combination leads to the greatest chance of success 1.