What is the recommended treatment for a patient with a bruised coccyx?

Treatment of Bruised Coccyx

For a patient with a bruised coccyx, initiate conservative management with NSAIDs (ibuprofen or naproxen), activity modification including avoidance of prolonged sitting, and use of a specialized pressure-relieving cushion (donut cushion or wedge cushion with coccygeal cutout). 1, 2

Initial Conservative Management (First-Line Treatment)

Conservative treatment is successful in 90% of coccydynia cases, and many resolve without medical intervention. 3

Pharmacologic Management

• Start with NSAIDs (ibuprofen or naproxen) as first-line treatment for pain and inflammation 2
• Add acetaminophen or small doses of narcotics if NSAIDs alone are insufficient 1
• Avoid iodine or antibiotic-containing topical solutions, as they are unnecessary 4

Activity Modification and Offloading

• Implement strict offloading immediately: avoid sitting or lying directly on the coccyx 4
• Use specialized pressure-relieving cushions (donut cushions or wedge cushions with coccygeal cutout) to reduce direct pressure on the coccyx 3
• Reposition frequently to prevent further pressure injury 4
• Limit prolonged sitting, as this is a primary aggravating factor 5

Physical Therapy

• Initiate pelvic floor rehabilitation for patients with persistent symptoms 3
• Manual manipulation and massage of the sacrococcygeal joint can be effective, particularly when hypomobility is present 5
• Transcutaneous electrical nerve stimulation (TENS) may provide additional pain relief 3

Timeline for Conservative Management

Continue conservative treatment for at least 2-3 months before considering interventional options, as most cases resolve within weeks to months after initial trauma. 6 Re-evaluate at 2 weeks to assess response to initial management. 4

Interventional Options for Refractory Cases

If conservative management fails after 2-3 months, consider the following interventions:

Injection Therapy

• Local injection of corticosteroids and local anesthetics into the sacrococcygeal region 7
• Ganglion impar block for targeted nerve blockade 7
• Caudal epidural block for broader regional analgesia 7

Advanced Interventional Techniques

• Pulsed radiofrequency (PRF) ablation of the ganglion impar 7
• Extracorporeal shock wave therapy 7
• Intra-rectal massage and manipulation of the coccyx 7
• Levator ani massage and stretching 7

Surgical Management

Coccygectomy should be reserved for patients with debilitating pain who have failed both conservative therapies and interventional techniques. 7

Indications for Surgery

• Persistent symptoms despite 6-12 months of conservative and interventional management 3
• Traumatically induced coccygodynia has significantly better surgical outcomes (88% good/excellent results) compared to idiopathic coccygodynia (38% good/excellent results) 6
• Patients with documented coccygeal hypomobility or fracture/dislocation on imaging 5, 8

Surgical Considerations

• Complete or partial coccygectomy can be performed based on the extent of pathology 7
• Surgical intervention is particularly beneficial for patients with traumatically induced persistent coccygodynia 6
• A multidisciplinary approach employing physical therapy, ergonomic adaptations, medications, injections, and possibly psychotherapy leads to the greatest chance of success before considering surgery 3

Diagnostic Imaging Considerations

While not part of initial treatment, if symptoms persist beyond expected timeframes:

• Sitting and standing lateral plain film radiographs are the initial imaging modality 5
• MRI or CT imaging should be obtained if plain films are inconclusive but clinical suspicion remains high, as these can reveal coccygeal pathology not visible on x-rays 8
• Imaging can identify coccygeal fractures, dislocations, or hypomobility that may guide treatment decisions 5, 8

Common Pitfalls to Avoid

• Do not delay conservative management: Early initiation of activity modification and NSAIDs improves outcomes 6
• Do not rush to surgery: 90% of cases resolve with conservative treatment alone 3
• Do not ignore psychosocial factors: Consider psychotherapy as part of a comprehensive approach for refractory cases 3
• Do not use inappropriate cushions: Standard cushions without coccygeal cutouts may worsen symptoms 3