What is the best way to manage coccyx pain in an adult with no significant medical history?

Management of Coccyx Pain in Adults

Start with conservative therapy including NSAIDs, a coccyx cushion with a cutout, and pelvic floor physical therapy, as this approach successfully resolves symptoms in the majority of patients without requiring invasive interventions. 1, 2

Initial Diagnostic Approach

Obtain dynamic lateral radiographs of the coccyx in both standing and sitting positions to identify abnormal mobility (hypermobility, subluxation, or luxation), which is the most common pathological finding in 70% of coccygodynia patients. 3 This imaging is the gold standard for diagnosis. 1, 2

Key Clinical Features to Assess

• Pain location: Midline pain directly on the lowest coccyx segment, below the sacrum and above the anus 4
• Pain pattern: Worse with sitting and intensified during position changes (sitting to standing) 1, 2, 4
• Trauma history: Only 50% of cases have identifiable trauma as a trigger 1, 2
• Physical examination: Focal tenderness during direct palpation of the coccyx 4

Rule Out Alternative Diagnoses

Exclude extracoccygeal causes including pilonidal cyst, perianal abscess, hemorrhoids, pelvic organ disease, lumbosacral spine disorders, sacroiliac joint problems, and piriformis muscle dysfunction. 3 Note that 30% of cases are idiopathic with no identifiable cause. 3

First-Line Conservative Treatment

Primary Interventions

• Oral NSAIDs for pain control 1, 2
• Coccyx cushion with a recess/cutout to relieve pressure while sitting 1, 2
• Pelvic floor physical therapy focused on muscle relaxation, with a mean of 9 sessions showing significant pain reduction (average pain decreased from 5.08 to 1.91, p<0.001) 5

Additional Conservative Options

• Local infiltration with glucocorticoid and local anesthetic directly into the painful area 1, 2
• Baclofen for muscle relaxation (used in 19% of patients in one study) 5
• Ganglion impar blocks (8% of patients) or coccygeus trigger point injections (17% of patients) 5
• Manual therapy including massage and stretching of the levator ani muscle, and mobilization of the coccyx 3

Treatment Duration and Success Rates

Conservative therapy achieves satisfactory results in the majority of patients with coccygodynia. 3 Patients completing pelvic floor physical therapy reported a mean 71.9% global improvement. 5

Surgical Consideration

Reserve coccygectomy (partial or total removal) for refractory cases that fail conservative treatment for more than 6 months. 1, 2 Surgery shows 80-90% success rates when indications are correct. 1, 2

Best Surgical Candidates

Patients with abnormal coccyx mobility and bony spicules (excrescence) respond best to surgical treatment. 3 Even postcoccygectomy pain patients showed improvement with pelvic floor physical therapy (mean average pain decreased from 6.64 to 3.27, p<0.001). 5

Common Pitfalls to Avoid

• Don't dismiss the diagnosis: Coccygodynia is frequently underestimated in orthopedic practice, and patients often endure prolonged suffering through multiple therapists without proper diagnosis. 1, 2
• Don't skip dynamic imaging: Static radiographs miss abnormal mobility, which is the most common pathological finding. 3, 1, 2
• Don't rush to surgery: The vast majority of patients improve with conservative measures, particularly pelvic floor physical therapy. 5
• Don't overlook pelvic floor dysfunction: Greater initial pain scores and history of previous injections correlate with higher pain on completion of therapy, but pain duration and trauma history do not affect outcomes. 5