Treatment for Stage 1 Coccydynia
For stage 1 (early-stage) coccydynia, begin with conservative management including NSAIDs, activity modification with decreased sitting, use of a coccyx cushion with a recess, and consider adding acetaminophen or small doses of narcotics if NSAIDs alone are insufficient. 1, 2
Initial Conservative Management (First-Line Treatment)
Conservative therapy is the gold standard for coccydynia and should be attempted for at least 6 months before considering surgical options. 2, 3
Pharmacologic Management
- Start with oral NSAIDs as the foundation of medical therapy 2
- If NSAIDs alone are insufficient, add acetaminophen or small doses of narcotics 1
- This stepwise approach allows for adequate pain control while minimizing opioid exposure in early-stage disease
Activity Modification and Mechanical Relief
- Decrease sitting time and duration 3
- Use a coccyx cushion with a recess to offload pressure from the coccyx during sitting 2, 3
- Implement postural adjustments to minimize coccygeal loading 3
Physical Therapy Interventions
- Coccygeal massage and stretching exercises 3
- Pelvic floor muscle work: strengthening or loosening as indicated by examination findings 2
- Manual therapy including massage and stretching of the levator ani muscle 4
- Coccyx mobilization techniques 4
When to Escalate Treatment
If symptoms persist despite 4-6 weeks of conservative management, consider interventional options:
Local Injection Therapy
- Infiltration with glucocorticoid and local anesthetic directly into the painful area 2
- This can be performed at the sacrococcygeal disc, first intercoccygeal disc, or muscle attachments around the coccyx 4
- Local injections are often promising for patients who have not responded adequately to initial conservative measures 2
Important Clinical Considerations
Diagnostic Confirmation
- The main symptom is pain directly on the lowest segment of the coccyx that occurs with sitting and intensifies when transitioning from sitting to standing 2
- Dynamic lateral radiographs of the coccyx in both standing and seated positions are the gold standard for imaging 2
- Abnormal mobility of the coccyx (hypermobility, subluxation) is found in 70% of patients with coccygodynia 4
Common Pitfalls to Avoid
- Do not rush to surgical intervention—conservative management achieves satisfactory results in the majority of patients 4
- Recognize that only 50% of cases have identifiable trauma as a trigger 2
- Be aware that 30% of cases are idiopathic with no identifiable cause 4
- Women are affected four times more frequently than men 2
Timeframe for Conservative Management
Continue conservative therapy for at least 6 months before discussing surgical options 2. Surgery (coccygectomy) should only be considered if symptoms persist beyond this period and there is evidence of advanced coccygeal instability or spicule formation on imaging. 3