Coccydynia
Pain in the vicinity of the coccygeal
bone
Associated Symptoms
• Dyspareunia
• Dyschezia
• Dysmenorrhea
Causes
• Trauma from a vertical blow
• Difficult vaginal delivery
Pathologic features
• Dislocated sacrococcygeal fracture
• Ligamentous damage
• Most cases the tip of the coccyx is subluxed or
hypermobile
Anatomy
• Fibrous sacrococcygeal joint connects the
sacrum to the one to four bone segments of
the coccyx
• Joint is reinforced by sacrococcygeal ligaments
which encloses the s5 nerve root
• S4,5 make the coccygeal plexus
Anatomy
• Levator ani and
coccygeal muscles
attach to and support
the coccyx during
childbirth and
defecation
• Gluteus maximus also
attaches to the lateral
coccyx
Anatomy
Prevalence
• 5x greater in women
• Female coccyx is more posterior in location
and larger
• 3x more frequent in obese women, maybe be
related to the decrease pelvic rotation during
sitting
Symptoms
• Pain
• Dull and achy
• Sensation of pressure
• Increased pain with
prolong sitting or sitting
on hard surfaces
Levator ani syndrome and
proctalgia fugax are
variants of coccydynia
What is levator ani syndrome?
Levator Ani Syndrome
• Dull ache or pressure
senation in the rectum
• Worse during the day
• Tenderness on
palpation
Pelvic Floor Muscles – Tension Myalgia
Proctalgia Fugax
Proctalgia Fugax
• Sudden onset of anal pain that last a few
minutes or seconds
• Spastic muscle contractions of the pelvic floor
muscles
• Five times per year or more
Physical exam
•
•
•
•
•
Tender over the coccyx
Pelvic symmetry
LE neuro exam
Rectal exam
Check lymph nodes
Functional limitations
• Driving
• Avoid social situations
• Equestrian
• Sexual
X-rays
• Subluxation and fx
Physiatric Prescription
• Pain control measures?
Pain relief
•
•
•
•
Ice
Warm sitz baths
Ultrasound
Galvanic stim
Pain relief
• Soft sitting surfaces –
donut holes?
• Pelvic floor relaxation
exercises
• Pelvic floor massage
• Massage
• Injections
What is Thiele’s massage?
Thieles Massage
What is sacral sitting?
Posture
• Sitting
Sacral Sitting
Sacral Flexion
Motion
• Anti-lordotic exercises –
Williams exercises
• Hip extensor
strengthening
What is Williams Exercises?
Williams Exercises
Alignment/Adjustment – Muscle
Energy
•
•
•
•
Sacral Flexion
Sacral extension
Sacro iliac
Unilateral or Bilateral
Pelvic floor and gluteal relaxation
Other measures
• Botox
• Prolotherapy
• Surgery
Activity modification
• No prolong sitting
• No sitting on hard
surfaces
