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