Tailbone pain

Tailbone pain, medically known as coccydynia, is a common condition that affects the coccyx or tailbone at the base of the spine. It can result from trauma, prolonged sitting, or underlying medical conditions and can significantly impact daily activities and quality of life.

Anatomy of the Tailbone

Structure of the Coccyx

The coccyx is the terminal portion of the vertebral column and typically consists of three to five small fused vertebrae. Its size and shape can vary between individuals, with some having a curved or straight coccyx. The coccyx provides attachment points for various ligaments and muscles that contribute to pelvic stability.

Surrounding Structures

The tailbone is supported by several surrounding structures:

• Ligaments: The sacrococcygeal ligaments connect the coccyx to the sacrum, providing stability and limiting excessive movement.
• Muscles: Muscles such as the gluteus maximus and levator ani attach near the coccyx, aiding in movement and pelvic floor support.
• Nerve Supply: The coccygeal nerve and branches of the sacral nerves provide sensory innervation to the coccygeal region.
• Vascularization: Small arteries and veins supply blood to the coccyx and surrounding tissues, facilitating healing and tissue maintenance.

Etiology (Causes)

Traumatic Causes

Trauma is a common cause of tailbone pain and can occur due to:

• Direct falls onto the coccyx during activities such as slipping, sports, or accidents.
• Repetitive strain from activities that involve prolonged sitting on hard surfaces.

Non-Traumatic Causes

Tailbone pain can also develop without an obvious injury:

• Degenerative changes in the sacrococcygeal joint leading to stiffness or inflammation.
• Infections or tumors affecting the coccygeal region, although these are rare.
• Idiopathic causes where no clear origin of pain can be identified.

Risk Factors

Certain factors increase the likelihood of developing tailbone pain:

• Age and Gender: Women and older adults are more commonly affected due to anatomical and hormonal differences.
• Obesity and Pregnancy: Increased pressure on the coccyx can contribute to discomfort.
• Occupational and Lifestyle Influences: Prolonged sitting, poor posture, and repetitive strain activities can predispose individuals to coccydynia.

Pathophysiology

Tailbone pain arises from irritation or inflammation of the coccyx and surrounding tissues. Trauma can lead to bruising, dislocation, or fractures of the coccygeal vertebrae, while chronic mechanical stress may cause degenerative changes in the joints. Inflammatory processes and nerve irritation in the coccygeal region contribute to persistent pain. Acute pain is usually associated with recent injury, whereas chronic pain may result from prolonged mechanical stress or inadequate healing.

Clinical Presentation

Symptoms

Patients with tailbone pain commonly report:

• Localized pain at the tip or base of the coccyx.
• Increased discomfort when sitting, especially on hard surfaces.
• Pain during standing up from a seated position or during prolonged standing.
• Discomfort during bowel movements or sexual activity in some cases.

Physical Examination Findings

During clinical evaluation, common findings include:

• Tenderness upon palpation of the coccyx or surrounding ligaments.
• Abnormal coccygeal movement, such as hypermobility or subluxation.
• Alterations in posture or gait due to pain avoidance.

Diagnostic Evaluation

History Taking

A detailed patient history is essential and focuses on:

• Onset, duration, and severity of pain.
• Recent trauma, falls, or prolonged sitting activities.
• Aggravating and relieving factors.
• Previous treatments or interventions.

Imaging Studies

Imaging can help identify structural abnormalities or rule out other conditions:

• X-ray: Evaluates coccygeal alignment, fractures, or joint degeneration.
• MRI: Assesses soft tissue structures, inflammation, and potential tumors.
• CT Scan: Provides detailed imaging of bone structures when needed.

Other Diagnostic Tests

• Bone Scan: Rarely used to detect fractures or bone lesions.
• Diagnostic Injections: Local anesthetic injections may confirm the source of pain.

Management

Conservative Treatment

Most cases of tailbone pain respond well to non-surgical management:

• Medications: Nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen can help reduce pain and inflammation.
• Physical Therapy: Exercises targeting the pelvic floor, lower back, and gluteal muscles improve stability and relieve stress on the coccyx.
• Ergonomic Modifications: Use of cushioned seating or doughnut pillows to reduce pressure on the tailbone during prolonged sitting.

Interventional Procedures

For patients who do not respond to conservative treatment, minimally invasive procedures may be considered:

• Corticosteroid Injections: Reduce local inflammation and provide temporary pain relief.
• Nerve Blocks: Target the coccygeal or sacral nerves to interrupt pain signaling.

Surgical Management

Surgery is reserved for chronic cases that are refractory to other treatments:

• Coccygectomy: Surgical removal of part or all of the coccyx may relieve persistent pain.
• Complications: Potential risks include infection, wound healing issues, and altered pelvic stability.

Prognosis

The outlook for tailbone pain varies depending on the cause and treatment approach. Most patients improve with conservative management within weeks to months. Chronic pain may persist in some individuals, especially those with trauma-induced or degenerative changes. Surgical intervention can provide significant relief in selected patients, but recovery may take several weeks, and the risk of complications should be considered. Early diagnosis and appropriate treatment improve long-term outcomes and reduce the likelihood of persistent symptoms.

Prevention

Preventing tailbone pain involves strategies to reduce pressure and strain on the coccyx. These measures are particularly important for individuals at higher risk due to occupational or lifestyle factors.

• Ergonomic Seating: Use cushions or specially designed chairs to distribute weight evenly and reduce direct pressure on the tailbone.
• Posture Awareness: Maintain an upright posture when sitting and avoid slouching to minimize stress on the coccyx and surrounding ligaments.
• Regular Movement: Take breaks from prolonged sitting, stand, and stretch periodically to reduce mechanical strain.
• Lifestyle Modifications: Maintain a healthy weight, engage in strengthening exercises for the pelvic floor and gluteal muscles, and avoid activities that increase coccygeal stress.
• Early Intervention: Address minor injuries or pain promptly to prevent chronic symptoms from developing.

References

1. Postacchini F, Massobrio M. Idiopathic coccygodynia. Etiology and treatment. J Bone Joint Surg Am. 1983;65(8):1116-1120.
2. Maigne JY, Chattelier P, Chatellier G. Causes and mechanisms of coccydynia. Spine (Phila Pa 1976). 2000;25(23):3072-3079.
3. Fogel GR, Cunningham PY 3rd, Esses SI. Coccygodynia: evaluation and management. J Am Acad Orthop Surg. 2004;12(3):49-54.
4. Woon JT, Seow KH. Coccyx pain: a review of causes, diagnosis, and management. Singapore Med J. 2014;55(9):471-475.
5. Robinson P, Chowdhury R, Vaux J. Coccygectomy for chronic coccydynia. Eur Spine J. 2008;17(11):1504-1508.
6. Maigne JY, Doursounian L. Surgery of the coccyx: results of coccygectomy in 40 patients. Spine (Phila Pa 1976). 2000;25(23):3057-3061.
7. Carvalho LH, Sampaio TR, Morais Filho A. Coccydynia: anatomical and clinical review. Rev Bras Ortop. 2017;52(3):260-266.