Pain with sitting is a common complaint that patients may present to the clinic with. While excess sitting has been shown to be detrimental to the human body, sitting is part of our everyday culture ranging from sitting at a meal, traveling in the car, or doing work at a desk. Often, physical therapists disregard the coccyx or tailbone as the possible pain generator, simply because they are fearful of assessing it, have no idea where it is, or have never learned about it being a pain generator in their education.

Coccydynia is the general term for “pain over the coccyx.” Patients with coccydynia will complain of pain with sitting or transitioning from sitting to standing. Despite the coccyx being such a small bone at the end of the spine, it serves as a large attachment site for many important structures of interest that are important in pelvic floor support and continence: (1)

• Anterior Tip: Iliococcygeus and pubococcygeus, Sacrococcygeal ligament
• Lateral: Coccygeal muscles that run parallel with the sacrospinous ligament
• Posteriorly: Fibers of gluteus maximus and sacrotuberous ligament

Along with serving as a major attachment site for the above structures it provides support for weight bearing in the seated position and provides structural support for the anus. However, the coccyx is only 10% weight-bearing, so what seems to go wrong that this bone is taking the brunt of the weight-bearing? Women are five times more likely to develop coccydynia than men, with the most common cause being an external trauma like a fall or an internal trauma like a difficult childbirth (1,2).

In a study of 57 women suffering from postpartum coccydynia, most deliveries that resulted in coccyx pain were from the use of instruments such as forceps delivery or vacuum-assisted delivery. A BMI over 27 and having greater than or equal to 2 vaginal deliveries resulted in a higher rate of coccyx luxation during birth (3). Other causes of coccyx pain can be non-traumatic such as rapid weight loss leading to loss of cushioning in sitting, hypermobility or hypomobility of the sacrococcygeal joint, infections like a pilonidal cyst, or pelvic floor muscle dysfunction (1).

When assessing a patient with coccyx pain, it is also of the utmost importance to rule out red flags, as there are multiple cases cited in the literature of tumors such as retro rectal tumors or cysts being the cause of coccyx pain. These masses must be examined by a doctor to determine if they are malignant or benign and if excision is necessary. Quite often, these masses can be felt as a bulge on rectal examination (4, 5).

A multidisciplinary approach including physical therapy, ergonomic adaptations, medications, injections, and, possibly, psychotherapy leads to the greatest chance of success in patients with prolonged coccyx pain (1). Special wedge-shaped sitting cushions can provide relief for patients in sitting and help return them to their social activities during treatment. Physical therapy includes manual manipulation and internal work to the pelvic floor muscles to alleviate internal spasms and ligament pain.

Intrarectal coccyx manipulation can potentially realign a dislocated sacrococcygeal joint or coccyx (1). Unique taping methods demonstrated in video by Dr. Abbate can be used as a follow-up to coccyx manipulation to help hold the coccyx in the new position and allow for optimal healing. Often coccyx pain patients have concomitant pathologies such as pelvic floor muscle dysfunction, sacroiliac or lumbar spine pain, and various other orthopedic findings that are beneficial to address. When conservative treatments fail, injections or a possible coccygectomy may be considered. Luckily, conservative treatment is successful in about 90% of cases (1).

Join Lila Abbate in her upcoming Coccydynia and Painful Sitting remote course on December 14th. By learning how to treat coccyx pain appropriately, you will be a key provider in solving many unresolved sitting pain cases that are not resolved with traditional orthopedic physical therapy.

References:

1. Lirette L, Chaiban G, Tolba R, et al. Coccydynia: An overview of the anatomy, etiology, and treatment of coccyx pain. The Ochsner Journal. 2014; 14:84-87.
   Marinko L, Pecci M. Clinical Decision Making for the Evaluation and Management of Coccydynia: 2 Case Reports. JOSPT. 2014; 44(8): 615
   3. Maigne JY, Rusakiewicz F, Diouf M. Postpartum coccydynia: a case series study of 57 women. Eur J Phys Rehabil Med. 2012; 48 (3): 387-392.
   4. Levine R, Qu Z, Wasvary H. Retrorectal Teratoma. A rare cause of pain in the tailbone. Indian J Surg. 2013; 75(2): 147-148.
   5. Suhani K, Ali S, Aggarwal L, et al. Retrorectal cystic hamartoma: A problematic tail. J Surg Tech Case Rep. 2104; 6(2): 56-60.

AUTHOR BIO
Lila Abbate, PT, DPT, OCS, WCS, PRPC

Lila Abbate (she/her) is the Director/Owner of New Dimensions Physical Therapy with locations in Roslyn, Long Island, and the Noho Section of New York City. Dr. Abbate graduated from Touro College in Dix Hills, NY with a Bachelor of Science (BS) in Health Sciences and a Master of Arts (MA) in Physical Therapy in 1997. She completed her Advanced Masters in Manual Orthopedic Physical Therapy (MS) at Touro College, Bayshore, NY in 2003 and continued to pursue her Doctor of Physical Therapy (DPT) at Touro in 2005. Dr. Abbate is a Board-Certified Specialist by the American Physical Therapy Association in Orthopedics (OCS) 2004 and Women’s Health (WCS) 2011. She obtained the Certified Pelvic Rehabilitation Practitioner (PRPC) from the Herman & Wallace Institute in 2014. She is a Diane Lee/LJ Lee, Integrated Systems Model (ISM) graduate and completed the New York series in 2012.

Dr. Abbate has been an educator for most of her physical therapy career. She has experience as a full-time faculty at Touro College, Manhattan Campus from 2002 to 2006 teaching the biomechanical approach to orthopedic dysfunction and therapeutic exercise as well as massage/soft tissue work that highlighted trigger point work, scar management, and myofascial release.

She is currently on faculty as a Lecturer at Columbia University teaching the private practice section Business & Management course (since 2016) along with the Pelvic Health elective (since 2012). She teaches nationally and internationally with the Herman & Wallace Pelvic Rehabilitation Institute teaching advanced courses of her own intellectual property: Orthopedic Assessment for the Pelvic Health Therapist, Bowel Pathology Function, Dysfunction and the Pelvic Floor, Coccydynia & Painful Sitting: Orthopedic Implications. She was a co-writer for the Pudendal Neuralgia course and teaches the Pelvic Function Series and the Pregnancy and Postpartum Rehabilitation courses. She has written two book chapters in 2016: Pelvic Pain Management by Valvoska and Healing in Urology: Clinical Guidebook to Herbal and Alternative Therapies by Chughtai.

She is a member of the American Physical Therapy Association, the National Vulvodynia Association, the American Urogynecology Association, and the International Pelvic Pain Society. Dr. Abbate is also a Senior Physical Therapy consultant for SI Bone, a sacroiliac joint instrumentation company.

The diagnosis of chronic constipation may seem like a simple concept; however, bowel patients can be a challenging group within our pelvic health population. The interesting part about treating these patients is that constipation can result in a variety of complaints. Diaz et al confirmed this in their 2023 research. Their article shared that “Constipation encompasses several subtypes, each with its unique characteristics and underlying factors.”(1) Common complaints can include frequency, size, length, and consistency which can become overwhelming for the practitioner to decide which clinical complaints seem the most important to focus on.

Knowing how to effectively treat these patients and ask the right questions is valuable in the scheme of pelvic floor rehab, secondary to overlapping symptoms and etiology of chronic constipation. Consideration needs to be taken into account for any outside factors that can also contribute to patient complaints. For example, taking different prescription medications, supplements, and eating different foods can all influence the patient's stool frequency and formation (2). Realizing where this issue stems from is the deep-dive question to get a handle on their complaints.

Bowel frequency can be one of the biggest clinical challenges for clinicians to educate patients to master – consistency is key! Understanding what their normal frequency should be, or what it should be now, is part of the clinical judgment skill when setting goals. If your patient is only getting a natural bowel movement urge every 10 days, their goal of daily BMs, at first, should be emotionally readjusted so that they don’t feel like they have failed their rehabilitation goals.

Most of us spend our day sitting and do not think about the position of our ilia, sacrum, or coccyx during the change from standing to sitting. Weight-bearing through a tripod of bilateral ischial tuberosities and a sacrum that should have normalized form closure should be easy and pain-free.

The coccyx typically has minimal weight bearing in sitting, about 10%, just like the fibula, however, it can be a major pain generator, if the biomechanics of the ilia, sacrum, and femoral head positions are not quite right. A lot of patients will state “My pain is worse with sitting” which can mean thoracic pain, low back/sacral pain, and even lower extremity radicular pain.

Scanning the literature for coccyx treatment does not always yield the best results for physical or occupational therapists. Most literature states what the medical interventions can be, and physical therapy is never at the forefront. However, as we are musculoskeletal and neuromuscular specialists, this is no different in our thinking patterns relating to coccyx pain or painful sitting.

Lila Abbate, PT, DPT, MS, OCS, WCS, PRPC is a Board-Certified Specialist by the American Physical Therapy Association in Orthopedics (OCS) 2004 and Women’s Health (WCS) 2011. She has obtained the Certified Pelvic Rehabilitation Practitioner (PRPC) in 2014. She is a Diane Lee/LJ Lee, Integrated Systems Model (ISM) graduate and completed the New York series in 2012. Dr. Abbate is Senior Faculty with Herman & Wallace and can be found instructing the Pelvic Floor Series as well as her own courses Coccydynia and Painful Sitting and Bowel Pathology and Function.

Pain with sitting is a common complaint that patients may present to the clinic with. While excess sitting has been shown to be detrimental to the human body, sitting is part of our everyday culture ranging from sitting at a meal, traveling in the car, or doing work at a desk. Often, physical therapists disregard the coccyx or tailbone as the possible pain generator, simply because they are fearful of assessing it, have no idea where it is, or have never learned about it being a pain generator in their education.

Lila Abbate PT, DPT, OCS, WCS, PRPC is the creator and instructor of Bowel Pathology Function & Dysfunction and the Pelvic Floor, a course which instructs in comprehensive evaluation and treatment techniques for bowel pathologies and dysfunctions, including fecal incontinence, chronic constipation, and the relationship between constipation and rectal and/or abdominal pain. Join Dr. Abbate in one of five events taking place in 2020!

Bowel dysfunction can be very rewarding to treat. Most pelvic health physical therapists are nervous about diving into bowel treatment. When I was training with my mentor, Elise Stettner, PT she used to remind me that “any PT can treat urinary symptoms. The patients who are really suffering are those bowel dysfunctions.” That statement really stuck with me and mentoring with her and treating those patients created a passion for treating patients who suffer from bowel dysfunction.

Within the term bowel dysfunction, fecal urgency, is a common symptom and is under-researched. In 2019, Similis, et al published A Systemic Review and Network Meta-Analysis Comparing Treatments for Faecal Incontinence, doesn’t even mention physical therapy and pelvic floor muscle rehabilitation as an intervention for fecal incontinence and fecal urgency treatment.

After completing an intake on a patient and learning that her history of constipation started about 3 years ago with insidious onset, the story wasn’t really making any sense of how or why this started. Yes, she was menopausal. Yes, she seemed to be eating fiber and drinking water. Yes, she got a bowel movement urge daily, but her bowel movements felt incomplete. Yes, she was a little older, using Estrace cream, and her mobility had slowed down, but nothing seemed to make sense in the story that was leading me to believe it was an emptying problem or a stool consistency issue. She had a bowel movement urge, she could empty, but it was incomplete.

So, after explaining about physical therapy, the muscle problems involved and what we do here, it led us to the physical examination portion. I explained that we check both the vaginal and rectal pelvic floor muscle compartments to determine rectal fullness internally, check for a rectocele, check for muscle lengthening (excursion) and shortening (contraction). She was on board and desperate to find an answer. She was eager for me to help her find an answer to her emptying problem that she had for the last 3 years.

Upon entering her vaginal canal slowly, I start to move around and felt a ring of plastic. “Are you wearing a pessary?” I asked. “Pessary? Oh, yes, I forgot to tell you about that!”, she exclaimed. “How long have you been using it?” I asked. “About 3 years…” she answered.

Pain with sitting is a common complaint that patients may present to the clinic with. While excess sitting has been shown to be detrimental to the human body, sitting is part of our everyday culture ranging from sitting at a meal, traveling in the car, or doing work at a desk. Often, physical therapists disregard the coccyx or tailbone as the possible pain generator, simply because they are fearful of assessing it, have no idea where it is, or have never learned about it being a pain generator in their education.

Coccydynia is the general term for “pain over the coccyx.” Patients with coccydynia will complain of pain with sitting or transitioning from sit to stand. Despite the coccyx being such a small bone at the end of the spine, it serves as a large attachment site for many important structures of interest that are important in pelvic floor support and continence: ¹

• Anterior: Levator ani muscles, Sacrococcygeal ligament
• Lateral: Coccygeal muscles, Sacrospinous ligament, Sacrotuberous ligament, Glute maximus muscle fibers
• Inferiorly: Iliococcygeus

Along with serving as a major attachment site for the above structures it provides a support for weightbaring in the seated position and provides structural support for the anus. Women are five times more likely to develop coccydynia than men, with the most common cause being an external trauma like a fall, or an internal trauma like a difficult childbirth. ^1,2 In a study of 57 women suffering from postpartum coccydynia, most deliveries that resulting in coccyx pain were from use of instruments such as a forceps delivery or vacuum assisted delivery. A BMI over 27 and having greater than or equal to 2 vaginal deliveries resulted in a higher rate of coccyx luxation during birth. ³ Other causes of coccyx pain can be non traumatic such as rapid weight loss leading to loss of cushioning in sitting, hypermobility or hypomobility of the sacrococcygeal joint, infections like a pilonidal cyst, or pelvic floor muscle dysfunction. ¹ When assessing a patient with coccyx pain, it is also of the upmost importance to rule out red flags, as there are multiple cases cited in the literature of tumors such as retrorectal tumors or cysts being the cause of coccyx pain. These masses must be examined by a doctor to determine if they are malignant or benign, and if excision is necessary. Sometimes these masses can be felt as a bulge on rectal examination. ^4,5

Faculty member Lila Bartkowski- Abbate PT, DPT, MS, OCS, WCS, PRPC teaches the Bowel Pathology, Function, Dysfunction and the Pelvic Floor course for Herman & Wallace. Join her in Tampa on April 2-3, or one of the other two events currently open for registration.

Constipation, an often under reported health issue, afflicts about 30% of Americans. ¹ The diagnosis of chronic constipation may seem like a simple concept, however the etiology of chronic constipation presents itself in many different forms. Dyssynergic defecation is one of many factors that can lead to a presentation of chronic constipation in a patient. Dyssynergic defecation or “paradoxical contraction” occurs when the muscles of the abdominals, puborectalis sling, and external anal sphincter function inappropriately while attempting a bowel movement. ² The lack of coordination of these muscles results in a contraction versus a lengthening of the pelvic floor muscles with baring down. Dyssynergic defecation is different than a structural issue such as a rectocele or hemorrhoids causing the inability to pass stool effectively or constipation due to slow colon transit time or pathological disease. Making the diagnosis of dyssynergic defecation by symptoms alone is often not reliable secondary to overlap of similar symptoms with chronic constipation due to factors such as a structural issue, irritable bowel syndrome (IBS), or irritable bowel disease (IBD). The diagnosis of dyssynergic defecation can be difficult and is often made through physiologic testing such as balloon expulsion testing or MRI with defecography. ² However, physical therapists can often manually feel that a paradoxical contraction is happening when asking a patient to bare down on evaluation.

Patients with dyssynergic defecation may present to pelvic floor physical therapy with complaints of: ¹ ²

Herman & Wallace faculty member Lila Abbate instructs several courses in pelvic rehabilitation, including "Coccyx Pain, Evaluation and Treatment". Join Lila this October in Bay Shore, NY in order to learn evaluation and treatment skills for patients with coccyx conditions.

Case studies are relevant reading for physical therapists. Reviewing case studies puts you into the writer’s brain allowing you to synthesize your current knowledge of a particular diagnosis taking you through some atypical twists and turns in treating this particular patient type. In JOSPT, August 2014, Marinko & Pecci presented a very well-written case study of two patients with coccyx pain. By then, I had already written my Coccyx course and couldn’t wait to see what the authors had written. I eagerly downloaded the article to see another’s perspective of coccyx pain and their treatment algorithms, if any, were presented in the article. How were the author’s patients different than mine? What exciting relevant information can I add to my Coccyx course?

I believe that coccyx pain patients have more long-standing pain conditions than other patient types. For the most part, the medical community does not know what to do with this tiny bone that causes all types of havoc in patients’ pain levels. Sometimes treating a traumatic coccydynia patient seems so simple and I am bewildered as to why patients are suffering so long - and other times, their story is so complex that I wonder if I can truly help.

This post was written by H&W instructor Lila Abbate PT, DPT, MS, OCS. Lila will be instructing Pelvic Floor Level 3 with Institute founder Holly Herman in San Diego at the end of this month! Sign up for the few remaining seats left in this popular course!

When treating your patient who has undergone a pelvic reconstruction in the not-so-distant past, does the mesh controversy come to your mind?Is the effect of the mesh causing your patient this dysfunction and is she complaining of urinary urgency, urinary frequency, or pelvic pain? Understanding pelvic muscle dysfunction, as pelvic rehabilitation providers do, can put us in a good position to help our patients, as well as to help our physicians with this oftentimes litigious issue.

Urogynecologists, gynecologists, urologists, or any surgeon who deals in the business of female sexual medicine and pelvic reconstruction seems to have been put in a position to defend their stance on the use of mesh when working with patients who present with any degree of pelvic organ prolapse (POP), be it complicated or simple.The decision to utilize mesh is now made with greater emphasis on education for the patient who is undergoing the procedure.