Coccydinia: The Ignored Splinter in the Buttocks

How many of us have heard a subjective report from a patient that clearly implicates the coccyx as the problem but quickly think, “I’m sure as heck not going there!”? We cross our fingers, hoping the patient will get better anyway by treating around the issue. That is like trying to get a splinter out of a finger by massaging the hand. As nice as the treatment may feel, the tip of the finger still has a sharp, throbbing pain at the end of the day, because the splinter, the source of the pain, has not been touched directly. For most therapists, the coccyx is an overlooked (and even ignored) splinter in the buttocks.

A colleague of mine had a patient with relentless coccyx pain for 7 years and was about to lose a relationship, as well as his mind, if someone did not help him. He had therapy for his lumbar spine with “core stabilization,” and he had pain medicine, anti-inflammatory drugs, and inflatable donuts to sit upon to relieve pressure, but his underlying pain remained unchanged. Luckily for this man, his “last resort” was trained in manual therapy and assessed the need for internal coccyx mobilization to resolve his symptoms. The patient’s desperation for relief overrode any embarrassment or hesitation to receive the treatment. After a few treatments, the man’s life was changed because someone literally dug into the source of pain and skillfully remedied the dysfunction.

Marinko and Pecci (2014) presented 2 case reports of patients with coccydynia and discussed clinical decision making for the evaluation and management of the patients. The patient with a traumatic onset of pain had almost complete relief of pain and symptoms after 3 treatment sessions of manual therapy to the sacrococcygeal joint. The patient who experienced pain from too much sitting did not respond with any long term relief from the manual therapy and had to undergo surgical excision. The first patient was treated in the acute stage of injury, but the second patient had a cortisone injection initially and then the manual treatment in this study 1 year after onset of pain. Both patients experienced positive outcomes in the end, but at least 1 patient was spared the removal of her coccyx secondary to manual work performed in what some therapists consider “uncharted territory.”

A systematic literature review was published in 2013 by Howard et al. on the efficacy of conservative treatment on coccydinia. The search spanned 10 years and produced 7 articles, which clearly makes this a not-so-popular area of research. No conclusions could be made on how effective the various treatments of manual therapy, injections, or radiofrequency interventions were because of the insufficient amount of research performed on the topic.

In an evidence-based era for physical therapy intervention, sometimes we limit ourselves in our treatment approaches. What if the best interventions just have yet to be oozing with clinical trials and published outcomes? The first person to pull a splinter out of a finger did not have a peer-reviewed guide instructing one to use 2 fingers to wrap around the splinter and pull it out of the skin. Coccyx mobilization internally and externally is a legitimate treatment without a lot of notoriety. The Coccyx Pain, Evaluation, and Treatment course uses the most current evidence to expand your knowledge of anatomy and pathology and hone your palpation skills to evaluate and treat an area where you never thought you’d go.

References: Howard, P. D., Dolan, A. N., Falco, A. N., Holland, B. M., Wilkinson, C. F., & Zink, A. M. (2013). A comparison of conservative interventions and their effectiveness for coccydynia: a systematic review. The Journal of Manual & Manipulative Therapy, 21(4), 213–219. http://doi.org/10.1179/2042618613Y.0000000040
Marinko LN, Pecci M. (2014). Clinical decision making for the evaluation and management of coccydynia: 2 case reports. J Orthop Sports Phys Ther, 44(8):615-21. doi: 10.2519/jospt.2014.4850