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

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