1. Coccydynia Pain in the vicinity of the coccygeal bone

2. Associated Symptoms Dyspareunia Dyschezia Dysmenorrhea

3. Causes Trauma from a vertical blow Difficult vaginal delivery

4. Pathologic features Dislocated sacrococcygeal fracture Ligamentous damage Most cases the tip of the coccyx is subluxed or hypermobile

5. 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

6. Anatomy Levator ani and coccygeal muscles attach to and support the coccyx during childbirth and defecation Gluteus maximus also attaches to the lateral coccyx

7. Anatomy

8. 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

9. Symptoms Pain Dull and achy Sensation of pressure Increased pain with prolong sitting or sitting on hard surfaces

10. Levator ani syndrome and proctalgia fugax are variants of coccydynia

11. What is levator ani syndrome?

12. Levator Ani Syndrome Dull ache or pressure senation in the rectum Worse during the day Tenderness on palpation

13. Pelvic Floor Muscles – Tension Myalgia

14. Proctalgia Fugax

15. 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

16. Physical exam Tender over the coccyx Pelvic symmetry LE neuro exam Rectal exam Check lymph nodes

17. Functional limitations Driving Avoid social situations Equestrian Sexual

18. X-rays Subluxation and fx

19. Physiatric Prescription Pain control measures?

20. Pain relief Ice Warm sitz baths Ultrasound Galvanic stim

21. Pain relief Soft sitting surfaces – donut holes? Pelvic floor relaxation exercises Pelvic floor massage Massage Injections

22. What is Thiele’s massage?

23. Thieles Massage

24. What is sacral sitting?

25. Posture Sitting

26. Sacral Sitting

27. Sacral Flexion

28. Motion Anti-lordotic exercises – Williams exercises Hip extensor strengthening

29. What is Williams Exercises?

30. Williams Exercises

31. Alignment/Adjustment – Muscle Energy Sacral Flexion Sacral extension Sacro iliac Unilateral or Bilateral

32. Pelvic floor and gluteal relaxation

33. Other measures Botox Prolotherapy Surgery

34. Activity modification No prolong sitting No sitting on hard surfaces