Updated: Nov 26, 2020
Coccydynia refers to any type of persistent tailbone pain.
The tailbone, located at the very bottom of the spine, is medically known as the coccyx. Coccydynia is typically felt as a localized pain that usually worsens when sitting or with any activity that puts pressure on the bottom of the spine.
The condition is much more common in women than men. It is usually caused by trauma to the tailbone or surrounding area, such as a backward fall or childbirth. On rare occasions, an infection or tumor can also cause pain in the coccyx.
This article provides an in-depth review of the causes of coccydynia, diagnosis, and both nonsurgical and surgical treatment options.
Coccydynia may be referred to in various terms, such as:
The various terms are all used to describe one set of symptoms in the tailbone that result in either persistent pain or intermittent, activity-related pain.
The goal of coccydynia treatment is usually to reduce pain by keeping pressure off of the tailbone, easing inflammation or muscle tension that add to pain, or reducing pain signals to the brain using medication. A combination of treatments and activity modification usually suffices to control or alleviate tailbone pain.
In rare cases, surgery to remove all or part of the coccyx may be recommended, but the surgery (a coccygectomy) is typically only considered if the pain is severe and at least several months of non-surgical treatment and activity modification has been ineffective in relieving pain.
An estimated 90% of coccydynia cases resolve with non-surgical treatments, and coccyx pain will often get better with conservative treatment.
History of Coccydynia
Coccydynia has a long history of being misunderstood. In the early 1900s, coccydynia was a popular diagnosis for all types of lower back pain. A fairly extreme treatment, the surgical removal of the coccyx (coccygectomy), was commonly undertaken to treat low back pain. At best, this operation had variable results.
General opinion then changed completely, and it was often postulated that since the condition mostly affected women it was in some way related to "neurosis." The assumption was that if the operation did not work, it was because the pain was psychological in origin.
Studies that have measured the efficacy of psychotherapy as treatment for coccydynia have found little success and conclude that coccydynia does exist as a medical condition.
The condition is now considered a valid diagnosis and is treated as such.
Anatomy of the Coccyx (Tailbone)
The coccyx is a triangular arrangement of bone that makes up the very bottom portion of the spine below the sacrum. It represents a vestigial tail, hence the common term tailbone.
Depending on an individual’s development, the coccyx may consist of three to five different bones connected by fused—or semi-fused—joints and/or disc-like ligaments. While it was originally thought that the coccyx is always fused together, it is now known that the coccyx is not one solid bone, but there is some limited movement between the bones permitted by fibrous joints and ligaments.
The coccyx usually moves slightly forward or backward as the pelvis, hips, and legs move. When a person sits or stands, the bones that make up the pelvis (including the coccyx) rotate outward and inward slightly to better support and balance the body.
Function of the Coccyx
Although the tailbone is considered vestigial (or no longer necessary) in the human body, it does have some function in the pelvis. For instance, the coccyx is one part of a three-part support for a person in the seated position. Weight is distributed between the bottom portions of the two hip bones (or ischium) and the tailbone, providing balance and stability when a person is seated.
The tailbone is the connecting point for many pelvic floor muscles. These muscles help support the anus and aid in defecation, support the vagina in females, and assist in walking, running, and moving the legs.
Why Do More Coccyx Injuries Occur in Women Than Men?
Coccydynia is generally much more common in women; some sources from the medical literature find that women are five times more likely to develop coccydynia than men.
The majority of coccyx injuries occur in women because:
A broader pelvic structure, which may decrease the amount of pelvic rotation and leave the coccyx more exposed to injury.
Women tend to place more weight on the coccyx when sitting, which leaves it more susceptible to injury.
Childbirth, which may cause acute damage as the baby moves over the tailbone
Pelvic muscle cramps can also play a role in increased coccyx pain in women. In physical evaluations, women have reported significantly increased coccyx pain during the premenstrual period.
Coccydynia (Tailbone Pain) Symptoms
Tailbone pain is usually accompanied by other, more specific symptoms that can sometimes indicate how pain is occurring. Coccydynia may be further characterized by one or a combination of the following symptoms:
Localized pain and tenderness. Pain is generally confined to the tailbone, and does not radiate through the pelvis or to the lower extremities. Pain is usually described as an aching soreness and can range from mild to severe. Tightness or general discomfort around the tailbone may be constant, or pain may come and go with movement or pressure.
Increased pain with sitting. Coccydynia is generally more intense when weight is placed on the tailbone, as in when a person leans backward in a sitting position. Likewise, sitting on hard surfaces without a cushion (such as a wooden bench or a metal folding chair) or leaning back against a wall puts added pressure on the tailbone, causing pain to worsen.
Pain that is worse when moving from sitting to standing. When moving from a seated position to standing or vice versa, the rotation of the pelvic bones (and muscle movements that assist this rotation) may be painful. It may be difficult to stand or sit, requiring one to lean against something to provide better stability.
Pain that may increase with bowel movement or sexual intercourse. Some patients experience heightened pain during sexual intercourse or defecation, due to the proximity of the coccyx to the anus and genitals.
Symptoms may differ from patient to patient, depending on one’s unique anatomy and the underlying structures causing pain.
Coccyx pain has the potential to become chronic, lasting longer than 3 months, if the bones’ structural instability persists and the surrounding muscles and ligaments continue to be strained, and/or if there is local inflammation.
Coccydynia (Tailbone Pain) Causes
Direct trauma to the tailbone is the most common cause of coccydynia, and usually leads to inflammation surrounding the coccyx, which contributes to pain and discomfort.
There are many cases reported in which pain begins with no identifiable origin (called idiopathic coccydynia).
Coccydynia is typically caused by the following underlying anatomical issues:
Hypermobility, or too much movement of the coccyx puts added stress on the joint between the sacrum and coccyx and on the coccyx itself. Too much mobility can also pull the pelvic floor muscles that attach to the coccyx, resulting in tailbone and pelvic pain.
Limited mobility of the coccyx causes the tailbone to jut outward when sitting, and can put increased pressure on the bones and the sacrococcygeal joint. Limited coccyx movement may also result in pelvic floor muscle tension, adding to discomfort.
In rare cases, part of the sacrococcygeal joint may become dislocated at the front or back of the tailbone, causing coccyx pain.
The above factors may result from an injury to the coccyx, or may develop as idiopathic coccydynia.
Possible Causes of Coccydynia
A diagnosis of coccydynia will usually identify one of the following underlying causes of pain:
Local trauma. A direct injury to the coccyx is probably the most common cause of coccydynia. A fall on the tailbone can inflame the ligaments and injure the coccyx or the coccygeal attachment to the sacrum. Coccygeal trauma usually results in a bruised bone, but may also result in a fracture or dislocation either in the front or back of the coccyx.
Repetitive stress.. Activities that put prolonged pressure on the tailbone, such as horseback riding and sitting on hard surfaces for long periods of time, may cause the onset of coccyx pain. Tailbone pain from these causes usually is not permanent, but if inflammation and symptoms are not managed, the pain may become chronic and cause long-term altered mobility of the sacrococcygeal joint.
Childbirth. During delivery, the baby's head passes over the top of the coccyx, and the pressure against the coccyx can sometimes result in injury to the coccygeal structures (the disc, ligaments, and bones). While uncommon, the pressure can also cause a fracture in the coccyx.
Tumor or infection. Rarely, coccydynia can be caused by a nearby tumor or infection that puts pressure on the coccyx.
Certain factors may increase the chance of coccygeal pain developing. Risk factors for coccydynia include:
Obesity. Pelvic rotation, including movement of the coccyx, is usually lessened in individuals who are overweight, leading to more continual stress being placed on the coccyx and increasing the chances of developing coccyx pain. One study found that a Body Mass Index (BMI) of more than 27.4 in women and 29.4 in men increases the risk for coccydynia following repetitive stress or a one-time injury.
Gender. Women have a higher chance of developing coccydynia than men, due to a wider pelvic angle as well as trauma to the coccyx endured during childbirth.
If pain is mild or moderate, it may not be necessary to identify the exact cause of coccydynia. In some cases, however, coccyx pain is severe or of a serious origin, so it is important to have a general idea why pain has developed so that it can be treated most effectively.
Diagnosis of Coccydynia (Tailbone Pain)
Coccydynia is typically diagnosed by gathering a thorough medical history and completing a physical exam. These two standard diagnostic practices are usually sufficient in obtaining a diagnosis and evaluating treatment options, but in some cases, diagnostic tests such as scans or injections may be used.
Initial Diagnostic Methods for Coccydynia
A complete medical history collected will likely include information on current symptoms, as well as when and how symptoms developed. A doctor may also look for environmental or lifestyle factors for the patient’s pain, such as recent injury, exercise habits, or obesity.
After a medical history is collected, a doctor will begin a physical exam. A thorough physical examination for coccyx pain may include:
Palpation to check for local tenderness. A doctor will feel by hand (called palpation) to identify swelling and tenderness around the coccyx. Palpation may also be used to identify potential coccygeal spicules (bone spurs), cysts, or tumors.
Intrarectal exam and manipulation. In some cases, a doctor may choose to manipulate the coccyx manually through the rectum, in order to assess limited or excessive mobility of the sacrococcygeal joint. Intrarectal manipulation may also be used to assess any muscle tension in the pelvis connecting to the coccyx.
The most consistent finding on examination is usually tenderness upon palpation of the coccyx. If the coccyx is not tender to palpation, then the pain is likely referred from another part of the spine.
Diagnostic Tests for Coccydynia
Diagnostic tests are usually not needed for coccyx pain. In some cases of severe, unrelenting pain, a diagnostic test may be used to determine how pain is being caused and how it can best be alleviated. Diagnostic tests for coccydynia may include:
Dynamic X-ray imaging tests. While there is some debate over the efficacy of imaging tests for diagnosing coccydynia, it is generally agreed that dynamic x-ray imaging is helpful. A dynamic X-ray produces two images—one of the patient sitting and another of the patient standing. A doctor will compare the images and measure the angle of pelvic rotation as well as the coccyx’s change in position from sitting to standing. If these measurements are outside of the normal range (between 5 and 25 degrees), too much or too little coccygeal movement can be identified as the cause of pain.
Coccygeal discogram. Similar to the same procedure done on the lumbar spine, a coccygeal discogram consists of an injection of local anesthesia in the sacrococcygeal region. The injection targets a specific area in the spine, such as an intervertebral joint or disc, to identify the precise location where pain is being caused.
CT or MRI scans. A static image of the coccyx taken by MRI or CT scan (one that does not illustrate pelvic rotation or movement) may be used if the suspected cause of pain is a fracture, tumor, or abnormal mobility of the sacrococcygeal joint.
In rare cases, routine blood tests are obtained to rule out the possibility of an infection or tumor. A doctor may also order a guaiac stool test to determine if the issue has its origin in the gastrointestinal tract.
Treatment for Coccydynia (Tailbone Pain)
Many studies find that non-surgical treatments are successful in approximately 90% of coccydynia cases. Treatments for coccydynia are usually noninvasive and include activity modification.
The first line of treatment typically includes self-care that can be done without the assistance of a medical professional, such as some of the following:
Non-steroidal anti-inflammatory drugs (NSAIDs). Common NSAIDs, such as ibuprofen (Advil), naproxen (Aleve), or COX-2 inhibitors, help reduce the inflammation around the coccyx that is usually a cause of the pain.
Ice or cold pack. Applying ice or a cold pack to the area several times a day for the first few days after pain starts can help reduce inflammation, which typically occurs after injury and adds to pain.
Heat or heating pad. Applying heat to the bottom of the spine after the first few days of pain may help relieve muscle tension, which may accompany or exacerbate coccyx pain. Common heat sources include a hot water bottle, chemical heat pack, long-lasting adhesive heat strip, or hot bath (as long as weight is kept off the tailbone in the bathtub).
Activity modification. Alterations to everyday activities can help take cumulative pressure off of the tailbone and alleviate pain. These activity modifications may include using a standing desk to avoid prolonged sitting, using a pillow to take the weight off the coccyx, or adjusting posture so weight is taken off the tailbone when sitting.
Supportive pillows. A custom pillow that takes pressure off the coccyx when sitting may be used. Pillows for alleviating coccydynia may include U- or V-shaped pillows, or wedge-shaped pillows with a cutout or hole where the tailbone is. Any type of pillow or sitting arrangement that keeps pressure off the coccyx is ideal and largely a matter of personal preference. A supportive cushion can be useful in the car, as well as in an office, classroom, or at home.
Dietary changes. If tailbone pain is caused by or worsened with bowel movements or constipation, increased fiber and water intake, as well as stool softeners, is recommended.
If the above treatments do not help manage or alleviate coccyx pain, additional treatments administered by a doctor may be necessary.
Additional Non-Surgical Treatments for Coccydynia
If tailbone pain is persistent or severe, additional non-surgical treatment options for coccydynia may include:
Injection. An injection of a numbing agent (lidocaine) and steroid (to decrease inflammation) in the area surrounding the coccyx may provide pain relief. The physician uses imaging guidance to ensure that the injection is administered to the correct area. Pain relief can last from 1 week up to several years. If the first injection is effective, patients may receive up to 3 injections in a year.
Manual manipulation. Some patients find pain relief through manual manipulation of the coccyx. Through manual manipulation, the joint between the sacrum and the coccyx can be adjusted, potentially reducing pain caused by inadequate coccyx mobility.
Massage. Coccydynia may be reduced or alleviated by massaging tense pelvic floor muscles that attach to the coccyx. Tense muscles in this region can place added strain on the ligaments and sacrococcygeal joint, limiting its mobility or pulling on the coccyx.
Stretching. Gently stretching the ligaments attached to the coccyx can be helpful in reducing muscle tension in the coccygeal area. A physical therapist, chiropractor, physiatrist, or other appropriately trained healthcare practitioner can provide instruction on appropriate stretches for relieving coccyx pain.
TENS unit. Transcutaneous Electrical Nerve Stimulator (TENS) units apply electric stimulation that interferes with the transmission of pain signals from the coccyx to the brain. These devices can be good option for patients who wish to keep their intake of medications to a minimum. There are many varieties of TENS units, with some using high-frequency stimulation that are worn for short periods of time, and others using low-frequency stimulation that may be worn longer.
After attaining sufficient pain relief so movement is better tolerated, daily low-impact aerobic activity is beneficial, as the increased blood flow brings nutrients to the area and encourages the body’s natural healing abilities. An additional benefit of aerobic activity is the release of endorphins, the body’s innate pain-relieving chemicals.
If non-surgical treatments or pain management methods are effective, prolonged use of these methods is a reasonable treatment option. In rare cases, a patient’s pain does not respond to non-surgical treatments and surgery on the coccyx may be considered.
Coccygectomy Surgery for Coccydynia (Tailbone Pain)
For persistent pain that is not alleviated with non-surgical treatment and/or activity modification, surgical removal of all or a portion of the coccyx (coccygectomy) is an option.
There are varying suggestions in the medical literature regarding how long non-surgical treatments should be tried before surgery is recommended. Some believe a two-month course of non-surgical treatment is sufficient, while others suggest non-surgical treatment should be tried for between three and eight months before surgery is advisable.
Coccygectomy surgery is rarely recommended and performed. While the surgery itself is a relatively straight-forward operation, recovery from the surgery can take some time after the surgery.
Surgical Approach for Coccyx Pain
Surgeons may take slightly different approaches to the operation. Perhaps the biggest difference between surgeons is that some remove only part of the coccyx, while others recommend removing the entire coccyx.
In general, the surgery involves the following steps:
A one to two-inch incision is made over the top of the coccyx, which is located directly under the skin and subcutaneous fat tissue. There are no muscles to dissect away.
The protective cartilage over the bone (the periosteum) is dissected from the bone starting on the back and carried around the front.
The coccyx is then removed. It may receive a biopsy if a tumor is suspected.
The operation takes about thirty minutes to perform and can be done on an outpatient basis.
Indications for Coccygectomy Success
Coccygectomy tends to be most successful in carefully selected cases. The following criteria have shown an increased chance of positive results after surgery:
Patients whose pain is caused by changes in the shape of the coccyx, such as the presence of a spicule (a small bone spur at the end of the coccyx)
Patients with excessive mobility of the coccyx
The presence of a bursa, or a fluid-filled sac at the joint between the sacrum and coccyx
A good response to injection treatments
Many studies have reported good or excellent results following coccygectomy surgery, but the procedure is not recommended for all patients. If a patient is not considered a good candidate for coccygectomy, non-surgical treatments will likely be adapted to the patient’s needs and attempted again.
Potential Risks and Complications of Coccyx Surgery
Perhaps the biggest risk is continued pain in the coccyx post-operatively, meaning that the patient has endured the long healing process and still has not had improvement in the symptoms. For this reason, patient selection is crucial to a positive surgical outcome.
A possible but uncommon risk of coccygectomy is injury to the rectum as the coccyx is being removed. While it is unlikely, it is possible that if this were to happen, a diverting colostomy would be necessary to allow the rectum to heal.
Other potential risks include wound healing difficulties and/or local infection, which can delay the overall healing process. Unlike most other spine surgeries, there are no significant nerve roots in the region that would be at risk.