Usually, chiropractic patients present for evaluation and management of painful conditions. Most often, neuromusculoskeletal conditions are the cause of their pain. The fortunate patients present to chiropractors with acute, painful, neuromusculoskeletal conditions that resolve with effective and safe chiropractic care.1
The less-fortunate patients do not visit a chiropractic physician until they are experiencing a chronic pain syndrome, frequently because of a posttraumatic injury. Let's discuss such a chronic pain patient with coccygodynia, which is often termed coccydynia.
Although the incidence of coccygodynia has not been reported in America, I suggest patients with this painful condition do report to chiropractic physicians and primary care physicians. We do know women are five times more likely to develop coccygodynia than men. The most common cause of this sometimes-disabling condition is a fall, but women may experience coccygodynia with childbirth. Postpartum coccydynia is often associated with a difficult delivery, with the use of forceps in 50.8 percent of cases. Luxation and fracture of the coccyx are the two most characteristic lesions.2
Case Presentation
Assume that this putative patient presents in your office for evaluation and management of chronic pain in the region of her tailbone. You had previously treated her for low back pain and cervicogenic headaches. She responded very well and appreciated your chiropractic services for these two neuromusculoskeletal conditions. She has confidence in your skills and ability to assist her.
Chief concern: "I cannot sit without pain in my butt."
History of Present Illness: "For the past 10 years, I have experienced pain in my rear end when I sit. The deep, achy pain becomes sharp if I sit and lean backward. I think the pain was caused by a fall down some stairs while carrying groceries. I landed hard on my butt. Although the initial, severe pain reduced after about three months, I still have pain if I sit on a hard surface. The pain is a 7-8/10 with sitting and 9/10 if I lean backward."
The pain does not radiate down the legs, but the severity has increased over the past six months. She has not received any treatment other than ibuprofen, which does not relieve the pain. Side-lying position in bed does reduce the pain. Her primary care physician mentioned she might want to consider a surgical procedure to remove the coccyx (coccygectomy). She would like your opinion.
Conservative Care or Surgery?
How will you determine if she should have the surgical procedure or consider conservative care and avoid the surgical intervention? It has been my experience that chiropractors frequently attempt to reduce the patient's coccygodynia with spinal manipulation of the pelvis and lumbar spine. I am not opposed to that protocol, providing there is a positive response by the patient with only a few treatments.
If spinal manipulation reduces or eliminates the pain and the patient can sit and lean back without pain, there is no need for the surgical procedure and the patient will be elated with your interventions. However, if spinal manipulation reduces this patient's pain, I suggest the pain was not a true coccygodynia caused by a sacrococcygeal lesion, or a myofascial pain caused by trigger points in the pelvic floor muscles.
Let's assume you provided spinal manipulation of the pelvis and the lumbar spine without any relief of the coccygodynia. Do you suggest to the patient that she consider surgical excision of the coccyx? Is there another choice? My response would be to refer the patient to a chiropractic physician trained to evaluate and manage patients with coccygodynia, if you cannot do so.
Orthopedic Examination
A properly trained chiropractic physician should be able to perform an appropriate orthopedic examination that will determine the pain generators. The most appropriate orthopedic examination would include an internal rectal examination of the sacrococcygeal joint and the pelvic floor muscles. It is necessary to reproduce the patient's chief concern pain.
Certainly, acute coccygodynia requires specific imaging studies of the coccyx, but chronic pain may or may not indicate the need to order specific imaging of the coccyx.
Remember, an orthopedic examination is most often a provocative maneuver that reproduces the patient's chief pain concern with compressing, contracting or stretching of the involved pain-generating tissues. An internal rectal examination of this female patient requires palpation of the sacrococcygeal joint and the pelvic floor muscles, most especially the coccygeus and the levator ani, and the obturator internus, which forms the lateral pelvic wall.
If palpation and passive mobilization demonstrate the sacrococcygeal joint is stable and there is an increase in the pain, you should then palpate the coccygeus, levator ani and obturator internus to determine if the compression reproduces the chief pain concern. It is common for myofascial trigger points in these muscles to be the cause of the chronic, posttraumatic coccygeal pain.
Treatment Tips
The treatment for myofascial trigger points in these three muscle groups involves compression of each trigger point for 15-20 seconds. If effective, the patient will respond that the pain subsides with the compression of each trigger point.
The evaluation following trigger-point pressure release will demonstrate the effectiveness of your intervention. Ask the patient to sit on a hard surface and lean backward. If the pain is eliminated or significantly reduced, the treatment was indicated. Normally, these patients will obtain relief of coccygodynia with only a couple of treatments. It is essential to avoid aggravating activities for 2-3 months following the treatment.
Quiz Time: Test Your Knowledge
True or False:
Quiz Answers: All of the above are true.
Most physicians, including chiropractic physicians, are not comfortable caring for patients with coccygodynia. This is unfortunate for patients suffering from this sometimes-disabling condition. If you would like to learn more about the evaluation and management of coccygodynia, please email me (jlehman@bridgeport.edu) and I will forward to you my PowerPoint presentation.
Suggested Reading
References
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