Coccydynia – Causes, Symptoms and Treatment

Last Updated on July 31, 2025

Coccydynia, also called coccygodynia, refers to pain in the coccyx region. The term was given by Simpson in 1859. However, the condition has been reported in the literature before that period as well.

The coccyx is the lowermost part of the spine and is also called the tailbone. One can feel the lower end of the coccyx in the proximal part of the gluteal cleft [The groove between the buttocks]. It is right there where a tail would begin in animals.

Other names for the condition are tailbone pain or coccyx pain, coccygeal pain, and coccydynia. Coccydynia is much more common in women than in men. Coccydynia is rare, accounting for less than 1% of back pain conditions.

Anatomy of Coccyx

The word “coccyx” is derived from the Greek word for the beak of a cuckoo bird, due to its resemblance in shape.

The coccyx is the terminal segment of the vertebral column and typically consists of three to five fused vertebrae, with variable degrees of intervertebral disc remnants. The most cranial segment articulates with the sacrum via a rudimentary joint, either a fibrocartilaginous symphysis or, less commonly, a true synovial joint.

Functionally, the coccyx is a vestigial tail, hence the name “tailbone.” It has a slightly concave anterior surface and a slightly convex posterior surface.

Anterior Surface

It is marked by three to four transverse grooves, representing fusion lines between segments. It serves as the attachment site for

• Levator ani muscle
• Anterior sacrococcygeal ligaments

The coccygeal ligament (lower extension of the filum terminale) inserts on the first coccygeal segment. This specialized ligament, formed by all three meningeal layers, anchors the spinal cord to the coccyx.

Posterior Surface

The proximal segment bears the coccygeal cornua, which articulate with the sacral cornua. These form part of the posterior sacral foramina, transmitting the posterior division of the fifth sacral nerve.

Lateral Surface

Lateral aspects provide insertion for:

• Coccygeal muscles
• Sacrospinous ligament
• Sacrotuberous ligament
• Fibers of the gluteus maximus

The iliococcygeus muscle, part of the pelvic floor, inserts onto the tip of the coccyx.

The attached ligaments and muscles alsosupport the pelvic floor and also contribute to voluntary bowel control. There is limited movement between the coccyx and the sacrum.

Types of Coccyx

Postacchini and Massobrio described four orientations of the coccyx. Two more types were further added by Nathan et al.

• Type I (50%)
  • Curved slightly forward, apex pointing caudally
• Type II (8-32%)
  • Curved more markedly anteriorly
  • Apex straightforward
• Type III (4-16%)
  • Sharply angulated forward between the first and second or the second and third segments
  • No subluxation
• Type IV (1-9%)
  • Subluxed anteriorly at the level of the sacrococcygeal joint or at the level of the first or second intercoccygeal joints
• Type V (1-11%)
  • Retroverted with the posteriorly angulated apex
  • 1–11% of the population
• Type VI (1-6%)
  • Scoliotic or laterally subluxated coccyx.

Patients with a type III-VI coccyx were found more commonly in cases with coccydynia.

Causes of Coccydynia

Coccydynia typically results from injury or repetitive stress on the coccyx, causing movement beyond its normal, limited range. This leads to inflammation of the surrounding ligaments, muscles, or bony elements.

In some cases, the source of pain may also include infection or neoplastic processes.

Common Causes [1,2]

• Trauma: The most frequent cause. Usually from a fall onto the buttocks or direct impact to the coccyx.
• Childbirth: Vaginal delivery may cause coccygeal strain or dislocation, especially with a difficult or prolonged labor.
• Prolonged Sitting on Hard Surfaces: Extended pressure on the tailbone, particularly in poorly supported positions.
• Repetitive Microtrauma: Activities such as horse riding, cycling, or rowing a boat.
• Coccygeal Hypermobility: Excessive movement at the sacrococcygeal joint can lead to irritation and pain.
• Infection: Rare but important; may involve osteomyelitis or adjacent soft tissue infection.
• Tumors: Primary or metastatic lesions can involve the sacrococcygeal region.
• Idiopathic: In many patients, no clear cause is identified.

Risk Factors

• Obesity – Increased body weight may add strain to the coccyx during sitting.
• Female sex – Coccydynia is significantly more common in women, likely due to pelvic anatomy and obstetric stress.

Clinical Presentation of Coccydynia

The hallmark symptom of coccydynia is localized pain over the coccyx, particularly when sitting or rising from a seated position. The pain is typically achy or sharp and may worsen with certain movements or pressure, like

• Pain while sitting, especially on hard surfaces
• Increased pain when leaning back in a seated position
• Pain when rising from sitting to standing
• Pain during defecation or sexual intercourse (in some cases)
• Tenderness over the coccyx on direct palpation

Pain may start suddenly after trauma or develop insiduously

Follwoing points should be enquired

• Onset and progression (traumatic vs. gradual)
• Sitting tolerance (how long the patient can sit before needing to change position)
• Recent childbirth in women
• Activity-related triggers (e.g., cycling, prolonged desk work)

Physical Examination

Palpation of the coccyx typically elicits localized tenderness

• Rectal examination helps assess coccygeal mobility — normally about 13° of flexion at the sacrococcygeal joint
• Inspection of overlying skin to rule out conditions like pilonidal sinus
• Evaluation of adjacent structures:
  • Ischial bursae
  • sacroiliac joints
  • Lumbosacral facet joints
  • Lumbosacral or gluteal muscles.

Differential Diagnoses

Several conditions can mimic coccydynia due to overlapping symptom patterns. A thorough history and examination help distinguish coccygeal pain from other causes.

• Lumbar spine pathology: Degenerative disc disease, lumbar radiculopathy, or facet joint pain may present with referred pain to the sacrococcygeal area.
• Sacroiliac joint dysfunction: Can produce pain near the tailbone, particularly with prolonged sitting or transitional movements.
• Ischial bursitis: Pain is more lateral and over the ischial tuberosities rather than midline.
• Pilonidal disease: Look for midline pits, swelling, or discharge near the sacrococcygeal skin crease.
• Endometriosis: In women, deep pelvic or coccygeal pain may be cyclical and associated with menstruation.
• Hemorrhoids or anal fissures: Anorectal pain may be confused with deep coccygeal discomfort, especially during defecation.
• Pelvic floor dysfunction: May present with perineal pain and dysfunction that overlaps with coccygeal symptoms.

Diagnostic Workup

Coccydynia is primarily a clinical diagnosis based on characteristic symptoms and localized tenderness over the coccyx. Imaging and diagnostic procedures are typically reserved for:

• Cases with trauma
• Persistent or unexplained pain
• Suspicion of infection, tumor, or other pathology

Imaging Studies

X-rays

• AP and lateral views of the sacrococcygeal region are standard.
• A coned-down lateral view offers better visualization of the coccyx.
• Findings may include:
  • Fractures or dislocations
  • Osteophyte formation
  • Abnormal curvature or angulation
  • Sacrococcygeal joint instability
• Dynamic views (sitting vs. standing lateral films) can reveal coccygeal hypermobility or abnormal sagittal rotation.

CT Scan

• Rarely required.
• May be used in medicolegal cases or when detailed bony anatomy is needed.

MRI

• Not routinely indicated.
• Consider if:
  • Coccygeal pain is atypical or persistent
  • Suspected intrapelvic pathology (e.g., tumor, infection)
  • Included as part of lumbosacral spine evaluation

Diagnostic Injections

• Local anesthetic injections, often combined with a steroid, can:
  • Confirm the coccyx as the pain source
  • Guide treatment decisions (e.g., suitability for coccygectomy)

A positive pain relief response following coccygeal injection supports a diagnosis of true coccydynia.

Treatment of Coccydynia

Most cases of coccydynia are self-limiting and respond well to non-surgical, conservative treatment. Surgery is reserved for severe, chronic cases unresponsive to all other interventions.

Conservative treatment remains the first-line therapy, especially physiotherapy, posture education, and ergonomic modifications.

Manual therapy, and injections like epidural steroid injections and ganglion impar platelet-rich fibrin injections for select cases are the second line of treatment.

Some consider PRP injections or neurostimulation when conservative and interventional therapies fail.

Surgery should only be considered as a last resort after careful patient selection.

Conservative Management

Ergonomic Measures and Posture Training

• Avoid prolonged sitting, especially on hard surfaces.
• Sit with a slight forward lean to reduce pressure on the coccyx.
• Use a standing desk where possible.

Cushions

• Use a wedge-shaped or donut-shaped coccyx cushion to offload pressure.
• Available over-the-counter and especially helpful for long sitting hours.

Activity Modification

• Avoid cycling, horseback riding, or activities that aggravate pain.
• Encourage frequent posture changes and movement breaks.

Sitz Bath

• Sitz baths is a method to provide hot or cold treatment to the perineal area
• It can help relax pelvic muscles and reduce inflammation.
• Local ice or heat packs may also provide temporary relief.

Medications

• NSAIDs for pain and inflammation
• Topical analgesics as an alternative to oral drugs

Physical Therapy

Pelvic floor rehabilitation can be helpful for coccydynia that is associated with pelvic floor muscle spasms. [2]

Tight, painful muscular structures such as the levator ani, coccygeus, or piriformis muscles are targeted. Myofascial release techniques may be used. Local modalities also may be helpful.

Pelvic floor physical therapy has been reported to be an effective treatment for chronic pain, including those who have chronic coccydynia even after coccygectomy.

Manual Coccyx Manipulation

• Intrarectal manipulation under anesthesia has been used in select cases.
• Evidence is limited, and results vary.

Interventional Treatments

Steroid Injections [3]

• Performed at the sacrococcygeal junction or around surrounding ligaments
• May be repeated if effective

Ganglion Impar Block [4]

The ganglion impar is also called the ganglion of Walther and is the unpaired terminal ganglion of the paravertebral sympathetic nervous system, usually located anterior to the sacrococcygeal junction.

Hypersensitivity of the ganglion impar is thought to be responsible for persistent chronic pain, which is sympathetically maintained.

Local injection of an anesthetic and/or steroid can effectively block the ganglion impar and thereby relieve coccyx pain.

Repeat ganglion impar blocks may be required and have been shown to provide additional benefit.

Nerve Ablation

Nerve ablation uses heat or cold, or current to destroy nerve fibers. Nerve ablation in coccyx pain is reserved for patients with chronic pains where none of the treatments has relieved pain [coccygectomy not included].

Destroys sensory nerve fibers via heat, cold, or radiofrequency. The site of pathology would depend on the specific site of coccygeal pathology. A diagnostic injection of local anesthetic prior to ablation is performed to ascertain the site of pain.

If one sitting of ablation does not provide relief, it may be repeated. Some patients may have a recurrence of pain after months or years due to collateral reinnervation. A repeat ablation may be performed in such cases.

Surgical Management

Coccygectomy (Partial or Total) [5]

• Reserved for severe, persistent coccydynia not relieved by any other treatment
• Involves the removal of part or all of the coccyx
• Can provide significant relief but has a relatively high complication rate (e.g., wound infection)

Other Therapies

• TENS (Transcutaneous Electrical Nerve Stimulation) may help select patients.
• Psychological support or therapy is recommended if a non-organic or chronic pain syndrome is suspected.

References

1. Lirette LS, Chaiban G, Tolba R, Eissa H. Coccydynia: an overview of the anatomy, etiology, and treatment of coccyx pain. Ochsner J. 2014 Spring. 14 (1):84-7. [PubMed]
2. Kelly M. Scott, Lauren W. Fisher, Ira H. Bernstein, Michelle H. Bradley. The Treatment of Chronic Coccydynia and Postcoccygectomy Pain With Pelvic Floor Physical Therapy, Volume 9, Issue 4, 2017, p367-76. [DOI]
3. Foye PM, Buttaci CJ, Stitik TP, Yonclas PP. Successful injection for coccyx pain. Am J Phys Med Rehabil. 2006 Sep;85(9):783–784 [PubMed]
4. Malik SH, Ahmad K, Ali L. Ganglion Impar Block For Chronic Coccydynia. J Ayub Med Coll Abbottabad. 2023 Feb-Mar;35(1):123-126. [PubMed]
5. Ahmed Y. Soliman, Bassem F. Abou El-Nagaa. Coccygectomy for refractory coccydynia: A single-center experience. Interdisciplinary Neurosurgery, Volume 21, 2020. [DOI]