Tag Archives: Coccydynia

Head, Shoulders, Knees…and Pelvic Floor!

I spent my first few years of practice going deep into the pelvis… and my most recent few years, desperately trying to get out. Now, I know that may seem like a strange statement to read coming from me, the pelvic floor girl. But bear with me. I love the pelvic floor, I really do. I enjoy learning about the pelvis, treating bowel/bladder problems, helping my patients with their most intimate of struggles. I like to totally “nerd out” reading about the latest research related to complex nerve pain, hormonal and nutritional influences, and complicated or rarely understood diagnoses. However, the more I learned about the pelvic floor, the more I discovered that in order to provide my patients with the best care I can possibly provide, I needed to journey outside the pelvis and integrate the rest of the body.

You see, the pelvic floor does not work in isolation.

It is not the only structure preventing you from leaking urine.

It is not the sole factor in allowing you to have pleasurable sexual intercourse.

It is not the only structure stabilizing your tailbone as you move.

It is simply one gear inside the fascinating machine of the body.

And, the incredible thing about the body is that a problem above or below that gear, can actually influence the function of the gear itself! And that is pretty incredible! One of the patients that most inspired me to really start my journey outside of the pelvis was an 18-year-old girl I treated 4 years ago. She was a senior in high school and prior to the onset of her pelvic pain had been an incredible athlete– playing soccer, volleyball and ice hockey. Since developing pelvic pain, she had to stop all activities. Her pain led to severe nausea, and was greatly impacting her senior year. When I examined her, I noticed some interesting patterns in the way she walked. With further questioning, she ended up telling me that a year ago, she experienced a fracture of her tibia (the bone by her knee) while playing soccer. She was immobilized in a brace for about a month, then cleared to resume all activity. (Yep, no physical therapy). Looking closer, she had significant weakness around her knee that was influencing the way she moved, and leading to a compensatory “gripping” pattern in her pelvic floor muscles to attempt to stabilize her hips and legs during movement. So, we treated her knee (She actually ended up having a surgery for a meniscal tear that had not been discovered by her previous physician), and guess what? Her pelvic pain was eliminated. BOOM. If you want to read more about her story, I actually wrote the case up for Jessica McKinney’s blog and pelvic health awareness project, Share MayFlowers, in 2013.

So, what else is connected to the pelvic floor? Here are a few interesting scenarios:

  • Poor mobility in the neck and upper back can actually lead to neural tension throughout the body– yes, including the nerves that go to the pelvic floor. (I’ve had patients bend their neck to look down and experience an increase in tailbone pain. How amazing is that?)
  • Being stuck in a slumped posture can cause a person to have decreased excursion of his or her diaphragm, which can then put the pelvic floor in a position in which it is unable to contract or relax the way it needs to.
  • Grinding your teeth at night? That increased tension in the jaw can impact the intrathoracic pressure (from glottis to diaphragm), which in turn, impacts the intra-abdominal pressure (from diaphragm to pelvic floor) and, you guessed it, your pelvic floor muscles!
  • An ankle injury may cause a person to change the way he or she walks, which could increase the work one hip has to do compared to the other. This can cause certain muscles to fatigue and become sore and tender, including the pelvic floor muscles!

Pretty cool right? And the amazing thing is that this is simply scratching the surface! The important thing to understand here is that you are a person, not a body part! Be cautious if you are working with someone who refuses to look outside of your “problem” to see you as a whole. And if you have a feeling in your gut that something might be connected to what you have going on, it really might be! Speak up!

As always, I love to hear from you! Have you learned of any interesting connections between parts of your body? For my fellow pelvic PTs out there, what cool clinical correlations have you found?

Have a great Tuesday!

Jessica

Wanna read more? Check out this prior post on connections between the diaphragm and the rest of the body!

 

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Why get Pelvic PT first? And, join me for a webinar Thursday 12/10!

If you didn’t know, December 1st was a day that all PTs came together to share with the public all of the benefits of seeking PT! My colleague, Stephanie Prendergast, founder of the Pelvic Health and Rehabilitation Center in California, wrote an amazing blog post on why someone should get pelvic PT first. I thought it was great (as you know…I post lots of Stephanie’s stuff), and Stephanie gave me permission to re-blog it here. So, I really hope you enjoy it. If you aren’t familiar with Stephanie’s blog, please check it out here. You won’t regret it. 

On another note, I will be teaching a live webinar Thursday 12/10 on Pelvic Floor Dysfunction in the Adult Athlete. I really hope to see some blog followers there! Register for it here.  

Now… enjoy this great post by Stephanie. ~ Jessica 

Why get PT 1st? Here are the Facts. By Stephanie Prendergast

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Vaginal pain. Burning with urination. Post-ejaculatory pain. Constipation. Genital pain following bowel movements. Pelvic pain that prevents sitting, exercising, wearing pants and having pleasurable intercourse.

When a person develops these symptoms, physical therapy is not the first avenue of treatment they turn to for help. In fact, physical therapists are not even considered at all. This week, we’ll discuss why this old way of thinking needs to CHANGE. Additionally, we’ll explain how the “Get PT 1st” campaign is leading the way in this movement.

We’ve heard it before. You didn’t know we existed, right? Throughout the years, patients continue to inform me the reason they never sought a physical therapist for treatment first, was because they were unaware pelvic physical therapists existed, and are actually qualified to help them.

Many individuals do not realize that physical therapists hold advanced degrees in musculoskeletal and neurologic health, and are treating a wide range of disorders beyond the commonly thought of sports or surgical rehabilitation.

On December 1st, physical therapists came together on social media to raise awareness about our profession and how we serve the community. The campaign is titled “GetPT1st”. The team at PHRC supports this campaign and this week we will tell you that you can and should get PT first if you are suffering from a pelvic floor disorder.

Did you know that a majority of people with pelvic pain have “tight” pelvic floor muscles that are associated with their symptoms?

Physical therapy is first-line treatment that can help women eliminate vulvar pain

Chronic vulvar pain affects approximately 8% of the female population under 40 years old in the USA, with prevalence increasing to 18% across the lifespan. (Ruby H. N. Nguyen, Rachael M. Turner, Jared Sieling, David A. Williams, James S. Hodges, Bernard L. Harlow, Feasibility of Collecting Vulvar Pain Variability and its Correlates Using Prospective Collection with Smartphones 2014)

Physical therapy is first-line treatment that can help men and women with  Interstitial Cystitis

Over 1 million people are affected by IC in the United States alone [Hanno, 2002;Jones and Nyberg, 1997], in fact; an office survey indicated that 575 in every 100,000 women have IC [Rosenberg and Hazzard, 2005]. Another study on self-reported adult IC cases in an urban community estimated its prevalence to be approximately 4% [Ibrahim et al. 2007]. Children and adolescents can also have IC [Shear and Mayer, 2006]; patients with IC have had 10 times higher prevalence of bladder problems as children than the general population [Hanno, 2007].

Physical Therapy is first-line treatment that can help men suffering from Chronic Nonbacterial Prostatitis/Male Pelvic Pain

Chronic prostatitis (CP) or chronic pelvic pain syndrome (CPPS) affects 2%-14% of the male population, and chronic prostatitis is the most common urologic diagnosis in men aged <50 years.

The definition of CP/CPPS states urinary symptoms are present in the absence of a prostate infection. (Pontari et al. New developments in the diagnosis and treatment of CP/CPPS. Current Opinion, November 2013).

71% of women in a survey of 205 educated postpartum women were unaware of the impact of pregnancy on the pelvic floor muscles.

21% of nulliparous women in a 269 women study presented with Levator Ani avulsion following a vaginal delivery (Deft. relationship between postpartum levator ani muscle avulsion and signs and symptoms of pelvic floor dysfunction. BJOG 2014 Feb 121: 1164 -1172).

64.3% of women reported sexual dysfunction in the first year following childbirth. (Khajehi M. Prevalence and risk factors of sexual dysfunction in postpartum Australian women. J Sex Med 2015 June; 12(6):1415-26.

24% of postpartum women still experienced pain with intercourse at 18 months postpartum (McDonald et al. Dyspareunia and childbirth: a prospective cohort study. BJOG 2015)

85% of women stated that given verbal instruction alone did not help them to properly perform a Kegel. *Dunbar A. understanding vaginal childbirth: what do women understand about the consequences of vaginal childbirth.J  Wo Health PT 2011 May/August 35 (2) 51 – 56)

Did you know that pelvic floor physical therapy is mandatory for postpartum women in many other countries such as France, Australia, and England? This is because pelvic floor physical therapy can help prepartum women prepare for birth and postpartum moms restore their musculoskeletal health, eliminate incontinence, prevent pelvic organ prolapse, and return to pain-free sex.

Did you know that weak or ‘low tone’ pelvic floor muscles are associated with urinary and fecal incontinence, erectile dysfunction, and pelvic organ prolapse?

Physical Therapy can help with Stress Urinary Incontinence

Did you know that weak or ‘low tone’ pelvic floor muscles are associated with urinary and fecal incontinence, erectile dysfunction, and pelvic organ prolapse? 80% of women by the age of 50 experience Stress Urinary Incontinence. Pelvic floor muscle training was associated with a cure of stress urinary incontinence. (Dumoulin C et al. Neurourol Urodyn. Nov 2014)

30 – 85 % of men develop stress urinary incontinence following a radical prostatectomy. Early pelvic floor muscle training hastened the recovery of continence and reduced the severity at 1, 3 and 6 months postoperatively. (Ribeiro LH et al. J Urol. Sept 2014; 184 (3):1034 -9).

Physical Therapy can help with Erectile Dysfunction

Several studies have looked at the prevalence of ED. At age 40, approximately 40% of men are affected. The rate increases to nearly 70% in men aged 70 years. The prevalence of complete ED increases from 5% to 15% as age increases from 40 to 70 years.1

Physical Therapy can help with Pelvic Organ Prolapse

In the 16,616 women with a uterus, the rate of uterine prolapse was 14.2%; the rate of cystocele was 34.3%; and the rate of rectocele was 18.6%. For the 10,727 women who had undergone a hysterectomy, the prevalence of cystocele was 32.9% and of rectocele was 18.3%. (Susan L. Hendrix, DO,Pelvic organ prolapse in the Women’s Health Initiative: Gravity and gravidity. Am J Obstet Gynecol 2002;186:1160-6.)

Pelvic floor physical therapy can help optimize musculoskeletal health, reducing the symptoms of prolapse, help prepare the body for surgery if necessary, and speed post-operative recovery.

Did you know….

In many states a person can go directly to a physical therapist without a referral from a physician? (For more information about your state: https://www.apta.org/uploadedFiles/APTAorg/Advocacy/State/Issues/Direct_Access/DirectAccessbyState.pdf)

You need to know….

Pelvic floor physical therapy can help vulvar pain, chronic nonbacterial prostatitis/CPPS, Interstitial Cystitis, and Pudendal Neuralgia. (link blogs: http://www.pelvicpainrehab.com/patient-questions/401/what-is-a-good-pelvic-pain-pt-session-like/, http://www.pelvicpainrehab.com/male-pelvic-pain/460/male-pelvic-pain-its-time-to-treat-men-right/http://www.pelvicpainrehab.com/female-pelvic-pain/488/case-study-pt-for-a-vulvodynia-diagnosis/)

Pelvic floor physical therapy can help prepartum women prepare for birth and postpartum moms restore their musculoskeletal health, eliminate incontinence, prevent pelvic organ prolapse, and return to pain-free sex: http://www.pelvicpainrehab.com/pregnancy/540/pelvic-floor-rehab-its-time-to-treat-new-moms-right/

Early pelvic floor muscle training hastened the recovery of continence and reduced the severity at 1, 3 and 6 months in postoperative men following prostatectomy. (Ribeiro LH et al. J Urol. Sept 2014; 184 (3):1034 -9). (Link blog: http://www.pelvicpainrehab.com/male-pelvic-pain/2322/men-kegels/

A study from the University of the West in the U.K. found that pelvic exercises helped 40 percent of men with ED regain normal erectile function. They also helped an additional 33.5 percent significantly improve erectile function. Additional research suggests pelvic muscle training may be helpful for treating ED as well as other pelvic health issues. (link blog:http://www.pelvicpainrehab.com/male-pelvic-pain/2322/men-kegels/

….that you can and should find a pelvic floor physical therapist and  Get PT 1st.

To find a pelvic floor physical therapist:

American Physical Therapy Association, Section on Women’s Health:

http://www.womenshealthapta.org/pt-locator/

International Pelvic Pain Society: http://pelvicpain.org/patients/find-a-medical-provider.aspx

Best,

Stephanie Prendergast, MPT

stephanie1-150x150Stephanie grew up in South Jersey, and currently sees patients at Pelvic Health and Rehabilitation Center in their Los Angeles office. She received her bachelor’s degree in exercise physiology from Rutgers University, and her master’s in physical therapy at the Medical College of Pennsylvania and Hahnemann University in Philadelphia. For balance, Steph turns to yoga, music, and her calm and loving King Charles Cavalier Spaniel, Abbie. For adventure, she gets her fix from scuba diving and global travel.

5 Ways to Decrease a Flare-up on Vacation

It never fails. Around this time of year, many of my patients are traveling, going on fun vacations (just like me! Yep, I was away last week– sorry for the lack of posts!), and the pelvic floor never seems to love that. Unfortunately, vacations for many mean a flare-up of symptoms–worsening of pain from sitting for long car or plane rides, constipation, or other unpleasant feelings. This seems to happen like clock-work. But the good news is, vacationing doesn’t have to be the start of a bad flare. You don’t have to be afraid to go on vacation. In fact, there are a few since steps you can take to reduce and manage the vacation blues.

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 1. Pack your toolbox.  One of the big ways you can reduce the likelihood of a flare, is to plan ahead and pack the necessary tools that normally help you.  Do you normally take a fiber supplement daily to manage the bowels? Pack it. Use an ice pack when you start feeling pain? Pack it. Listen to a progressive relaxation CD or youtube video before bed? Make sure you bring it along!  The more you plan ahead, the better it will be if you do start having pain or see a change in your bowel/bladder symptoms.

2. Keep your bowels in check.  Now, some of you are probably thinking, “I have pain Jessica– not bowel problems!” BUT, keeping the bowels in a routine is so important for ANY pelvic floor problem. A bout of constipation can increase bladder leakage or worsen pelvic pain. Unfortunately, constipation is very common while traveling.  One of the main reasons for this is that most of us significantly change our habits when we travel. For example, I normally start my day with a protein shake and a piece of fruit—but on vacation, I will have french toast, or a big omelet, cheese danishes, and other larger, richer breakfast options. Delicious, right? But the bowels don’t love the change. The best thing we can do for our bowels while traveling is to stay consistent. Remember, your bowels love a good routine, so try to eat similar meals that you normally eat at similar times! Keep up with fiber or supplements to maintain a good consistency, and don’t forget your fluid intake!! For more tips for bowel health, check out my previous posts here.

3. Stay consistent with your routines. Yes, we just hit on this with the bowels, but this is equally true with the other routines you use to manage your pain or other problems. Vacation is a great way to relax, but many people will find they drop their helpful habits while traveling.  Sometimes this may mean waking up a few minutes earlier in order to get your morning stretching in, or perhaps taking a break in the afternoon to use an ice pack, or maybe even setting an alarm to make sure you do your exercises–but these small steps can really do a lot to decrease the risk of a symptom flare!

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4. Pace yourself. This one is most important for those dealing with pelvic pain. We know that movement is medicine for persistent pain, and a vacation is often a very motivating time to move! That being said, it is important to gradually add movement and take breaks as needed to allow your body time to rest and adapt to a higher level of activity. I often will see men and women who may be very sedentary in their day-to-day lives, but then, go on vacation and want to be on-the-go 24-7! It is a much better alternative to try to slowly increase your activity, giving yourself adequate time to rest based on your prior activity level and what your body needs. For example, if you are normally inactive, it may be helpful to plan an activity for a few hours in the morning, but to plan for a resting period after that (great time to ice and do your stretches!). If you have several activities you would like to do, consider making a list and spacing those activities out over the days you are traveling.

5. Try not to freak out.  I get it. Flares are scary–especially when you’ve been seeing progress and have been feeling great! But, don’t let it get the best of you! Remember to see a flare for what it really is– a flare.  Keep your mindset positive, use the tools you have, and you will be back to vacationing in no time! And if you feel like you need a boost, contact your pelvic PT (we really don’t mind!). We’re always happy to talk through some strategies to calm things down, and are happy to help get you back to relaxing! 🙂

What strategies do you use to decrease a flare on vacation? PTs out there– are there any other tips you like to give your patients? Let me know in the comments below!

~ Jessica

A Pain in the Tail…bone (Part 2: Treatment)

“Due to the dearth of research available and the low levels of evidence in the published studies that were located we are unable to recommend the most effective conservative intervention for the treatment of coccydynia. Additional research is needed regarding the treatment for this painful condition.” 

This statement comes from a 2013 systematic review on conservative treatments for coccydynia… isn’t it so encouraging? We discussed what coccyx pain meant, the causes, and the examination approach last week in Part 1 of “A pain in the tail…bone.”  Today’s post will take a close look at my approach for treating people with tailbone pain and what we do know in the current research. Unfortunately, as you see from the comment above, research for the best treatment for tailbone pain is significantly lacking…so we’ll have to rely on my clinical experience as well as the knowledge from courses I have attended and practitioners I have collaborated with in the past.

So, what should treatment for tailbone pain include?

1. Pain reducing strategies: Day one of treatment should always include recommendations for reducing pain by changing some basic daily habits. Typically, this includes:

  • Cold packs/hot packs: Basic, I know, but they feel good and can help a sore coccyx feel better after a long day. I prefer ice, but others prefer heat. I recommend using for about 10-15 minutes, a few times per day or as needed. Recent recommendations always include using cold/heat as needed.
  • Alignment, & Cushions when needed: Alignment, especially in sitting, is very important for reducing pressure on the tailbone in the initial phase of treatment. Slumpy postures actually put more pressure against the tailbone and neutral postures distribute weight to the bony parts of our pelvis more evenly. Along with this, firm comfortable chairs tend to support a more neutral posture, but cushy couches or chairs usually promote a more slumped posture. As I mentioned in my previous post, many people with tailbone pain tend to develop a side-twisted sitting posture. It makes sense– they’re trying to unweight the tailbone–but over time, this “wonky” sitting can lead to low back pain, and that’s not fun for anyone! So, we need to learn to sit up comfortably, and a good tailbone cushion can be a helpful tool for that. Note: Donut cushions don’t tend to help as much with tailbone pain unless the pain is totally referred from the pelvic floor musces. These unweight the perineum due to the center cut-out, but they don’t unweight the coccyx.  A cushion that has a back cut-out, like the ones pictured tend to be more helpful.
  • Coccyx cushion from Amazon.com

    Aylio Seat Cushion

  • Body Scanning or “Check-ins”: Many people with tailbone pain will clench muscles around the tailbone as a protective strategy–usually the glutes and the pelvic floor to be precise. As we discussed previously, these muscles can refer to the coccyx, so it is important that we decrease this hypervigilant clenching pattern. I typically recommend scanning the body, or checking-in, a few times a day to feel if muscles are clenched hart or relaxed. If you feel any clenching, try to drop the muscles and allow them to let go.
  • Pelvic Floor Drops: As mentioned previously, many people with coccyx pain have tender and over-contracting pelvic floor muscles. Pelvic floor drops are exercises that encourage a completely relaxed pelvic floor. Typically, these pair well with breathing exercises as functional diaphragm use can encourage appropriate pelvic floor relaxation.
  • Stretches: My favorite stretch for someone with coccyx pain is what I call “The frog.” This stretch not only helps to stretch out the buttock muscles, but also is a position of optimal relaxation for the pelvic floor! Other stretches to open the pelvic or stretch the muscles around the pelvis can also be helpful–but this one is my go-to on day
Performed with arms holding knees, dropping open to the side (should not be painful or uncomfortable!)

Performed with arms holding knees, dropping open to the side (should not be painful or uncomfortable!)

2. Manual Therapy Techniques: The goal of manual therapy should be to decrease soft tissue sensitivity/pain and to improve the mobility of the coccyx, SI joint and low back if indicated. Typically we do the following:

  • Soft tissue treatments: This should not be a horribly painful experience! Skilled clinicians can help to improve sensitivity and tender spots in the buttocks, hips, low back muscles and pelvic floor muscles. For the pelvic floor, this can be done externally, vaginally (in women) or rectally. Specifically, the coccygeus, iliococcygeus, pubococcygeus and obturator internus muscles should be evaluated and treated. Sometimes dry needling can be helpful also in reducing soft tissue sensitivity.
  • Coccyx Mobilization: The coccyx can be mobilized some externally with a person in sitting (I use what is called the “closed-drawer technique” here). The best way to mobilize the coccyx is with internal rectal treatments. Internal rectal mobilizations or manipulations can include direct mobilization into flexion or extension, distraction of the coccyx and mobilization into sidebending. The most recent review I found published in 2013 found 3 studies looking at intrarectal manipulation for coccyx pain and all of them did show some improvements in pain for patients…but from a research standpoint, 3 studies is hardly anything and to be honest, the studies weren’t that good. So, we’re stuck with some of my clinical opinion 🙂 I believe intrarectal mobilization can be hugely beneficial for patients! And, I shouldn’t have to say it–but it should always be done by someone trained and skilled in performing it.
  • Lumbar & SI treatment: I highlighted in part 1 that many men and women would tailbone pain often have low back and SI pain as well. In these cases, these areas should be addressed and treated through manual therapy techniques as well as specific exercise recommendations

I often will also use a little bit of taping to help support what I do manually and give my client some input on what I want their bodies to do. I like kinesiotape the best for this and use a few different techniques depending on the person. McConnel tape can also work well.

3. Retrain the Nervous System: Our brain rules– remember, pain is our brain’s alarm system to tell use there is a problem and to protect. A person who has had coccyx pain for a long period of time may develop a sensitized nervous system–and it is so important that this be addressed! So as not to re-invent the wheel, you can read more about it in my previous post reviewing the book, Why Pelvic Pain Hurtsand in my previous post summarizing my presentation to the Atlanta Interstitial Cystitis Support Group. 

Side-note: Pain neuroscience is currently not discussed often enough in the research regarding treatment for coccydynia. I think this is a huge problem–we know that experiencing pain for a long period of time truly impacts the nervous system and we can’t ignore that! This case study showed 2 patients treated for tailbone pain–one was acute, treated immediately and got better quickly. The second had pain for over a year before being treated and did not get as good results– could this “brain retraining” be the missing piece? I think it can’t be ignored.

4. Manage Bowel, Bladder and Sexual Problems: Remember, the pelvic floor muscles attach to the tailbone, so it is so common for people with tailbone pain to notice bowel, bladder or sexual symptoms.  This should always be addressed with good behavioral education and appropriate treatment techniques. I’ll leave it at that…because each one could be a few blog posts in and of themselves.

5. Return to Normal Function: I talk about this in almost every post, but ultimately, our goal is always to get you back to moving, sitting, exercising, etc. as quickly and effectively as we can. As pain decreases, our goal is to retrain the system to function optimally. We do this by retraining proper patterns of muscular activation (yep, diaphragm, pelvic floor, abdominals, low back…with all of the other muscles!), teaching movement with lots of good variation, and a lot of education.

So, that about sums it up… PTs out there, did I miss anything important? I would love to hear from you and start a discussion!

For those of you out there dealing with tailbone pain–please let us know how we can help you better! If you have not tried working with a pelvic physical therapist in the past, I do strongly recommend it!

A Pain in the Tail…bone (Part 1- What is it? How does it happen? How does it feel?)

Let me tell you a little story. Several years ago, I was on my way to a continuing education course in Minneapolis, MN. I arrived to the airport early for my flight and settled in at the gate with a good book waiting for the boarding call. My flight was delayed…and delayed… a one hour wait became a four hour wait. But, I was reading a great book. I believe I got up one time over those four hours. Then I boarded the plane and sat for another 3 hours (finished the book!). Then I had tailbone pain.

Thankfully, in my case, I was headed to a course full of pelvic health practitioners, and I begged one of them to treat my tailbone on the first day. (Yes, it literally went, “Hi, my name is Jessica, will you treat my coccyx?”) She did, and one day later it felt totally better.

The truth is, my story is not a totally uncommon one. I sat in one place for 7 hours straight (likely in a slumped posture)– and my tailbone didn’t like it. I was lucky, because I know about tailbone pain…I was able to get it treated and I got better very quickly. Many people with the same pain will stay in pain for a long time before getting the treatment that helps. So, my goal today is to tell you exactly what tailbone pain is, how it happens, and what it feels like… and then in part 2 to tell you what you can do about it.

First, where exactly is the tailbone? Seems easy, but you’d be surprised how many people don’t actually know where it is.  Several months ago, I received a referral from a PT colleague to treat a nice lady who was having “tailbone pain.” She came into my office and when I asked where her pain was, she pointed directly to the sacrum.  I have had this happen in reverse too where a patient told me his “back hurt” but pointed to his coccyx. So, where is the tailbone? 

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The coccyx (tailbone) refers to the 3-5 fused bones at the very end of the spine. These fused segments attach to the sacrum. To feel your coccyx, slide your fingers down from the sacrum between each cheek of your bottom. You will feel a very small boney structure, and can often feel the tip of the coccyx (which will be very close to the anus!).

Several ligaments and muscles attach to the coccyx, including the gluteus maximus and the pelvic floor muscles.  The coccyx does not stay still when we move. In fact, the coccyx moves as we sit and moves again as we stand.

coccyx

Now that we got that out of the way, here are a few things to know about coccydynia (tailbone pain): 

-What is it and what are the common symptoms associated with it? Coccydynia translated means “pain in the coccyx,” and that is how coccydynia is defined.  Most people with coccydynia will complain of pain in sitting (especially on hard surfaces), pain in standing for a long period, and pain when moving from sitting to standing or from standing to sitting. Since the pelvic floor muscles attach to the coccyx, many people with coccyx pain will have pelvic floor muscle involvement to some extent and may complain of constipation or pain with bowel movements, changes in urinary frequency/urgency or pain with sexual intercourse. Clinically, I also will often find that people with tailbone pain will begin to have low back pain too– I believe this occurs as people alter sitting positions and “side-sit” to avoid sitting on the tailbone.

-How common is it? The prevalence is actually unknown. Some literature state that it is “uncommon,” but I don’t really think that’s true. I think it’s likely under-reported (as are many things in the pelvis), and I believe the lack of understanding on treatment options contributes to this. Coccydynia seems to affect women more than men (5x more approximately!) and is more common in people with obesity. 

-What causes it? Coccyx pain is typically divided into two categories– traumatic and non-traumatic. Traumatic coccydynia typically occurs either with a backwards fall on the bottom or during childbirth. In these cases, the coccyx can become bruised, dislocated or even fractured. Nontraumatic coccydynia can occur due to prolonged or repetitive sitting on a hard surface (microtrauma), hypomobility or hypermobility of the coccyx (basically, the tailbone isn’t moving properly), degenerative joint or disc disease, and other variations in the structure of the coccyx. In addition, the coccyx can sometimes become painful if a person has overactive pelvic floor muscles as these muscles attach to the coccyx.  Note: Although much less common, coccyx pain can sometimes come from more serious problems like an infection or even cancer. It’s always important to see a skilled health care provider who can help you determine the contributors to your pain. 

-How is coccydynia diagnosed? As I said previously, coccydynia refers to pain in the coccyx, so the best way to diagnose coccyx pain is with a thorough history of the pain and an exam involving touching the coccyx to determine if it is uncomfortable to the person. (This is where some clinicians run into issues…you see, the tailbone is close to the anus, and people don’t always like going there. But it is SO important as a clinician to actually touch the tailbone to help determine why the person is experiencing pain! No one would examine shoulder pain without touching the shoulder! So, please clinicians, palpate the tailbone. Soapbox over.)

I know you would think that most people would “know” if their tailbone was painful…but like we discussed above, many people do not even realize where the tailbone is! Also, it is important to note that tailbone pain can be radicular in nature, meaning that nerves in the area are contributing to the symptoms or it can be “referred pain” meaning that it is coming from a different structure. Some of the muscles that can contribute to tailbone pain are the pelvic floor muscles, the obturator internus ( a deep hip rotator) and the gluteus maximus. I have seen several patients that felt pain in their tailbone that was actually coming from tenderness in these muscles. That’s why an exam with palpation is so important.

Sphincter Ani, Levator Ani, Coccygeus, Obturator Internus (2)

Image from Travell and Simon, Trigger Point Manual

– How is the coccyx examined? Examination with a physician typically will include a subjective history, physical exam and may also include some type of diagnostic imaging (x-ray, MRI). Typically, when a person comes into my office seeking physical therapy for coccydynia or tailbone pain, my initial assessment includes the following:

  • A comprehensive history to understand what the person believes is causing the pain, what makes pain better/worse, obstetric history, bladder/bowel history and symptoms, sexual history and symptoms
  • A movement exam– basically taking a person through movements of the spine, sitting, standing, squatting to see how the person moves and what movements (if any) bring on the pain, worsen it, or alleviate it. I also will feel the coccyx in sitting vs. slumping to feel the movement of the coccyx and identify pain.
  • An external assessment of the spine– Mobilizing the segments of the low back, the sacrum and then the coccyx helps me identify which structures may be involved in the person’s discomfort.
  • An external muscle assessment– feeling the muscles of the low back, buttocks, pelvic floor and thighs to see if the muscles are tender and if that tenderness contributes to tailbone pain.
  • An internal assessment of the pelvic floor muscles and coccyx- For patients experiencing significant pain, I will often defer this to the 2nd visit or even later depending on the person. The best way to assess the coccyx is by an internal rectal assessment by a very skilled practitioner. This examination allows a clinician to feel the movement of the coccyx and assess the muscles around the coccyx for tenderness. (Note: examination and treatment should always be a “team” decision. If a person feels uncomfortable with an internal exam and does not wish to have one, the practitioner should respect that and treat the person as well as she can with external approaches)

1115_Muscles_of_the_Pelvic_Floor

How is tailbone pain treated and what can you do NOW to make it better? Stay tuned next week for Part 2… 🙂 

As always, I love to hear from you! Please let me know if you have any questions or comments! Happy Friday!

~ Jessica