Learning Objectives
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Learn the common causes of coccygeal pain.
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Develop an understanding of the anatomy of the coccyx.
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Develop an understanding of the causes of coccydynia.
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Develop an understanding of the differential diagnosis of coccygeal pain.
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Learn the clinical presentation of coccydynia.
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Learn how to use physical examination to identify coccydynia.
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Develop an understanding of the treatment options for coccydynia.
Buddy Johnson
Buddy Johnson is a 32-year-old electrician with the chief complaint of, “Ever since I fell off my ladder, I’ve had a horrible pain in my tailbone.” Buddy stated that a couple of months ago, he was installing a security camera on the outside of a building when he missed a step on his ladder and fell backward and landed right on his tailbone. He said that he’s lucky he didn’t break his neck, but as he got up he noticed a sharp pain in his tailbone. The pain was so severe that he had a hard time walking back to his truck. Buddy noted that sitting down on his truck seat made the pain much worse. He figured he would get better over the next few days, but it just didn’t happen. Sitting became a real problem, as did squatting and climbing a ladder. He tried both ice packs and a heating pad, which provided only minimal relief. He used Extra-strength Tylenol, which he felt took the edge off. “Doctor, this is real pain in the ass. Being an electrician is not a spectator sport. I am up and down my ladder 50 to 60 times a day, and I need to be 100% because I am working with 220 and 440 every day. I can’t believe I fell off my ladder. I should know better.”
I asked Buddy if he had experienced any pain, numbness, or weakness in his legs since the fall and he just shook his head and replied, “Never. Doc, the pain is all right in my tailbone, and if I push on it—oh boy, the pain goes through the roof!” I asked Buddy how he was sleeping and he said, “Not worth a crap. Every time I roll over, the pain in my tailbone wakes me up. My wife is sleeping in our kid’s room because I keep waking her up. The biggest problem is that I can’t sit for more than a few minutes without the pain getting so bad that I have to get up. Driving has become a real problem, too. I’m afraid I’m going to lose my job.”
I asked Buddy to show me where the pain was and he pointed to his tailbone. “Doc, this is right where the pain is.” I asked, “Does the pain radiate anywhere?” Buddy shook his head and said, “It’s just the tailbone. I must have broke it or something.” I asked Buddy about any fever, chills, or other constitutional symptoms such as weight loss, night sweats, etc., and he shook his head no. He denied any musculoskeletal, systemic symptoms, or bowel or bladder symptoms.
On physical examination, Buddy was afebrile. His respirations were 18, his pulse was 72 and regular, and his blood pressure was 124/76. Buddy’s head, eyes, ears, nose, throat (HEENT) exam was normal, as was his thyroid exam. Auscultation of his carotids revealed no bruits, and the pulses in all four extremities were normal. He had a regular rhythm without ectopy. His cardiac exam was otherwise unremarkable. His abdominal examination revealed no abnormal mass or organomegaly. There was no peripheral edema. His low back examination was unremarkable. There was no costovertebral angle (CVA) tenderness. Visual inspection of the right buttock and the skin over his coccyx was unremarkable; specifically, there was no rubor or color and no evidence of ecchymosis. Palpation of the coccyx did not reveal any obvious deformity or abnormal mass, but it caused Buddy to cry out in pain. “Doc, you’re right on it. Please don’t push that hard.” I did a rectal exam, and when I palpated Buddy’s coccyx, he came off the table. “Doc, I have had about all the fun I want to with that—enough already!” A careful neurologic examination of both lower extremities was within normal limits. Deep tendon reflexes were physiologic throughout.
Key Clinical Points—What’s Important and What’s Not
The History
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A history of onset of severe coccygeal pain immediately following a fall from a ladder
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The pain is localized to the coccyx
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Sitting or any activities that cause pressure or movement of the coccyx cause pain
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There are no bowel or bladder symptoms
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There is significant sleep disturbance
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No fever or chills
The Physical Examination
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The patient is afebrile
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Marked tenderness to palpation of the coccyx
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Marked pain with movement of the coccyx on rectal examination
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Palpation of the coccyx on rectal examination did not reveal any obvious deformity or abnormal mass
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Normal neurologic examination
Other Findings of Note
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Normal HEENT examination
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Normal cardiovascular examination
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Normal pulmonary examination
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Normal abdominal examination
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No peripheral edema
What Tests Would You Like to Order?
The following test was ordered:
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X-ray of the coccyx
Test Results
X-ray of the coccyx reveals an inline fracture with no obvious displacement ( Fig. 15.1 ).
Clinical Correlation—Putting It All Together
What is the diagnosis?
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Coccydynia secondary to acute trauma that resulted in a nondisplaced fracture
The Science Behind the Diagnosis
Anatomy
The five sacral vertebrae are fused together to form the triangular-shaped sacrum ( Fig. 15.2 ). The dorsally convex sacrum inserts in a wedgelike manner between the two iliac bones with superior articulations with the fifth lumbar vertebra and caudad articulations with the coccyx. On the anterior concave surface, there are four pairs of unsealed anterior sacral foramina that allow passage of the anterior rami of the upper four sacral nerves. The posterior sacral foramina are smaller than their anterior counterparts. Leakage of drugs injected into the sacral canal is effectively prevented by the sacrospinal and multifidus muscles. The vestigial bony remnants that are the result of the incomplete fusion of the inferior articular processes of the lower half of the S4, and all of the S5 vertebrae project downward on each side of the sacral hiatus (see Fig. 15.2 ). These bony projections are called the sacral cornua and represent important clinical landmarks when performing ultrasound-guided caudal epidural nerve block. The U-shaped sacral hiatus is covered posteriorly by the sacrococcygeal ligament, which is also an important clinical landmark when performing ultrasound-guided caudal epidural nerve block. Penetration of the sacrococcygeal ligament provides direct access to the epidural space of the sacral canal. The triangular coccyx is made up of three to five rudimental vertebrae. Its superior surface articulates with the inferior articular surface of the sacrum ( Fig. 15.3 ).
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