welcome everyone to a pain in the tail review of the evaluation, diagnosis, and treatment of tailbone pain. I'm pleased to present with five other speakers. Again, I'm the moderator. I'm pleased to present with Dr. Saloni Sharma, Dr. Michael Maynard, Dr. Cecilia DeStefano, and Dr. Mehul Desai. What we plan to do is take you through the introduction, the evaluation, diagnosis of tailbone pain, the information about history and physical examination, diagnostic testing, an overview treatment, physical therapy presentations, and interventional treatments, and hopefully we'll have some time for questions and answers at the end. I thought about doing this lecture for the last two years because in my private practice I've seen a significant increase in the incidence of these patients. Most of the patients I present with tailbone pain in my clinic are younger, healthier patients, especially women who are active. I have a lot of cyclists, a lot of bicycle riders, a lot of runners who are presenting with tailbone pain for some reason, and hopefully we'll be able to delve into the reasons why some of these some of these patients are presenting now to our clinics. Without further ado, this was first started by Dr. Simpson in 1859. He described it in the medical literature. There's two other names that are synonymous with it, coccyx pain and tailbone pain, and I'll turn it over to Dr. Sharma for continuation. Hi there. Thanks again for the introduction Dr. Conliff. I want to start with just going through a brief overview here. Let me line this up a little bit better. There we go. Okay, so I'm doing the introduction part. We'll talk about demographics, etiology as well. As Dr. Conliff mentioned, the name is coccydynia. It's synonymous with tailbone pain. We'll sort of run through just the basic introduction stuff. The coccyx is the end of the spinal column. It articulates with the sacrum, and coccydynia's definition is pain in the coccyx region, so pretty self-explanatory. Just like most spine and joint issues, some of the problem with it is that it's multifactorial, so there's not just one cause or one single source of the pain. There's multiple factors, and we'll sort of delve into the anatomy, some of the reasons for that as well. Oftentimes it's acute. Other times it can become chronic, and obviously that's when it becomes a little more challenging. So going through the anatomy, it's derived from the Greek word for the beak of a cuckoo bird due to its shape. It's a triangular-shaped bone, has three to five rudimentary pieces of vertebral units. They're usually fused, but the first segment is not often. It does articulate with the sacrum, as noted. It can be a trusonovial joint as well, which is interesting, especially when you get to some of the treatment parts of it. There's a coccygeal ligament, and then also there's the muscular attachments there. So there's actually multiple factors for it, and that sort of leads us into the function portion. It's insertion site for multiple muscles, ligaments, and tendons. It's a weight-bearing, along with the ischial tuberosities, or the sit bones. While seated, leaning back actually increases coccygeal pressure, and that goes into some of the things that Dr. Conliff mentioned as well. You know, it's really about posture, alignment, and ergonomics. All those things can affect whether or not someone has coccygeal. It's also a support structure for the pelvic floor. It does not discriminate. It can affect anyone, although the average age of onset is 40 years old, and it's five times greater than women. It's especially a larger incidence of people who are obese with BMI over 30. They have a three times greater prevalence, but it's sort of a little bit like a Goldilocks syndrome, because if you're too small or too thin, there's higher incidence, and if you're obese, there's also higher incidence. And going into etiology, you know, there's always a differential you want to consider, including trauma, childbirth, and it can be a regular childbirth, but especially difficult childbirth that's instrumented, that can especially lead to more incidence of coccydynia. The other etiologies include infections, such as osteomyelitis, tumor instability of the ligament, fractures, bursitis, pelvic floor spasms, and referred pain. And just like with other spinal issues and spinal column issues, referred pain is a big thing to consider. It could actually be radiating from the discs, could be a lower sacral arachniditis, could be an abscess, so there's multiple things that could actually contribute to it. It's unlikely it's completely idiopathic, but it's definitely possible that's always a diagnosis of exclusion, as with any syndrome, and somatization is really less likely with this condition. And then, in terms of etiology, most cases are due to hypermobility or subluxed coccyx bone. Incivility can cause some chronic inflammatory changes, and you can actually, you know, demonstrate these on exam or with imaging, as my colleagues will get into. So, there is a pattern typically with radiographs. Obese patients, more of a posterior subluxation, normal weight, people are considered more hypermobile, or even the radiograph could be completely normal. And we see that a lot, where there's no blatant abnormality on x-rays or advanced imaging, but there's clearly pain and inflammation in the region. And then, with thinner people, the pattern tends to be anterior subluxation. So, I'm going to leave the further work up to my colleague, Dr. Boehner. Thank you. So, I'm going to talk a little bit about where we go from here. So, I have no disclosures also, and I'd like to thank Dr. Patrick Foy, who does a lot of work on patients with coccygeodinia, who's been one of my mentors, and also Dr. Charles Butace, who's also done some work in this field, and has been a colleague of mine in the past. So, we covered kind of the general idea of what it means to use the term coccyx pain or coccygeodinia. When we're talking about things like history and physical, you know, the history is really has a binary goal, which is to basically say, is what we're talking about pain from the tailbone, or is there another source that we would want to pursue separately? So, it's basically a rule in or a rule out, but we still want to do a pretty comprehensive evaluation. So, in asking our patients who come in, they'll have a pretty straightforward complaint, and they'll usually tell you, my tailbone hurts. It's pretty, it's a pretty direct complaint. But after that, you want to say, well, exactly where is it, exactly what kind of pain is it, and is it radiating? We kind of want to get a sense of, is it a severe pain, is it a sharp pain, or a dull ache? In terms of aggravating or alleviating factors, often this pain is going to be worse with sitting, and that can vary if it's a soft surface or a hard surface. As Dr. Sharma had mentioned, you know, when you're sitting, there's kind of a tripod support structure of your ischial tuberosities and your tailbone. The patients may say that they have to lean to one side or another, or that they actually have to lean forward to get relief. A lot of times, they'll give the history that it's worse when arising from sitting, and Dr. DiStefano, I believe, is going to cover some of the other questions, but sometimes there'll be some important factors with sex or bowel movements, and even just discussing that, does it aggravate it, is it involved in those symptoms? So, a pretty comprehensive history is also going to include red flag questions, and in addition to just asking about pain, we want to know, is there rectal bleeding? Are there signs of an infection or an abscess that the patient has noticed, like discharge or fevers? Have they noticed any kind of an actual discrete mass, or is there nocturnal pain? It's important to ask about any kind of a history of malignancy, particularly nearby structures. So, you know, we talked a little bit about the fact that the most important goal of the history is kind of binary. Is it tailbone pain, or is it not? Probably the most important history point is to say, is there a history of trauma? Because that will usually push you directly towards a skeletal problem, or a musculoskeletal problem in the region of the sacrum and the coccyx. So, people will say, I fell onto my tailbone, but that trauma history can include, you know, repetitive stress, such as, are they a cyclist, and have they changed their mileage, and have they noticed that their symptoms are worse when they ride more on bumps? It can also involve things like a vaginal delivery. It can involve overuse from activities such as horseback riding. So, as I said, to me, that's kind of the single most important point. And a lot of times, the history will include pain with sitting. So, you know, this is a picture of a tripod and a picture of a bony pelvis. So, we talk about the ischial tuberosities bearing weight and the coccyx bearing weight, and we want to know, does putting pressure directly on that tailbone when you're leaning back, when you're leaning to the side, when you're going from sit to stand, does that affect the symptoms? So, those are kind of the important points of the history to me. The physical exam, I think, has some value as well, and I think part of the value is just ruling out any other musculoskeletal condition, or in particular, a spine condition. So, the musculoskeletal exam should largely be normal in terms of lumbar range of motion, in terms of things like strength and manual muscle testing of the lower extremities, in terms of testing sensation in lumbosacral dermatomes and lower limb reflexes. But we still want to, you know, pursue other structures in the region of the coccyx and the tailbone, such as the sacroiliac joint. So, provocative maneuvers for sacroiliac joint pain certainly could have some value. The physical exam is also going to include just looking at that patient. A lot of times when you walk into a room to talk to them, they're already leaning to one side or they're already standing. So, sometimes they'll actually demonstrate pain when they change from sit to stand. I think the important points of the exam, specifically for a complaint of tailbone pain, include inspecting the area. You actually should look at it for a lesion or a sore or erythema. On palpation, the expectation is that there is going to be focal tenderness in that area. Sometimes things like guarding will be part of the exam that will be a pertinent finding. Palpation of the ischial tuberosity or other structures in the region, again, has the goal of kind of looking for other explanations for their pain. And I think considering a rectal exam, particularly for that patient who has some of those red flags questions or a history of blood per rectum, would be valuable in that scenario. The physical exam should also include the other bony landmarks that could be contributing to pain. So, palpation of the sacrum, the coccyx, the sacroiliac joint, the ischial tuberosity, and the hamstring attachments. That all should be a part of what we're looking at for a patient who presents with this complaint. Dr. Sharma talked a little bit about etiologies, but certainly that overlaps with our differential diagnosis. So, you know, what else do we want to think about in terms of diagnosing and treating this condition? So, you know, trauma, I think, obviously, is going to point towards pain directly from the tailbone. A large number of patients who come in with tailbone pain don't have a trauma or a specific injury, but there can be acute or chronic ligamentous strains of the ligaments in the region of the the tailbone and some of the ligamentous attachments. Contusions directly to the area and the soft tissue could be contributing to pain in the tailbone region. There could be fracture or dislocation of the coccyx after a trauma. There could be arthritic changes in the intercoccygeal segments. Just like any other bony structure, it can develop an osteomyelitis, or you could have just a localized soft tissue infection, and you can have malignancy, which directly involves the bony tailbone structure. Other, you know, musculoskeletal etiologies, which we touched on a little bit, would be sacroiliac joint pain, pain from the lumbosacral Z joints, pain from the hip area, which will rarely be in the posterior aspect, lumbosacral radiculopathy, ischial bursitis, or a hamstring tendinopathy. Moving on from there, you kind of get into the things that I consider outside musculoskeletal medicine. So that would be cancer or malignancy of a different thing, like a pelvic viscera, an infectious process, you know, not related to the bony structures, referred pain from pelvic viscera, or unexpected things such as, you know, hemorrhoids or a pilonidal cyst. Some of kind of the more, you know, less seen conditions, I think, would be levator ani syndrome, which is usually described as a burning pain of the rectal or the perineal area. The postulated mechanism is levator ani spasm, but I don't think it's that well defined of a condition. It is often worse with sitting, so it can be kind of confused with coccyx pain, and it can be a dull ache, usually on the left side above the anus, and on a good manual exam or rectal exam, that muscle is tender to palpation. There's another diagnosis that could be considered called proctalgia fugax, which is really an epicritic, episodic, severe pain in the rectal area. Pudendal nerve entrapment, obviously, would not be a directly a coccyx problem, but that's also known as Alcock canal syndrome, which is a positional pain that is usually worse with sitting. It's often unilateral and patients will usually localize it to one side or the other. You know, this can be evaluated further with pudendal nerve testing or with EMG testing, or even a diagnostic pudendal nerve block can have some benefit. Anything involving the pelvic structures, male or female, so prostate mass or prostatitis should be considered. Other issues could be an acute salmonegitis, an ectopic pregnancy, and endometriosis. An input from a GYN can be helpful in this scenario, as well as a good evaluation from a pelvic floor therapist can really lend a lot to the diagnosis and management. I think a big question that comes up is imaging. So once we move past history and physical exam, I think X-rays are pretty much a necessary part of a thorough evaluation. That's probably more important in traumatic injuries, or certainly before some interventional procedures, I think at least obtaining a radiograph is valuable. Generally, it's a coned-down lateral view of the coccyx to really visualize it well, and it's notoriously a difficult image. And the reason is that you kind of have the bony coccyx, it has gas-filled viscera anterior to that, and has a very thin layer of skin before there's atmospheric air behind that. So it tends to wash out a lot on X-rays or even fluoroscopic images, but you know, a well-educated X-ray technician can do really wonderful images for us. Dynamic imaging of the tailbone with sitting and standing views has been recommended, and that's very helpful. Sometimes in standing, the alignment of the coccyx looks normal, but when they sit and wait there, as Dr. Sharma had mentioned, it will sublux anteriorly or posteriorly. And the X-ray technique for that was very well-defined. As early as 2001, there's a really good paper that demonstrates some of the changes we'll see in the tailbone with sitting and standing X-rays. So you can see some of these demonstrate subluxation and the change in the incidence of the coccyx with weight-bearing. You know, I would caution, and I think it's fairly intuitive, that a lumbar MRI doesn't really visualize the coccyx. A lot of times when you look at lumbar MRIs, you get back, you just won't see that structure present. So you really need to consider actually ordering an MRI of the pelvis. A CT scan of the pelvis can be helpful, certainly for trauma, and a bone scan should be considered with, you know, perhaps a hard-to-pick-up insufficiency fracture or a subtle stress fracture or metastatic disease. With regards to is imaging necessary, and this was a patient who did not have a traumatic injury, had point tenderness, and actually was able to describe that they felt like there was a pebble, and our X-rays demonstrated a bony osteophyte there. So I don't, to me, this patient doesn't really need more imaging than what we're able to get from an X-ray, but I do think this helped to confirm our diagnosis. There's other cases where I think imaging, particularly high-level imaging, can be more helpful, and that would be our patients who are coming in without a traumatic injury. So this patient had kind of insidious onset of pain. It was worse with the weight-bearing, but it was also present at night, and it really wasn't responding to much of anything. And this is one of those patients where an MRI of the lumbar spine did not demonstrate the problem, but when we took the extra step and ordered an MRI of the pelvic area, there's actually a fairly obvious mass anterior to the distal coccyx, and that mass was actually found to be a chordoma, which is a slow-growing malignancy in spinal cancer. It is rare. It's postulated to develop from a notochord remnant, and it generally requires a fairly extensive resection and radiation therapy. So in this case, we were actually told by the the surgical team that it would require sacrifice of some of the sacral nerve roots. Again, I'm Theodore Conliff. I have nothing to disclose. I'm going to talk a little bit about the overview of coccydemia. I'm going to take us through some seating system evaluation, some pharmacology. I'll talk briefly about physical therapy, massage therapy, and manual therapy. I'll touch on acupuncture. I'm going to leave a lot of the heavy lifting for interventional procedures to Dr. Desai, but we'll talk briefly about corticosteroid injections, nerve blocks, neuromodulation, radiofrequency, shockwave therapy, and surgery. I just wanted to present a comprehensive list so that you guys can come back for reference later. We'll start initially with seating systems. Patients can certainly be educated through physical therapy on proper seating postures. Adjuvant seating systems can be introduced to minimize pressure on the coccyx. Less pressure, less pain. Devices can certainly be obtained online or through medical supply companies, and these are some examples. The first is your donut-shaped cushion, which can probably be found for about $20 online. A little bit more advanced, and this is my preference, is the wedge-shaped cushion, which is probably closer to $40 to $50 online. I have seen them as expensive as $200. The last seating system I wanted to mention was a U-shaped cushion, also known as a coccyx pillow. That can be more expensive. I've seen that as expensive as $200 also online. I find that this is the first-line treatment for coccyx in my practice, and I find that patients typically do pretty well with adjusting their seating. What are some other things we can do for them? Certainly, ergonomic adjustments are very, very important. I recommend sit-to-stand workstations very, very commonly, and I'm willing to write letters to human resources to get that done for our patients. I would suggest a timer on your phone or on your watch with a 30-minute to 60-minute interval to encourage position changes. Get up, use the restroom, get some water, whatever. Make sure you get pressure off your coccyx. And finally, I'm more than willing to write letters to employers with the possibility of working from home. I think this is really important that we are advocates for our patients as well. Next, I wanna touch briefly on pharmacology. In my opinion, I don't think pharmacology works particularly well for these patients. I think the front-line treatment for coccydynia with our patients is nonsteroidals and acetaminophen. I find that these medications can be efficacious. Less commonly and less effective are oral steroids and muscle relaxants. In my opinion, those work better for radicular pain and for back pain, which certainly overlaps a lot in these patients. Topical analgesics, again, difficult area to treat with regards to topical analgesics, patches, and creams. Opioids, I typically try to avoid them with regards to these patients. In very rare cases, will I prescribe an opioid to treat this condition. Next, moving on, there's massage and manual therapy. There's a few different studies out there that have described efficacy of massage therapy and manual therapy in the treatment of coccydynia. A famous study by Ray in 1991 compared injection techniques to injection techniques and manipulation. What they found in was that the manipulation and injection group had a 25% greater improvement over the injection treatment alone. So there was certainly some benefit. This was published in the British Journal of Joint and Bone Surgery. Mayne and Gillies in 2001 also studied multiple manual treatments. Those included elevator anus massage, a mild elevator stretch, and a coccydynial joint mobilization and found that there was a 25% improvement at six months of treatment. This was also published in the Journal of Spine. Extracorporeal shockwave therapy isn't really an alternative treatment. I have seen one or two studies about this. One study that was quoted is from Marwin in 2017. It was a very small group, 23 subjects. Out of those 23 subjects, 16 of those patients received some benefit with their visual analog or numeric pain score going from a seven to a two with treatments for three consecutive weeks. Obviously, more work needs to be done in that area. Acupuncture has not really been studied that greatly, specifically with coccydynia. I saw one or two studies that were more case reports as opposed to an anecdotal findings as opposed to significant organized research. I would say that there is some benefit. A lot more studies have been done on the area of back pain, musculoskeletal, other conditions. Physical therapy, I'm gonna leave primarily to Dr. DeStefano, but pelvic floor exercises, pelvic health, other things like manual therapy, she's gonna leave to her. Physical agent modalities can also be helpful such as therapeutic heat and cold, electrical stimulation, ultrasound, iontophoresis are all tools that we can in our armamentarium for this condition. Interventional spinal procedures, again, I'm gonna leave primarily to Dr. Desai. However, there are several different categories. Local injections with steroids have been attempted. Caudal epidural injections have also been evaluated and tried for these patients. Ganglion and PAR blocks, I use commonly in my clinic to treat these patients and I find they're pretty effective. Radiofrequency ablation, spinal cord stimulation are also other tools we have at our disposal to try to assist these patients. And finally, surgical procedures are also attempted. Coccygectomy, partial coccygectomy are also, are the two primary procedures that are done. They're indicated for refractory pain. There've been a few different studies. I don't know if they're high volume patient studies, but I would say that the biggest issue that I found with the surgical interventions were there's a high risk of complications, especially in infections. I'd like to turn it over now to Dr. DeStefano. I'd like to talk about how we put the pelvis back in the body from a physical therapy perspective. I have no relevant financial relationships to disclose. I am the owner of a private practice clinic, Optimal Motion Physical Therapy in Herndon, Virginia. I also serve as an adjunct professor with George Mason University in Fairfax and do research with George Mason and in collaboration with NIH. I'm also the president of the Academy of Pelvic Health, Physical Therapy. And I think we don't talk about this pelvic health enough and so often it gets lost in our clinical care and screening and patients get passed around. So by the time they actually end up in physical therapy with us, it's been quite a journey for them. So they've been in pain a long time, which leads to another sequelae of chronic pain, anxiety, depression, and decrease in their overall health function. So I think for me, the key is that we address these patients early on and that we're able to diagnose them and get them treatment as early as possible. We've already reviewed the anatomy, which was wonderful. Thank you so much. And we've talked about other system questions that we should be asking to make sure we're sending them to the right places quickly enough to gynecology or urology or wherever these patients need to go soon enough. Along with the questions we should be asking, one of the things that we do is we talk to them, we ask them about their Bristol scale, what type and shape are they having? Is it more diarrhea? Are they having more constipation? And along with their pain as well. We look at the common referral sites, as we've discussed, the levator ani can be a big one. And in physical therapy, we're gonna address these systematically by doing a manual exam in their vagina as well as their anus. And we're gonna look at the perineum. We're gonna look at the coccyx as well as the glute max. You talked about the hamstring, which was really important. You can see that some of these patients will have some referral sites that can be confusing. As we discussed, they'll state that they have, they feel like they have a full bowel movement, but they've already had a bowel movement. So we look at their glute max, their coccyx. Some people will describe kind of a choking in their hip. They'll describe some hip pain as well, but it's mostly posterior and where the hamstring attaches a lot of times if it's not further down in their coccyx region. We look at their adductors too. So they may be having, if they've had this pain a long time, some of the rest of their hip muscles will start to really come into play when their pelvic floor is affected, such as the adductor magnus. They'll describe maybe a golf ball in their rectum. And then again, as you discussed earlier, pudendal nerve may be impacted as well. So what can you do? Monday morning applicable, we obtain a clinical history and a physical examination and we rule out any other things, as you well said, cancer and other tumors related to the area. What do you believe is the primary driver? What's the secondary driver? Sometimes they'll have coccydynia, but as you discussed, it'll be related to other things. One of the things that I like to point out and that I've seen in clinical practice is that hypermobility, as you pointed out earlier, is a big one. Thank you for pointing that out because a lot of patients will have hypermobility. I see a lot of high level athletes, dancers, as you mentioned, the cyclist, and oftentimes their underlying hypermobility may be missed. So I like to do a Bayton-Brighton exam on those patients. Most all of my patients to see, do they have more of a hypermobile presentation or do they have more of a hypomobile presentation in their active range of motion? Is it limited? As well as getting a strength examination because a lot of these patients related to the literature, not only do they have pelvic floor dysfunction, but they may have hip strengthening and core strengthening abnormalities as well, especially if they've had the pain longer than a year. We look at their patient reported outcomes measures to lead us in the right direction and give us more information about their presentation. Algometry threshold, wind up and ping prick to see do they have aledinia, hyperalgesia. I like to do ultrasound imaging in my office to see how they're functioning, their pelvic floor, their abdominals, their multifidus in their back, perhaps their other hip muscles related to the glutes and the external rotators. But I also think sometimes it's indicated to get a pelvic ultrasound and MRI as you discussed earlier and that's why the team approach is so important to have a great team of professionals working together. Analytes and hormones I think are a good thing to have in your repertoire because some of these patients will have more trouble, more pain when they're on menstruation or the three days before menstruation, the three days at the beginning of menstruation, which may speak to some of the hormones, estrogen, progesterone, testosterone may be affected as well. Here are some of the questionnaires. I went ahead and just put a list here so you could refer to it later. Here's a list of pelvic pain questionnaires that are helpful to have in your repertoire to give you more information about a patient with pelvic pain. The research basically shows in summary that conservative management is the key. So going ahead, as we discussed earlier, some of the different things, manual therapy in particular, biofeedback, which as I pointed out, I like to use the ultrasound, but there's also a lot of other ways, which we'll talk about later to get some biofeedback to the patients. Some research has showed taping and definitely exercise helps as well. What are you gonna expect on your physical therapy examination? It's different than your typical pelvic pain examination when you go into the OBGYN's office. Oftentimes, we do a perennial exam. We check the vulva, the rectum externally to identify any asymmetries or scarring or tissue abnormalities. A lot of you have already checked this. Their doctors have already checked that. You've checked it in the physiatrist's office, but it's helpful to have a second pair of eyes looking at these things to make sure we're all on the same page and one person saw something different than somebody else. So we check that as well. We do visual and palpable. We're checking for inflammation, any increased sensitization, hemorrhoids, tenderness or irritation to the area. In the vaginal region, the vulva as well as the anus. We palpate the pelvic muscles as well, vaginally and rectally. Internally, if the patient can tolerate it with and without contraction to identify any tenderness, specifically as you pointed out, the tip of the coccyx and whether or not they have pain or trigger points, do they have, how's their strength and endurance in those muscles? Can we actually reproduce the patient's pain? Which is important to know. We look at the first layer of superficial muscles in both areas and we check to see if the coccyx is in fact flexed or extended. What's the position of the coccyx and is it mobile or not? We look at quick contractions as well as holds, a brink score and a pelvic clock. The resting tone is also important in the vagina and the rectal area. Is the resting tone, is it hypertonic? Is it more relaxed? What's the quality of their rest? A lot of times these patients have a difficult time obtaining rest. Can they obtain that? And then do they have the ability to contract and hold? What's the quality of their recruitment, elevation? Are they able to relax? Are they able to hold? What's the stability of their hold and relax? And what's the baseline contraction like? We also look at their pelvic fascia and muscle integrity. One of the researchers that's on our research team, Antonio Stecco specifically focuses on the fascia. So we've really been looking at the abdominal and hip and pelvic fascia and the integrity of the muscle sliding and gliding on the ultrasound as well. What's the echogenicity? Are they hyperechoic? Are they hypoechoic? What do they look like in their quality of movement and the tissue texture? So as you can see here on the left-hand side, I'm looking at the bladder and underneath it is the pelvic floor. And what I have the patients do is contract. I have them do regular contractions. I have them do quick contractions. I have them do some holds. And you can see the quality of their movement. Is there symmetry? Is there not symmetry? Where does... Then I look, obviously, basically going back externally, we're looking at the range of motion, functional or dysfunctional, painful or non-painful for their upper and lower extremities. And I say upper extremities, because we also want to see how is their stiffness in their thoracic spine? Are they holding their breath? Is that a factor for the pressure they're putting on the pelvic floor? What's their strength and endurance, again, in their core muscles, myotomes, dermatomes, reflexes, as was mentioned before, as well as the sacroiliac joint. This is just an example, and I put it here for you to have in case you're not familiar with the Batten and Brighton score for hypermobility. And... For the gold standard and effective in 90% of the cases. So we want to try as much as we can to think of conservative non-surgical treatments that will be helpful to these patients. For example, I put a case presentation here of a 23-year-old professional ballet dancer that I had seen who, she had a fall from a lift she was doing in ballet a year prior. She was negative on all of her imaging. She was unable to dance, though, for a year and had to somewhat change professions because of fear of falling and also some of the seated movements that were required for her profession. She couldn't sit for more than 15 minutes without severe coccyx pain. She had pain with sex and bowel movements and had no relief with any of the things that were tried previously. So what did we do in physical therapy? As you mentioned earlier, a lot of the treatments that you discussed obviously with ergonomics and seating, we also worked on her motor control, which surprisingly for a dancer, she had lost a lot of her motor control and she did have strength deficits in her glutes and her abs and tightness in her, which is very common in her hip flexors and external rotators. We got her some cushions as well as we talked about ergonomics. The big thing with ergonomics was variability. So not just sitting in one position for long periods of time. I loved the conversation earlier. I suggest the same thing about being able to stand and sit with the different desk options. Now, we also do dry needling. Levator ani, obturator internus, and coccygeus work best for her. And I find those three are the ones that really do the best with the dry needling. We mentioned the postural reeducation. We did an ultrasound assessment and some biofeedback with the ultrasound, which was very effective for her to put those muscles back on her brain map. We also did some graded motor imagery with mirror because she did have a lot of sensitization to the area and around the area, given the length of time that she had had the pain. Also, knowing when to refer is very important. So we also got a comprehensive team approach for her, referred her to get some counseling, which she found very helpful, and some other coaching as well to get her back into dance, which was her passion. Other things that we did, we did internal biofeedback. So we utilized a lot of different approaches related to this. There are many out there, but it's an internal biofeedback and it has an app with it. So the patients can see, are they contracting? Are they relaxing? And there's a way for them to measure and see that on the app, which is really nice. We did myofascial work, manual therapy to the various muscles, as well as vibration, pain science education, essentially putting the pelvis back in the body. Her prognosis was great, and we had a resolution of symptoms and returned to dance. And we learned through the literature that prognosis is best if it's caught early and treated early, if the patient's motivated and active and has intermittent pain relief and limited seating. If they're currently having pain-free sex and they have support system, that it's non-progressive and the pain itself is provocable. Here are my references. And may your coffee, your pelvic floor, your intuition, and your self-appreciation be strong. Thank you so much. And I think now I would like to introduce you to Dr. Desai. So normally I would have, hopefully, some witty comments to make at this point or a joke or two, but we're clearly recording this talk. So those who possibly fall on deaf ears, again, my name is Mehul Desai. I'm located in Washington, DC. I'm in private practice and previously was in academic medicine at George Washington University Hospital and also run the division of pain medicine at Virginia Hospital Center in Arlington, Virginia. I have a fairly diverse practice, but approximately 30% of my practice involves folks with pelvic pain. And furthermore, there's a significant chunk of those patients that actually have coccydynia. So this is an area that I really feel passionately about and I'm interested in helping patients who come to see me with. One of the things that's been discussed throughout the course of this conversation and this presentation is sort of the importance of a large number of different treatment options. So whether it's medication management, whether it's physical therapy, whether it's interventions, whether it's a host of other sort of self-care techniques, the fact is that there's a lot of different things that can be utilized for this. So obviously, understanding the anatomy, understanding the approach to this patient is probably sort of the most important starting point. But beyond that, an interdisciplinary, or if you're lucky, a multidisciplinary approach is probably the most helpful thing you could offer these patients. And as Dr. DiStefano talked about several times, and maybe I'm sort of highlighting even more so, it does take a village. I mean, a lot of what we do for these patients requires all of us to be communicating. And a lot of the patients that come see me who have pelvic pain, or specifically who are dealing with coccydynia, feel that they're lost in a sea of medical specialists. They don't really know where they belong. They've been passed from person to person without really any hope. And oftentimes they're looking for a quarterback, someone who's really has a passion for helping them, but also a passion for organizing their care, for talking and speaking to their physical therapist, their psychologist, if they have one, their primary care physician. Because this is, in some ways, like many other painful conditions, a silent disease in that because no one can see what's wrong, oftentimes there's some disbelief around what the person is suffering from. So I think it's important to sort of be aware of that role and to realize that that role is paramount for the patient and allows them to, you know, form confidence and create a bond with you as their provider. Furthermore, even though I'm going to be talking really specifically about interventional options, I actually firmly believe that the most important thing that we can offer our patients who are suffering from tailbone pain or coccydynia is access to a great physical therapist. A lot of what I do, whether it's medications, whether it's getting them in to see a behavioral health specialist, or in this case, interventional options is really intended to facilitate their ability to see a physical therapist more successfully, because I believe that those physical therapy interventions are the ones that are most sustainable for this disease state. And what I do helps potentiate and create often an analgesic window during which physical therapy can be even more effective, hopefully. So with that, these are my disclosures coming up next. I've listed my disclosures because I have quite a few talks, but none of them are relevant, particularly to this talk. So we're really going to jump right into it with the different interventions that are options. So those treatment options include local injections, caudal epidural shared injections, ganglion and PAR injections. That's sort of a first line treatment option that's available. Sort of a second line, I've divided this up a little bit, would include radiofrequency ablation, prolotherapy, spinal cord stimulation or dorsal ganglion stimulation, or surgical intervention. And we're going to talk about each of these in a little bit of detail. Local injections are typically injections of local anesthetic with or without cortisone. There's very little evidence of efficacy for their use, although they're used very commonly. There are no controlled trials for their use. I personally am not a big proponent of using cortisone in the pelvic floor for a variety of reasons, including the fact that repeated cortisone injections can cause atrophy of subcutaneous tissues, of fat, and even of muscle. And my concern is in these cases that we will end up with patients who have, we've inadvertently worsened their situation. However, Mitra et al. reported that patients were more likely to have significant pain relief following corticosteroid injections if the pain had been present for greater than, or excuse me, for less than six months. Rye reported that 60% of patients achieved significant pain relief following injection into soft tissues and at the surrounding areas of the coccyx with local anesthetic combined with corticosteroids. The success rate actually improved to 85% if the injection was combined with the manipulation of the sacral coccygeal joint. Now my little anecdote here is that many years ago I had a secret service agent who was rollerblading down the street who fell onto their tailbone and had a displaced coccyx. This person comes in to see me and was looking for help. And we got x-rays and noted that the coccyx was out of alignment. And we talked about doing a coccygeal manipulation following a injection. The look on that person's face was not enthusiastic. And I'm pretty sure if it was an option, they would have pulled their gun on me and I would have gone off to some difficult to escape prison. But they actually ended up having the procedure and got better and moved on with their lives and hopefully got back to rollerblading. But you know, I think these patients, that anecdote is really intended to highlight the fact that all of these patients require a unique approach. A cookie cutter approach to coccydynia is unlikely to work. Without having done an appropriate physical exam, without having obtained the appropriate radiographic studies, you're likely to go down a road that's not as helpful for these patients as if you were to stop, think through what they're dealing with, what their priorities are and how to best get them through this issue and to move on with their priorities. Caudal epidural steroid injections. I think there's a lot of folks that use these. They're completely empiric and anecdotal in the treatment of coccydynia. There's no evidence or controlled trials that support their use. Caudal epidural steroid injections really target the sacral segments. So in many ways, they miss the coccygeal segments to begin with. And they may get, they may get some, you may get lucky and they may get some spread into coccygeal areas. But really, caudal epidural steroid injections, which are delivered through the sacral hiatus, have historically been used to treat post laminectomy syndrome, lumbar spinal stenosis, and more spinal conditions than they really have been used or have been effective, certainly in the treatment of coccygeal pain. Ganglion impar blocks. These are performed under a fluoroscopic guidance and have been shown to provide pain relief in patients with coccydynia. A study was done that found that there was a 60% mean reduction in the numerical rating scale and a 47% mean reduction in the Oswestry Disability Index at 24 weeks post procedure in patients who underwent ganglion impar blocks. Ganglion impar blocks are performed at the junction of the sacrum and the coccyx. They're usually performed through the vestigial disc that almost inadvertently or almost always exists at the sacrococcygeal junction. There's either a two needle technique or a single needle technique, or in some cases you can hook around the coccyx to perform this procedure. I personally use a single needle technique where I cannulate through and through the vestigial disc onto the other side. The big risk here is to not go too far onto the other side and inadvertently perforate colon. But when done properly, you inject contrast and see a sign called the comma sign, which looks like a comma sitting adherent to the coccyx, which is suggested that you're in the right spot. Oftentimes these are sequential injections that are done. When a person has some relief from an injection, you may proceed with the repeat injection if that would be potentially helpful. And sometimes there is a cumulative benefit to these procedures. Radiofrequency ablation, we're kind of moving on to a sort of a higher level of intervention, something a little bit more invasive. Radiofrequency ablation has been shown to decrease pain scores extending up to six months post-procedure in a variety of disease states. Certainly in this disease state, there's some small trials that suggest that it can be helpful. The challenge with coccydynia is that there's no standard radiofrequency ablation technique that's used for this procedure. And as such, it can be variable in the sense of what people use to try to address this, and therefore the results can be variable. Jean Marquet demonstrated a 66% reduction in visual analog scores and 34% improvement in EQ5D scores with ganglion impart radiofrequency ablation. Chen et al carried out a retrospective review on 12 patients that had RFA for coccydynia and found a mean pain reduction of 55.5%. In their study, eight of these patients underwent prognostic blocks prior to RFA, and of that eight, seven achieved 50% or greater pain relief. So the conclusion there was that considering diagnostic blocks may be helpful and may be illustrative or positively predictive of success with radiofrequency ablation. One of the big things we do in our practice, particularly for patients with coccygeal hypermobility or migrated coccygeal segments or situations where the coccyx is displaced, is we combine coccygeal manipulation with dextrose prolotherapy. So there are two case series that look at the efficacy of dextrose prolotherapy for the management of persistent coccygeal pain. Kahn reported on 37 patients with chronic coccydynia who were all nonresponsive to traditional conservative management and found that there was a mean vast improvement from 8.5 to 2.5 after two injections of prolotherapy. They used 8 ml of 25% dextrose and 2 ml of 2% lidocaine in their work, and they injected the most tender location identified by a manual palpation. Of their group, 30 of 37 patients had good pain relief, while seven had minimal or no improvement. In another small case series by Chen and his colleagues, they demonstrated improved coccygeal pain after ultrasound-guided prolotherapy in three patients. They used 1.5 ml of 50% dextrose and 1.5 ml of 1% lidocaine. They used ultrasound guidance with multiple needle fenestrations into the sacrococcygeal ligament followed by injected delivery deep to the ligament at the point of maximal tenderness. All three patients reported improvements in VAS at endpoints varying from 4 to 12 weeks. So one of the challenges of dextrose prolotherapy, pardon me, is that it's a incredibly variable technique delivered over an incredibly variable space. And so what I mean by that is everyone has a slightly different target and uses a slightly different concentration, which makes studying it that much more difficult. In our practice, for example, we always or typically always do a series of three prolotherapy injections two weeks apart over six weeks. So at week one, at week three, and at week five. And what we do is we use up to 10 cc's or usually 10 ml of half percent dextrose and we use or 50% dextrose. We use 5 ml of 4% lidocaine and 5% of 0.75% bupivacaine and we inject that mixture along the sacrococcygeal ligaments and ventral to the sacrococcygeal junction. And so we're pretty standardized with regards to how we deliver this medication in our practice. So sort of the next step of invasiveness, we have neuromodulation. So Dr. Li and Lei, Dr. Li is a physiatrist based out in California. They published a single case demonstrating percutaneous sacral nerve stimulation utilizing a burst spinal cord stimulation system. And burst stimulation is a stimulation parameter that delivers closely spaced high-frequency electrical pulses delivered in groups followed by a period of inactivity. This increased their patient's ability to sit for extended periods without additional support or pain medications and decreased pain scores from 10 out of 10 to 2 out of 10 while sitting. Giordano et al also demonstrated a successful case using dorsal root ganglion simulation for the treatment of chronic coccydynia. Dorsal root ganglion stimulation is theoretically a more specific stimulation platform where an electrode is placed directly on a nerve root or specifically along the dorsal root ganglion of a specific spinal segment with the hopes of getting a more specific stimulation pattern and geography. The next step up is surgical intervention. So partial or complete coccygectomies are performed for refractory cases of coccydynia typically. In my personal experience, I've never sent a patient to get a, to have a coccygectomy or partial coccygectomy performed. My concerns are twofold. One, as this slide discussed, the complication rates vary significantly throughout the literature from zero to 50%, particularly infection, particularly in an area that's not always easiest to clean and upon which we do a significant amount of sitting and in some cases weight bearing. But also there are in some cases neuropathic implications of coccygectomy so that when the coccygeal segments of the spinal cord are sacrificed or theoretically sacrificed, there may be a neuropathic pain that results. There was a study conducted by Ray where 23 out of 120 patients required surgery following the failure of conservative management with 21 out of 23 patients achieving sustained pain relief. A total coccygectomy resulted in improved long-term outcomes in 79% of patients with chronic refractory coccydynia, pardon me, when compared to continued conservative treatment. And another study found that in reviewing seven different studies, that 90% of patients showed good or very good results following coccygectomy. One of the challenges of coccygectomy or whether partial or complete is that the studies are rarely if ever, and I'm not aware of any studies that are controlled or randomized. So these are open label prospective studies and the followup intervals are quite variable. So while outcomes can be reported as positive, the same deficits and challenges exist with these studies that exist with the other studies I presented in that there's not great long-term data and not great controlled long-term data. Again, as I summarize, I would once again reiterate the importance of a interdisciplinary approach to these patients, taking and creating a team of providers, including physical therapists, physiatrists, and other providers who have an interest in treating these patients. These are my references. And with that, I'll pass it back. Dr. DeStefano, if you wouldn't mind commenting on a realistic timeframe for treating patients with coccydynia, what's our expectation? Basically, it depends on how long the patient has had it. If you get it early, you can get a pretty quick result from it, 6 to 8 to 12 weeks, depending on the activities they want to refer to and what symptomology they turn out with combined with their clinical presentation strength, range of motion, underlying comorbidities, hypermobility, those kinds of things. Like I was saying, do they have painful sex? How are their bowel movements? Those kinds of things. Depending on how all that shakes out, you can have a pretty good result in a relatively quick amount of time if you catch it early. However, for example, like the patient example that I gave, if they've had it for a year, it may take longer, and it may depend on their pain presentation. Do they have central sensitization? You know, what other things are happening at that point, and how deconditioned they've gotten over that period of time. However, you know, like I said, that patient that I gave the example of, we had a quick result in three months, and she was in maybe once a week, once every two weeks, and she got better relatively quickly. So. The take-home messages for coccydynia, one, coccydynia is an uncommon, yet challenging and debilitating cause of spinal pain. It's thought to be about 1% of complaints of patients who are going to spinal clinics for evaluation. History, physical examination, and dynamic diastolic imaging are essential in the diagnosis. As stated previously multiple times, there are many treatments, but most have limited efficacy. Combination treatments, as we again reiterate, are the most effective approach. So a multidisciplinary approach is the best way to treat this. And again, refractory coccydynia may involve invasive spinal interventions, and possibly even surgery. With that, I just want to say thank you for your attention.

tailbone pain

coccydynia

evaluation

diagnosis

treatment

anatomy

coccyx

pelvic floor

etiology