History and exam

Key diagnostic factors

common

coccyx pain

Pain occurs while sitting or transitioning between standing and sitting, and occasionally with defecation and sexual intercourse.

Pain is lancinating, aching, and boring.

May radiate to the lumbar spine, or unilaterally down the back of the thigh.

The patient should be asked to quantify sitting tolerance, progression of symptoms over time, and interference with lifestyle.

coccygeal tenderness

Pain or tenderness may occur on palpation and movement of the tip of the coccyx, externally or through rectal exam.

The coccyx may be hypermobile on rectal exam.

spasm of pelvic floor musculature

May be detected on digital rectal exam. The finger is swept laterally from the coccyx, and tightness or tenderness of the pelvic floor musculature may be detected.

relief of symptoms after corticosteroid injection

A therapeutic trial with a corticosteroid injection (e.g., dexamethasone, methylprednisolone) and a local anesthetic (e.g., lidocaine, bupivacaine) around the dorsal surface of the coccyx often results in rapid relief of symptoms in coccygodynia.

Can help distinguish true coccygodynia from referred pain (pseudococcygodynia).

Other diagnostic factors

uncommon

guarding

Patient may sit on their hands or elevate one buttock to avoid pressure on the sacrum.

Risk factors

strong

female sex

There is a 5:1 incidence in females versus males.[5][6]

The ischial tuberosities are further apart in the female pelvis compared with the male pelvis, exposing the female coccyx to trauma during a fall onto the buttocks.[8]

Multiparity and dystocia can result in weakening of the pelvic floor and stress of the sacrococcygeal ligaments.[8]

history of trauma to the coccyx

A history of trauma (e.g., a fall or childbirth) involving the coccyx is recorded in 60% to 70% of patients with coccygodynia.[5][7][8] The traumatic event can occur as early as 20 years prior to clinical presentation.[5]

obesity

Individuals with obesity have less sagittal rotation of the pelvis when sitting, resulting in a more perpendicular angle of incidence of the coccyx with the seat surface. The coccyx is more exposed to injury during a fall onto the buttocks, or repeated sitting down, due to insufficient pelvic rotation.[5]

In one study, obesity among patients with coccygodynia was 3.4 times greater than average.[5] However, the relative risk of coccygodynia among individuals with obesity is unknown.

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