Coccydynia: Physiotherapy Management 

Coccyx is a small, triangular bone at the base of the spine which serve as insertion site for multiple muscles, ligaments, and tendons. It provides weight-bearing support to a person in the seated position. Coccydynia is described as pain in the coccyx, which range from mild discomfort to severe and debilitating.

Types of Coccydynia Pain

• Localized pain which is dull ache and sharp pain
• Radiating pain which extends into the lower back, the buttocks, or even down the legs
• Chronic coccydynia results from repetitive strain or trauma over time
• Acute coccydynia is often associated with a recent injury 
• Positional pain intensify during sitting for prolonged periods, especially on hard surfaces
• Trauma-Induced pain results from falls, sports injuries, or childbirth. It is more acute and intense initially.
• Idiopathic coccydynia occurs without a clear traumatic incident or underlying condition

Causes of Coccydynia

• Obesity
• Prevalent in women as compared to men
• External trauma - such as a backwards fall, leading to a bruised, dislocated, or broken coccyx
• Internal injury - during instrumented delivery
• Repetitive or prolonged sitting
• Degenerative joint or disc disease
• Hypomobility of the sacrococcygeal joint
• Infectious etiology
• Can also be radicular or referred pain
• Nonorganic cause - somatization disorder
• Excessively curved or dislocated coccyx
• hypermobility due to weakened ligaments can contribute to coccyx pain
• Aging can lead to wear and tear of the coccyx

 

Symptoms of Coccydynia

• Pain around the coccyx area
• Pain tends to worsen when sitting for prolonged periods, especially on hard surfaces
• Discomfort may also increase when transitioning from sitting to standing or vice versa
• Activities like bending or rising from a seated position provoke pain
• Squatting or cycling can exacerbate the pain
• Radiating Pain
• Tenderness over the coccyx
• Presence of pilonidal cyst
• Pelvic floor muscle spasms
• Discomfort with Bowel Movements
• Painful Intercourse

Differential Diagnosis

• Piriformis Syndrome
• Herniated Disc
• Sacral Fracture
• Pelvic Floor Dysfunction
• Hemorrhoids
• Anal fissure
• Infections or Tumors
• Sacroiliac Joint Dysfunction
• Myofascial Pain Syndrome 
• Sacroiliitis

 

Diagnosis

Palpation: 

Physiotherapist palpate the coccyx and surrounding structures to identify tenderness, swelling, or abnormalities. This helps differentiate localized coccyx pain from pain originating elsewhere.

Range of Motion Testing: 

Assessing the range of motion of the pelvis, hips, and lower back can help identify limitations or pain-provoking movements specific to coccydynia. Restricted motion or pain during specific movements might point to coccyx-related pain.

Provocative Tests: 

Physiotherapists might perform certain tests to reproduce the patient's pain. For example:

1. The Patrick Faber test assesses sacroiliac joint dysfunction by reproducing pain in the sacroiliac joint region.
2. The seated slump test or straight leg raise test might differentiate between sciatic nerve-related pain (as in piriformis syndrome or disc herniation) and coccyx-related pain.

Muscle Strength and Flexibility Assessment: 

Evaluating the strength and flexibility of the pelvic floor muscles, hip muscles, and surrounding structures can help identify any muscle imbalances or weaknesses contributing to coccydynia.

Functional Assessment: 

Observing how the pain affects functional activities such as sitting, standing, walking, or performing specific movements can provide insight into the nature and impact of the pain.

Diagnostic and Imaging Studies

• Single-position Radiographs - show morphologic differences between normal individuals and patients with coccydynia
• Dynamic radiographs - obtained in both the sitting and standing positions, allow for measurement of the sagittal rotation of the pelvis and the coccygeal angle of incidence. 

1. normally pivot angle - between 5 and 25° when the patient sits  
2. coccydynia angle - immobility (<5° motion) or hypermobility (>25° of motion)

• Magnetic resonance imaging (MRI) - inflammation of the sacrococcygeal area 

Response to Treatment: 

Sometimes, initiating treatment targeted at coccydynia, such as exercises or manual therapy techniques focusing on the coccyx area, can help confirm the diagnosis. Improvement in symptoms with tailored interventions supports the diagnosis of coccydynia.

Physiotherapy Treatment

Pain Management

Use of Modalities like:

• Superficial Heat Therapy
• Cryotherapy
• Therapeutic Ultrasound
• TENS (Transcutaneous Electrical Nerve Stimulation) 

Manual Therapy

Soft tissue mobilization, or manipulation techniques can help in releasing tension in surrounding muscles and improving joint mobility.

Mobilization in the AP direction

The mobilization is done in Grade II Slack Zone, oscillating force for 10 to 15 seconds each application,  to promote pain reduction. It is then performed at the end range to allow tissue stretching which help reduction of the pain perceived when seated.

Traction mobilization and AP Glides

The glide is performed at end-range techniques for 10- to 15-second holds and 4 repetitions in each direction. The sacrococcygeal traction at end range of motion, is performed for 10 to 20 seconds and repeated 4 times, was performed.

 

Exercises

Stretching exercises:

Targeted stretches for the pelvic floor muscles, hamstring, and lower back can alleviate tension around the coccyx.

• mild levator stretch
• stretching of piriformis and
• iliopsoas stretch
• erector spinae muscles

Strengthening exercises:

Gradual strengthening of the core muscles, pelvic floor, and glutes to provide better support to the coccyx.

Postural exercises:

Emphasis on maintaining proper posture during sitting, standing, and activities to reduce pressure on the coccyx.

Pelvic Floor Rehabilitation:

Specific exercises to improve pelvic floor muscle strength and coordination might be prescribed. These exercises could include Kegels or biofeedback techniques.

Frequently Asked Questions

What is coccydynia ICD-10?

ICD-10 (International Classification of Diseases, 10th Revision) is the updated and more comprehensive coding system. Coccydynia in ICD-10 is classified more specifically under code M53.3, which is part of the Musculoskeletal system and connective tissue chapter.

ICD-10's expanded code set allows for a more detailed description of conditions, which can lead to better tracking of diseases, improved reimbursement accuracy, and enhanced data analysis for healthcare purposes.

What is coccydynia ICD-9?

ICD-9 (International Classification of Diseases, 9th Revision) was the earlier version of the coding system, coded as 724.79, which falls under the broader category of "Other symptoms referable to the back."

What are coccydynia exercises?

• Pelvic tilts
• Cat-Cow stretch
• Child's pose
• Knee-to-chest stretches
• Seated forward bends
• Modified cobra stretch
• Butterfly stretch
• Glute stretches
• Bridges
• Core strengthening exercises (e.g., plank variations)