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?
Pain Reducing Strategies For Tailbone Pain
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 muscles. 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.
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
Photo by Mark Zamora on Unsplash. Arms can be reached out in front. You can also place a pillow underneath you while you lean forward if that is more comfortable.
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! This is often done with a person lying on their back with knees pulled up to chest and held open. Alternatively, a wide kneed child's pose can also promote relaxation for the muscles. 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 1.
Manual Therapy Techniques For Tailbone Pain
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 one of this mini-series 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.
Retraining The Nervous System For Tailbone Pain
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 Hurts, and 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.
Manage Bowel, Bladder and Sexual Problems For Tailbone Pain
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.
Return to Normal Function With Tailbone Pain
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!
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