Dr. Clemens Franzmayr, Musculoskeletal Medicine Clinic, 256 Papanui Road, Christchurch 5, New Zealand. Consultant for musculoskeletal medicine.
Article published in New Zealand Doctor 1999, reprinted here with the permission of the author
It is one of the smallest parts of our skeleton and rather unimportant - a rudiment actually - because we don't wear a tail any longer. But for some it is hell, and sometimes for years. Please meet os coccygis, the tailbone. In the old anatomists tradition of naming parts according to similarities in nature, coccyx comes from Greek 'kokkoux' (cuckoo), as the human tailbone resembles the shape of a cuckoo's beak.
We learned at university the tailbone is in the way during childbirth, so with hormonal changes towards the end of pregnancy the synchondrosis between the sacrum and coccyx softens and increases mobility to enable the child's head to pass through the pelvis. We also learned that anatomically the tailbone consists of four or five bony connected rudiments of vertebrae. The tailbone in the whole is connected to the sacrum in a synchondrosis which allows flexion - extension movement, similar to a pendulum movement.
When moved passively - with the index finger on the anterior surface and the thumb on the posterior surface of the tailbone - one can feel an anterior posterior movement comparable to the joint play in real joints. As every pain in the motor system has a reason, why can the coccyx be so painful in some patients? Fractures do occur and can be very painful, especially when the fracture parts are dislocated. The fracture is an acute pain problem. The fracture finally heals, but the fracture of the coccyx seldom occurs. Why do we then have this chronic pain problem?
Nociceptors Site of Pain
The structures which hurt are those which carry nociceptors. When the tension in the muscle, tendon or joint capsule becomes too high the nociceptors start firing and the signal is pain. Too high a level of tension in the motor system is synonymous with pain.
In some cases there is a clear-cut, decades-old history. In patients with chronic pain in the tailbone area we find as good as ever a direct injury such as a kick or a fall during childhood, eg, when some pulled the chair away just as the person was sitting down. Trampoline springers who hit the bar know how painful this is. Most horse riders who fall off a horse fall onto their back or pelvis, but some may have the impact direct to the tailbone. An x-ray in these cases normally shows no fracture. The insidious dysfunction to the sacrococcygeal synchondrosis which may result from the impact does not ';heal'. It can persist over years. It does not ';grow out' from childhood to adulthood as a mal-aligned fracture does. The body adjusts to the dysfunction by accepting a protective posture and protective movements but the tense soft tissue structures remain and with it remains the pain. Anatomically, levator ani muscle right or left plays a key role and so can anococcygeal ligament, sacro-tuberal ligament and sacrospinal ligament, as well as gluteus maximus muscle.
During the FIMM Conference in Brisbane last year a specialist for manual medicine, Dr. Leo van Deursen, spoke about ';homo sedens' in our century, meaning ';the seated man'. He said we sit from 38 years to 72 years. But patients with a chronic dysfunction in the tailbone cannot sit. Driving a car for any length of time may be hell. They cannot attend a movie nor a concert.
Condition Treatable even after years
The positive part of the pathology of dysfunction is that it remains a treatable condition even after years. What type of treatment is available after so many years of suffering?
In his book about the healthy and the diseased vertebral column, Junghann, described in 1968 that injections with Novocaine can give good results. He also injected the anterior aspect of the tailbone.
When the tailbone hurt and was considered of no use anyway, it was sometimes cut out. The results were seldom good and mostly as disappointing as in other areas with similar conditions, such as the calcaneal spur. The structure which was too tense, the soft tissue, was irritated additionally by scar tissue, remaining tense and often more painful. [but see note at end]
The only book I found in my library which dedicated more than a page to the tailbone was Manipulative Therapy in the Rehabilitation of the Motor System by Professor Karel Lewit. He describes in 1979 the manipulation/mobilisation of the sacrococcygeal synchondrosis per rectum, with consequent relaxation of the whole area.
Professor Hans Tilscher from Vienna, in his book about infiltration therapy, describes meticulously, the technique of injecting lignocaine in M gluteus maximus, M levator ani and M coccygeus (a part of the sacro-tuberal ligament). The patient lies prone with the heels extremely rotated to relax the big pelvis muscles. Even those without a musculoskeletal education can carry out this infiltration therapy. Tilscher describes that the local anesthetic not only has a local effect but also influences the autonomous nervous system, increasing circulation locally and decreasing tension locally. This therapy applied repeatedly may have the same relaxation effect as manipulation.
Myofascial Release Another Option
I myself have done this and the manipulation effectively for 25 years. Recently we learned a new relaxation technique, myofascial release, from a teacher of manual medicine, Professor Johannes Fossgreen of Denmark (see New Zealand Doctor 24th June 1998 and 22nd July 1998). I tried it on five patients who all relaxed nicely without the painful injection technique and the painful (rectal) manipulation. This is a good result but observation with many more cases is necessary.
Note: In his letter giving me permission to reproduce his article, Dr Franzmayr added: 'I discussed with Mr Howie from Auckland my article and it appeared that his results from surgery are far better than we had approximately 20 years ago in Europe.' [Dr Howie is the surgeon who operated on Debra Hopkins]