Article in Dynamic Chiropractic, reproduced here by permission of the author
Marc Heller, DC
(This was the last in a series of articles about the spine)
We'll finish our tour of the spine and dura with the most caudal segment, the coccyx. The coccyx is key for a number of reasons. One, its often injured, especially in falls on the buttock. Two, it's the last attachment of the dura mater and the filum terminale. The coccyx can subluxate secondary to the dural pull on it. This can occur suddenly in a whiplash injury, or gradually when a disc problem irritates the dura. Releasing the coccyx can make a profound difference in dural tension, affecting discogenic pain or other chronic spinal tension patterns.
When the coccyx is under stress, whether from a fall or just from an accumulation of factors, it usually seems to be stuck primarily forward. An exception to this is a posterior coccyx post-pregnancy. We'll emphasize correction of an anterior coccyx in this article.. The anterior positioning is rather inconvenient for the chiropractor, as this makes it more difficult to access. It can simultaneously be pulled to either the right or the left, and this will reflect itself in increased tension on the sacro-tuberous ligament. The coccyx can also be jammed superiorly, creating a compression at the sacro-coccygeal joint.
I could give multiple case histories of patients I have helped by correcting the coccyx. They basically fall into two categories. One is someone who fell on his or her tailbone, and has suffered with coccygeal pain since, sometimes for weeks, sometimes for years. The second type of case is the patient with lower back pain who is not responding to my work on their sacro-iliac, disc, lumbar segments and/or muscles. Correcting a subluxed coccyx often makes a dramatic difference in their spinal pattern, helping both their symptoms and allowing them to stabilize and correct.
Assessment of Coccyx
How can we assess the tailbone? You will miss most coccygeal problems if you strictly palpate down to the sacro-coccygeal junction. You need to reach the tip of the coccyx. The best method I know is to have the patient sitting, with the doctor behind and to the side. I have the patient loosen their pants, and I palpate between their pants and their underwear. Thong underwear makes the area impossible to feel, so I'll wear a glove and reach under the thong underwear. Reach under the tailbone, and have the patient lean forward. As they lean forward, you slide your index or middle finger further forward until you reach the anterior tip of the tailbone, and then have the patient sit upright slowly, which will bring the tip of the tailbone down onto your hand. If the inferior tip of the coccyx doesn't come into your hand, pull gently posterior and superior with your finger to find this structure. You'll notice that most men have a short stubby coccyx, while most women have a longer coccyx that goes further anterior. Sometimes it is difficult to reach the most anterior part of the coccyx with your finger. Note that the coccyx has multiple segments, but we will treat it as if it is one single bone.
Obviously, you need to tell the patient what you intend to do. The coccyx is a difficult and sensitive area to get to, being at the very bottom of the buttock. Be clear, explain with a model if you need to, and get clear permission for your palpation and correction.
You are looking for tenderness and restriction. When the tailbone is a problem, it will usually be sharply tender. Test with gentle palpation for restriction in the a-p direction and assess the lateral to medial direction on both sides. Tenderness and restriction will usually both be found together.
External Coccyx Correction
How do we correct the coccyx? I'll outline external techniques first. Some techniques emphasize releasing the sacro-coccygeal junction with a posterior to anterior adjustment, hoping that this will bring the coccyx itself further posterior. I have not found this particularly effective. I prefer to directly pull the tip of the coccyx further posterior, simultaneously addressing superior jamming and right or left lateral bending. . In order to do this I have to get to the front of the coccyx. This can usually be done either in the sitting position, as outlined in the palpation method above, or in a prone or side-lying method.
With any patient position, there are two basic techniques I will use. The main technique I'll use is ELF, engage listen follow. Engage the beginning of the barrier by bringing the coccyx posterior, left or right and inferior if needed. We always fine tune, the subluxation is never purely linear, find the exact 3D direction of the barrier. You'll feel the coccyx and the associated soft tissues soften and release over 10-60 seconds. If the area is not releasing, you are probably pressing too hard, going to the hard end of the barrier. You just need to back off a bit to allow the patient's body to begin the correction.
Another useful tool for a coccyx that is not releasing easily is post isometric contraction. Having the patient hold a very gentle pelvic floor contraction after you have engaged the coccyx to its initial barrier can help the whole area release. Repeat 3-5 times having the patient maintain the gentle contraction for 3-5 seconds. In the relaxation phase, you are taking the coccyx further into the receding barrier. A recoil adjustment also enhances the release when the area feels stuck. In recoil (Engage-Release) you engage the barrier, and then suddenly release your pressure. This can be made more effective by using respiration, either at the end of inspiration, or at the point in the respiratory cycle where the tension suddenly builds. Note that this is quite different than toggle-recoil.
Internal Coccyx Correction
I always start with some variation on the above external techniques. If they are successful, and the tenderness and restriction does not recur, great! If the area remains tender after one or two treatments, I may suggest an internal correction to the patient, explaining this some detail. I mention that I will be using a lubricated gloved finger to contact the coccyx through the rectum. I tell them that it is uncomfortable, but not usually painful. I tell them that I will have an assistant in the room.
Trying to explain this technique with strictly the printed word is not ideal. Practice with a colleague or spouse, until you are comfortable with the basic procedure. Next, do it, when clinically indicated, on a patient with whom you have a good trusting relationship. You really don't want to be fumbling around with a new patient in this sensitive area. I am aware that this procedure may not be legal in some states. I recognize that doing an internal coccygeal correction may carry increased liability risk. I am also very clear that my duty as a chiropractor is to correct whatever structures need manual correction in the whole neuro-musculo-skeletal axis. If this requires me to work internally on the tailbone, I will do this. I want to have perfect clarity, confidence, and have clearly explained the procedure to the patient, and gotten their clear consent. Document that you did a PARQ (Procedures, Alternative, Risks, Questions) conference with the patient. A signed written consent form is ideal.
Many of your patients will have experienced physical or sexual abuse as children, and may have issues with touch to sensitive areas. I try to be aware of this, and when I ask permission to work on a sensitive area, I am attempting to assess their response. I want the patient to maintain eye contact with me, and give me a clear YES, a clear permission. If the patient dissociates in any manner, by closing their eyes, looking away, or not stating a clear permission, I am very hesitant to proceed.
How do we do the internal correction? We start with having the patient draped, and lying on either their side or prone with a pillow under their belly. To initiate the entrance into the rectum one must be aware that there are 2 anal sphincters. Ask the patient to contract the anus. As they do so, you will apply a slight pressure to the external anal sphincter (EAS) then ask them to relax. As they relax, enter the EAS with a well-lubricated gloved finger. Repeat the contract and relax several times to get past both sphincters (internal is softer and wider). Another way to do this is sidelying. Enter the rectum with the patient having pulled their legs up into a fetal position, have them straighten their legs for the correction.
Once I find the coccyx, I am palpating, and asking the patient where the coccyx is tender. I note the tender places, and begin my low force Engage, Listen, Follow manipulation as described above. I can use my other methods, including recoil and post-isometric relaxation, in concert with the ELF. I can also use the other hand or the thumb of my active hand on the external surface. I am engaging the coccyx externally while the internal finger listens and assists. I have the coccyx sandwiched between my two contacts, which improves my palpatory sense. This enhances the correction, especially if I need to pull the coccyx inferiorly to correct superior compression. I always keep both contacts gentle. I need only mild pressure to make the correction.
Once I've corrected the basic restriction of the coccyx in the a-p and lateral to medial directions, I'll assess and correct two other potential lesions. The first type is a tender spot anywhere on the anterior surface of the coccyx or sacrum, wherever I can reach. If I find a tender spot, which will feel stiffer, I again use ELF, more as a myofascial release, to release the tension in the fascia on the anterior surface of the sacrum. The second possible correction is for myofascial tensions at the origin of the piriformis. The piriformis originates from the lower anterior surface of the lateral aspect of the sacrum. It is usually within reach. I find the tender spots within this, and use ELF as a myofascial release. I only want to make this invasive correction once, so I try to correct every dysfunction I find on the anterior surface of the coccyx and sacrum.
Once I've completed the corrective procedures, I reassess for tenderness. I remove my finger slowly, asking the patient to contract the pelvic floor again. This prevents them from feeling like they are having a bowel movement.
The whole internal procedure takes me between one and four minutes. I always make this the last major procedure I do on the patient on the office visit. I may finish with a balancing of the sacrum's cranio-sacral motion, following it inherent motion. This calms the nervous system, and integrates the sacrum and coccyx with the whole of the spine.
This internal coccygeal correction is one of the most powerful and effective procedures in my toolbox, and I use it with respect. If the problem is acute, from a recent trauma, it may respond in one to two adjustments. The average case takes four to six treatments. More complex cases, that involve the pelvis and lumbar spine as well, may take even more sessions.
Marc Heller, DC
References and Resources
Special thanks to Surya Bolom, DC, Mark Thomas, DC, and Ramona Horton, PT for feedback on this article
Barral, Jean Pierre, Visceral Manipulation, 1989, Eastland Press
Barral, Jean Pierre, Urogenital Manipulation, 1993, Eastland Press,
Urogenital Manipulation course, October 2000, St. Etienne, France, taught by Jean Pierre Barral
Note to people suffering from coccyx pain
Training for this type of work is quite variable. I would suggest that you call around to various practitioners, including chiropractors and physical therapists. If you find someone who does know how to do internal corrections of the coccyx, they should have done at least 10 of these before you allow them to touch you. I wish I could direct people suffering from this further, but its very hard to know how to find a practitioner for these procedures.