See also personal experiences of injections and needles
This is the standard first treatment once it has been established that the coccyx is the source of the pain. The injections of corticosteriod (cortisone or a related anti-inflammatory drug) are similar to those given to treat tennis elbow. Most people find that the injection makes the pain worse for a week or so, and it may take up to two weeks for a real benefit to be felt. The relief from pain may or may not be complete and permanent. The injections can be repeated, though different doctors advise differently: some will not give more than 2 or 3, some will give a 10 or more, spread over months or years. I heard from one woman who has had more than 50 injections over 9 years, and is continuing to have them every 3 months as they work very well for her. Her anesthesiologist sees no problem with this so long as they are effective.
If these injections do give some relief, even if it is partial and temporary, it is regarded as a good sign that surgery is likely to be effective.
An important point to note is one made by Dr Maigne, who showed that half of people with coccyx pain have a coccyx which dislocates or moves outside the normal range of movement when the patient sits down. He says that if the injection treatment is successful, 'The abnormal mobility, if present, remains, but ceases to be painful.' So this treatment is not curing the original cause of the pain, but relieving the reaction to the original cause.
There are three versions of this treatment that I have come across. The first is the simplest, and may be carried out in the doctor's surgery, but it is less effective than the other two versions.
The drug injected is normally referred to as 'cortisone' or 'corticosteroid'. A corticosteroid that lasts for several weeks, such as methylprednisolone (trade names Depo-Medrone and Solumedrol), is used. A local anesthetic is injected at the same time to reduce the pain from bruising and allow you to get home and lie down. One patient, bj, said that her anesthetologist gave her Aristocort because 'it is the drug of choice for that interjoint area'. Aristocort (generic drug name triamcinolone) is a corticosteroid which reduces swelling and decreases your body's immune response. He also gave Marcaine, a local anesthetic, for short-term relief. But she was better off with a previous anesthetologist, who gave injections of Aristocort with Solumedrol. She said: 'The Solumedrol keeps you from being so sore after the injections (you know that time where you feel like someone has kicked you in the butt for about a week or two.) That mixture really works well.' According to a medical web site, methylprednisolone is administered to patients with spinal cord injuries to attempt to decrease the extent of injury.
Dr Clemens Franzmayr, author of Therapies successful on pain in coccygeal area, says: 'I don't inject corticosteroids, but I use a local anesthetic (Lignocaine 1%), and carry this out repeatedly up to five times. It has been proven worldwide that injections of local anesthetic to trigger points, or dry needling, have the same results as cortisone injections, but have practically no side effects.'
A ligament repair treatment called prolotherapy or sclerotherapy has been used for coccydynia. It involves injecting an irritant solution (which may just be a glucose solution) into the ligaments and the ligament/bone interface, and it is claimed that the inflammation that this causes results in shorter and stronger ligaments. On the face of it, this would seem to be particularly suitable for cases of coccydynia caused by damaged ligaments. But this method is generally frowned on by the medical establishment, who say that it is not a proven method.
Seven people who have had this treatment have contacted me, and two had bad experiences. One said that the treatment had left her in a wheelchair for 6 weeks, and the other said it had set her back 9 months. Three others found that it significantly reduced the pain, Two who did not post their stories, and one being Ron's personal experience. The other two patients found no significant improvement. One said "the first 2 injections looked promising ... certainly my ligaments are not as lax now ... but the coccyx pain is still there and I still can't sit down".
A paper by Polsdorfer gives an account of the successful treatment by prolotherapy of two people whose coccyx pain was not cured by other treatments. A more detailed trial of prolotherapy using dextrose by Khan et al found that 30 out of 37 patients received good pain relief using this method, the other 7 being no worse than when they started. Note that the patients selected for the trial did not include any whose coccyx pain was the result of trauma or subluxation (dislocation) of the coccyx. Dr Khan has told me that he has found that prolotherapy was less successful in cases of coccyx pain caused by trauma.
The doctors who advocate this treatment say that it is important that it is carried out by someone who is properly trained. So if you do decide to go for this, make sure you ask the doctor what training he or she has had, how may people he or she has treated with prolotherapy and how successful it was. Also note that one patient pointed out that the purpose of the treatment is to create irritation, so it is important to avoid painkillers that reduce inflammation while undergoing prolotherapy. If you have had this treatment, please let me know what the outcome was.
'Dry needling' means that a needle is inserted, but nothing is injected.
Acupuncture
Acupuncture is based on traditional Chinese practice. Needles are inserted into the body at specific points, not generally the places where the pain is. While they are in place the needles may be rotated or connected to a low current electrical supply. It has been suggested that acupuncture may stimulate the body's production of endorphins (natural pain-killers), or that one stimulation of the nervous system can block signals in another pathway. Most people who have written to me who have tried this have found that any relief of pain is only partial and temporary.
Intramuscular stimulation (IMS)
This is a treatment for chronic pain involves the insertion of thin acupuncture type needles into muscles at the site of the pain, which the practitioners say are supersensitive and shortened. At first this is uncomfortable, then the muscle relaxes. The treatment is used for various types of pain including back pain and the pain caused by loss of an arm or leg. An average of 8 treatments are given at weekly intervals. The doctors, osteopaths, etc who give this treatment report that it is often effective with long-standing pain. No trials of the treatment for any type of pain have been published in a medical journal, so far as I can discover, but a trial has been published on the internet, Dry-Needling of Muscle Motor Points for Chronic Low-Back Pain. A clinical trial has started at Addenbrookes Hospital, Cambridge, UK. More details on IMS at the Intramuscular Stimulation site and the GEMT site.
Mesotherapy is a method to treat pain invented in France, involving many small injections. The injections are made just under the skin with short needles or an electronic injector. Injections of small amounts of medicines are made local to the site of the pain. There are many practitioners in France - see Geraldine's story (in French). A practitioner in Portugal has been recommended by a Fausto. In the USA, mesotherapy has been adopted mainly as a cosmetic treatment, supposedly destroying fat cells.
In my opinion, the way the four different needle treatments discussed above work is very poorly understood, and more research is needed in this area. That is not to say that they don't work, but the explanations given for how they work are contradictory. If we understood properly how they worked, then maybe we could decide which treatment is best, find better treatments, or avoid ones with unpleasant side effects. All of these treatments involve sticking a needle into the painful area, but different liquids or no liquid at all is injected, and all claim to reduce pain afterwards. And there is a treatment for low back pain by injecting botulinum toxin, which has been shown to be effective. Maybe I should add that to the list.
Corticosteroids are supposed to work by damping down the inflammatory response of the body to damage. The reasoning behind Prolotherapy is exactly the opposite: it is intended to cause damage and cause an inflammatory response, in the belief that this will lead the body to repair the original injury. Putting needles into the painful area, if it is done as Intramuscular Stimulation, is claimed to relax supersenstive, shortened muscles, though how sticking a needle into the muscles is supposed to relax them is not clear. Dry needling of muscle motor points seems to have a similar reasoning behind it, so far as I can make out.
So a lot of similar treatments have very different explanations. Do they really work by the same mechanism?
There is some evidence that damage to tissues is at least part of the story. Doctors have been treating ligament injuries like tennis elbow (which is thought to be similar to many cases of coccydynia) using high intensity focused ultrasound, similar to a treatment that is given to break up kidney stones. This causes damage to tissues. The doctors say that perhaps damaging the tissue causes new blood vessels to form, promoting healing. This is a different explanation from that put forward for Prolotherapy, though in both cases the object of the treatment is to cause damage, which is then thought, by some mechanism, to produce a change in the tissue leading to a reduction in pain.
The fact that several of these treatments appear to cause damage to tissue raises the question of whether the corticosteroid injections work because they cause damage, instead of , or perhaps as well as, because of the drug that they use. It would be very helpful to know that, because doctors don't like to give too many corticosteroid injections. If injections of glucose, local anesthetic, or nothing at all (dry needling) were as effective as the corticosteroid, then it would allow patients to receive more treatments without the risks of corticosteroids. What we need is a medical trial comparing these different methods, including the botulinum toxin method. And we need detailed research to understand why the treatments work.
Updated 2008-04-20