Journal of the American Chiropractic Association
Susan St Claire, DC, DACBN, CCN
Professor at Palmer College of Chiropractic, West.
Chiropractic Philosophy & Clinical Technique
Internal coccyx adjustments are sometimes recommended for patients with coccygodynia (coccygeal pain) thought to be of mechanical origin that has not resolved with other treatment - whether chiropractic, physical therapy, or drugs - and before considering surgical removal of the coccyx.
Pain in the coccyx is the indication for internal adjustments, especially if external adjusting has not been successful in alleviating the patient's complaint. Most commonly, the patient presents with "tailbone" pain after some type of fall or after vaginal childbirth. The pain may be recent or longstanding. The pain is worse with sitting, and, in women, it may be worse just before and during menses. Occasionally, bowel movements may aggravate the pain.
Endometriosis, pelvic tumors, fractures, and cancer can cause coccyx pain; none of these conditions warrant internal or any other type of coccygeal adjustment. Although some doctors of chiropractic adjust in some cases of coccygeal fractures, this is not recommended.
Prior to the Adjustment
1. Be sure internal adjustments are within your scope of practice.
2. Review x-rays of the coccyx area.
3. Explain to the patient what you are going to do. A spine model or an anatomy book is useful to show the exact structures you will be contacting.
4. Explain the purpose of the adjustment. The most common purpose is to check for and realign structures, remove inflammation, and stretch and massage ligaments.
5. Get a signed informed consent (see p. 40 for sample). Have the patient initial each item and both of you sign and date the form. I keep a copy in the patient's file and give the patient a copy. A witnessed signature would be even better.
6. Have the patient evacuate bowels and bladder just before the adjustment.
I find that patients often have preconceived and fearful notions about internal adjustments. The most common questions are addressed on the informed consent form, but ask the patient if he or she has additional questions. I reassure the patient that the procedure is normally not painful and that he or she may interrupt it at any time. I continue to converse with the patient the entire time both for the purpose of gathering information and to distract the patient's mind from the procedure.
Have a gown or drape available, at least one surgical glove, KY jelly, and tissue.
Both male and female patients should disrobe from the waist down and wear a gown. Have the patient in a comfortable side-lying position with knees flexed, pillow under the head, and the back toward the doctor. Additional draping can be used, if desired. Tell the patient what you are going to do just before you do it.
Sit on a low stool at the side of the patient near the buttocks, facing toward the patient's head. Move the gown just enough to see the buttock area. Glove the hand closest to the patient since this will be the internal contact hand. Add KY jelly to the longest gloved finger. Touch the patient near the anus and then gently insert the longest finger into the anus. Slowly and gently follow the normal contours of the rectum until the finger touches the coccyx. (Fig. 1) Never do a coccyx adjustment with a vaginal contact.
Gently palpate all the structures as far as your finger reaches. These structures will include the coccyx, lower sacrum, lower SI joints, the sacrotuberous and sacrospinalis ligaments, and their attachments. After checking the entire area, you will know where there is tenderness, swelling, asymmetry of the structures, tautness of the ligaments, and deviation of the sacrum. Ask the patient to report any areas of pain and change the pressure so that the adjustment is comfortable. I do not recommend a thrust maneuver although some DCs do so. Instead, the contact on the coccyx should be a continuous, firm pull in the direction of correction.
In most cases, the coccyx has deviated toward the anterior, so pull firmly posterior (Fig. 2). If it has also deviated right or left, pull into the correction - with counter pressure applied externally by the outside hand. (Fig. 3) Then, massage across the anterior face of the coccyx and sacrum to improve circulation. This is especially beneficial if you suspect "bruising" of the periosteum after childbirth. Next, do a transverse friction massage along the ligaments on one side up to the sacroiliac joint. There is commonly one ligament that is taut and tender due to sacral deviation, with swelling at the SI joint on the same side. The swelling is palpable and tender when present. Do the same with the opposite ligament and sacroiliac joint. I recommend repeating the entire adjustment for a total of three times while increasing the pressure slightly each time within the comfort level for you and the patient. Your finger and hand will get tired and may ache, so protect yourself from strain. Never induce pain in the patient. The entire procedure takes about 10 minutes.
Offer the patient tissues and access to a bathroom after the procedure. The insertion of a finger into the anus will induce peristalsis, so fecal material will move into the area. Unless the patient has incontinence or current diarrhea, this should not be a problem, but the sensation is unpleasant for the patient.
I find that one visit a week for four weeks is adequate for an initial trial. If the patient shows improvement, additional visits can be scheduled at one-week intervals. If there is no improvement, do not continue. In my experience, this procedure either causes improvement, or it does not work at all. I find no advantage in doing the procedure more often than once a week. When the patient shows improvement, I sometimes suggest a break of a couple weeks to see if the "adjustment" holds. We can then gauge the frequency of visits accordingly.