Patrick Foye, M.D.
Founder and Director of the Coccyx Pain Center (Tailbone Pain Center), www.TailboneDoctor.com
Professor at Rutgers New Jersey Medical School, United States,
Author of the book: Tailbone Pain Relief Now
Contact details for Dr Foye are on the List of doctors and specialists in the USA (New Jersey).
See a list of Dr Foye's publications on coccyx pain
Summary of Evaluation and Treatment of Coccyx Pain
DIAGNOSIS: It is important to get an accurate diagnosis for what is causing your tailbone pain.
- When I give lectures about coccyx pain at medical conferences for physicians, I stress the importance of first seeking to make an accurate diagnosis of what is causing the patient's pain in the first place... prior to doing injections, surgery, or similar treatments.
- An accurate diagnosis often becomes the basis upon which all treatments can then be based.
- Making an accurate diagnosis typically involves 3 main steps:
- Listen to the patient. Take a careful medical history.
- Perform a thoughtful physical examination. It consistently amazes me how many patients tell me that despite years of seeing physicians specifically for tailbone pain, the patient note that no prior physician actually looked at the area of the tailbone, or physically touched on the different parts of the coccyx to try to confirm where the pain was coming from.
- Personally review the imaging studies. It's important to make sure that the imaging studies of the coccyx were done properly, so that adequate views of the coccyx were included. The most important diagnostic imaging test is the sitting-versus-standing x-rays, to look for unstable joints at the coccyx (which is the most common cause of coccyx pain).
When patients travel in to see me at our Tailbone Pain Center, we typically do a thorough assessment to figure out what is causing their pain, and then we review treatment options.
TREATMENT: Dr. Foye's general considerations when treating tailbone pain
- Overview: As noted above, a crucial first step prior to treatment is to search for a specific cause for the patient's pain. Next, treatment of tailbone pain typically follows a stepwise progression, starting with the most simple approaches first, as shown in order below.
- Avoid exacerbating factors: We brainstorm with the patient regarding which activities make coccyx pain worse in most coccydynia patients and in their case specifically. Consider alternatives: for example, in their exercise program instead of doing sit-ups to strengthen their core/abdominal muscles, they could instead perform plank exercises and thus avoid putting pressure on the coccyx.
- Cushions: Most patients prefer cushions that have a "wedge" cut-out at the back. The coccyx essentially hovers over the cut-out area, instead of making contact with the chair.
- Sit-stand workstations: This can be helpful so that the patient can alternate between sitting and standing during the workday while at their desk or computer, for example.
- Modalities: a limited number of patients may find benefit from local icing at the area, although this body region is relatively inconvenient and awkward for applying such modalities while the patient is out and about, at work and such.
- Medications by mouth: There is a limited role for short-term use of medications taken by mouth to relieve pain or decrease inflammation. The problem with medications by mouth is that they can cause substantial side effects throughout the body, such as causing medical complications at the stomach, intestines, liver, kidneys, etc. Another problem with medications by mouth is that the medication is diluted out across the entire body, so that unfortunately very little of the medication taken by mouth actually makes it to the coccyx site where the patient is having their problem.
- Pelvic floor physical therapy: In the published medical literature, manipulation of the coccyx has relatively mediocre results. Still, if there is substantial muscular pain and dysfunction throughout the pelvic floor, pelvic floor physical therapy can be extremely helpful for those components of a patient's pain syndrome.
- Consider local medical interventions at the coccyx itself: By the time patients travel to see me at our Tailbone Pain Center, most people have already tried the items listed above. So, we often then move on to placing medication locally at the painful site, which is done by a small local injection.
- Coccyx steroid injection:
Ganglion Impar sympathetic nerve block:
- A type of corticosteroid that fights inflammation (an anti-inflammatory steroid) can be injected at the coccyx.
- But the most crucial step is to make sure that the physician first has ordered and reviewed the sitting-versus-standing x-rays of the coccyx, so that the physician knows specifically where at the coccyx the injection should be performed.
- It is unfortunately VERY common that patients come to see us and they have had many previous coccyx injections but none of them were at the specific location where the patient has their pain and where the imaging studies show their abnormalities.
- For accuracy and safety, ideally these injections should be performed under image guidance. Typically this is done by using fluoroscopy, so that the physician can see the anatomy of the coccyx and can direct the tip of the needle to the specific target location.
Nerve ablation injections:
Nerve ablation means that the physician is intentionally destroying or deadening the involved nerve fibers, so that they can no longer carry the pain signals.
- The "sympathetic nervous system" is best known for being responsible for the "fight or flight" response.
- Irritation of the sympathetic nervous system can cause increased pain and hypersensitivity in the involved body region.
- In many patients, the tailbone pain has been present for so long that there is increased sensitivity and increased irritability of the nerves in the region.
- Injection of local anesthetic at the ganglion Impar, either with or without steroids, can help to quiet down the nerve irritability.
- For accuracy and safety, these injections should be performed under image guidance, specifically using fluoroscopy.
- There are multiple different techniques for performing these injections. It is unfortunate that many pain management physicians are not experienced at performing these, despite multiple publications on this topic. These injections were first published by Dr. Plancarte, and more recently I have published multiple newer approaches. Which specific approach or technique is used depends on the anatomy of each individual patient, so it is important for the treating physician to be familiar with multiple ways to perform this procedure.
Regenerative medicine injections:
- It is of course important that the ablation be performed in a very specific way, to result in destruction of the target nerve fibers while sparing other nearby tissues.
- This is performed under image guidance, typically by using fluoroscopy.
- There are multiple different ways to perform ablation. Radiofrequency ablation (RFA) uses radio frequency waves to heat up or burn the nerves. The nerves can also be killed by placing certain chemicals on the nerves, which is called chemical ablation. Chemical ablation usually involves placing Phenol or alcohol onto the nerve fibers.
- This is an area of growing interest and research.
- Regenerative medicine injections are sometimes considered to be a part of "alternative" or "complementary" medicine.
- Regenerative medicine involves injecting substances such as PRP (platelet rich plasma) and/or prolotherapy.
- PRP is intended to place parts of a patient's own blood sample at the site of their musculoskeletal abnormality, in hopes of helping cause healing.
- In prolo-therapy, the "prolo" is an abbreviation for "proliferative", because the injected substance is intended to act as a local irritant, causing proliferation or increase of the patient's inflammatory response at the target site.
- So far, there have been extremely few publications regarding the use of regenerative medicine injections for coccyx pain. Further research into this topic is needed before we will have a better idea of whether regenerative medicine injections are helpful for some of the multiple different specific causes of coccyx pain.
Ongoing treatment after coccygectomy:
- Coccygectomy is surgical amputation, or removal, of the coccyx.
- Fortunately, a coccygectomy is only necessary in a small percentage of patients who have coccyx pain. I would estimate that in most people with coccyx pain it is short-lived, to the point where most never seek or need treatment from a physician. But there are still many where the pain persists. Still, for those who do have substantial ongoing pain, most patients will respond well to non-surgical treatment, if they can get appropriate medical care (including sitting-versus-standing x-rays, medication injection under fluoroscopic guidance, etc.). At our Tailbone Pain Center, we end up referring less than 5% of our patients for surgical consultation, in those instances where injections are not providing adequate relief.
- Also, of course those with cancer at the coccyx get referred for surgical removal of the cancer.
- It can be difficult for patients to find a surgeon with experience or willingness to perform this surgery.
- Problematic complications of coccygectomy include: infection at the surgical site, difficulties with wound healing at the surgical site, and prolapse or herniation of the rectum through the area where the coccyx existed prior to surgery.
- In nearly all published literature, the majority of patients who undergo coccygectomy for coccyx pain do get some relief, but most still have some degree of pain and sitting limitations, even despite having the tailbone removed.
- As noted above, most patients unfortunately still have some degree of pain and the coccyx region, even after having most or all of the coccyx removed.
- It is important to look for any new or ongoing abnormalities at the surgical site, to see if a specific cause for the ongoing pain can be found.
- Many of the same types of treatments that were reviewed above can also be considered for patients who have already undergone coccygectomy. These treatments include avoiding exacerbating factors, using cushions, trying pelvic floor physical therapy, receiving various local injections, and in some cases undergoing repeat surgery.
CLOSING SUMMARY, by Dr. Foye:
It is unfortunate that such a large majority of people suffering from tailbone pain face such substantial difficulties in obtaining helpful medical care. It is a shame that most physicians have little or no experience in evaluating or treating coccyx problems. So, patients unfortunately have substantial roadblocks in getting appropriate testing (especially obstacles in getting the sitting-versus-standing x-rays of the coccyx), which leads to a lack in any accurate or specific diagnoses being made. Next, patients face challenges getting treatments that help to relieve their pain. I have treated thousands of patients with tailbone pain over the past 20+ years. I understand that people with tailbone pain can find the condition to be exhausting and frustrating. My heart goes out to those of you suffering from this condition. Through my publications, YouTube videos, website, etc., I continue working to educate physicians and patients about coccydynia. But we have a long way to go to get the message out. I wish you well on your journey to find relief. While the summary above is not intended as medical advice, my hope is that it will provide a helpful outline for you to discuss with your in-person treating physician. Please also make use of the wealth of additional information available here on www.coccyx.org and on my website www.TailboneDoctor.com.
-- Patrick Foye, M.D.