Michael Durtnall - email@example.com
See also personal experiences of patients treated by Michael Durtnall
Original posting, 2003-03-16:
As a chiropractor practising for twenty years in central London I have treated well over a hundred cases of coccygeal pain - many due to dislocation after a fall or during pregnancy or as referred pain from sacro-iliac or lumbo-sacral disc or facet joint lesions. I have been successful in every case to resolve all symptoms of pain and disability using manipulation treatment aimed at restoring function to joints which are locked or dislocated/subluxated whilst reducing mobility in hypermobile (loose or unstable) joints by core stability exercises and postural rehabilitation. Specifically, careful and skilled coccygeal manipulation is a crucial factor for good results.
Most of the above cases were of relatively recent onset - up to twelve weeks - and most responded rapidly to treatment. Since my listing on www.coccyx.org I have treated very many more people who have suffered coccyx pain of much longer duration (up to thirty years) and who have, in many cases, had multiple cortisone injections (up to fifteen injections in one case). I have reviewed these cases and have concluded that approximately 70% of these patients reported improvement of 75-100% in symptoms.
I suspect that cortisone injections damage the coccygeal joint cartilage thus accelerating calcification and fusion of the joint and thereby minimising any chance of regaining normal pain-free joint function, particularly when repeated many times. Of course it will usually reduce the pain temporarily but without having regained any improvement in joint mobility and or position. So, the longer the delay in manipulative treatment after onset of pain or injury and the more cortisone injections tend to make the condition more difficult to treat effectively.
Many patients bring their x-rays and MRI scans from referring GPs which is very helpful - but in several cases the MRI scans missed the lower sacrum and coccygeal joints completely. Many patients have been prescribed anti-depressants. Many patients have not had any examination of the actual area of pain.
In summary, when coccyx pain is of long duration and if coccygeal joints are completely fused, especially in extension (bent backwards) and more particularly if the person is thin (lacking padding), then the chances of improvement are reduced dramatically. In these cases the last option is surgical removal. But - here's a possibility - buttock implants for thin patients - it is performed for cosmetic reasons, so why not to reduce agonising pressure on a prominent, fused coccyx?
I have been consulted by email by many patients, osteopaths, physiotherapists and chiropractors from all over the world via www.coccyx.org and have done my best to explain treatment and techniques. I am certainly still learning and I only wish I could have helped more of those suffering this painful and demoralising condition.
Over the last two years I have been seeing a higher proportion of overweight, very sedentary, typically 'IT'/computer patients in their 30's to 60's with extended (bent backwards) and calcifying or osteoarthritic sacro-coccygeal joints. There has typically been no significant history of traumatic injury.
This is clearly shown on standing lateral coccyx x-rays which are VERY closely collimated (angled, narrowed down and lead shielded) to ABSOLUTELY MINIMISE the area of the x-ray and avoid pelvic organs, especially testes and ovaries. Of course even these x-rays are not taken if there is any chance of pregnancy.
Most patients had been refused x-ray or MRI evaluation in NHS hospitals from all parts of the UK where standard x-rays ( without extreme collimation) of the entire pelvis would have had to routinely be taken.
I have concluded that most of these cases have been caused by long-term leaning back and slumping in bad car, office, and home seating at the computer or TV which, with the pelvis slid-forward against the leading edge of what Homer Simpson calls 'an arsegroove', over time, produces a depression in the middle of the seat cushioning with a frontal ridge against which the coccyx is pressed backwards, gradually over months and years, into extension.
The higher the person's BMI (BODY MASS INDEX) or more overweight they are, the greater this pressure on the coccyx.
I treat but also IMPORTANTLY help my patients to ensure their employer gets them a Swedish HAG Credo or HO4 chair WITH neckrest... (these chairs are fantastic but expensive)... which allows the chair to recline RIGHT BACK at a dramatic angle with a supporting neckrest for surfing the net, phoning and talking , BUT can then tilt far forward with the feet tucked under the chair & thighs tilted down at 25 degrees & 'back straight' to work on the keyboard... which takes all pressure off the coccyx and gives good working posture with no neck strain! I love them...all my clinic staff and family have had them over the last 20 years. Find a HAG chair supplier and try them out as I have described.
When these coccydynia patients have been previously assessed or treated medically, in my opinion, they have generally been misdiagnosed with the assumption that it is the more distal, flexed and supposedly hypermobile coccygeal joints which are the cause of the chronic and often extreme pain.
Mobilisation at the correct level, patient exercises which I have developed, medical acupuncture to acutely focus the healing process and correct seating brings good and rapid resolution in most cases. Acupuncture around the joint is designed to OVERWHELM the relevant brain area linked to the chronic coccyx pain and which has typically become hypersensitive and which is easily triggered by emotional upset and stress and which potentiates the onset and perception of acute pain.
There are some cases when it is too late and where the joint cannot be mobilised sufficiently to improve symptoms.
I have received many more requests for help and advice from coccydynia sufferers, osteopaths, physiotherapists doctors and chiropractors from all over the world thanks to www.coccyx.org and have done my best to liase,train and explain my evolving treatment techniques and protocols.
This research and continuing re-evaluation of treatment protocols has been extremely useful in improving results in patient pain reduction and improved function in my practice. I have been heartened by positive reports via email from chiropractors and therapists around the world who are learning from my experience.
My advice is :-
In April 2007 we installed and have seen the benefit of using the new Fuji Computed Digital x-ray system at Sayer Clinic, Kensington for very high quality x-ray imaging of the spine, pelvic and coccyx joints. We can now manipulate and magnify the images and more precisely show the coccyx sufferer the position and condition of the joints, make a clearer diagnosis and better explain the likely timescale for improvement of symptoms.
I have been seeing more sedentary, computer/IT patients suffering coccyx pain than ever and usually with associated postural problems affecting the whole spine.
More and more patients from all over the world are flying in to see me in London UK for a course of treatment.
Since my last update I have focused on and and attended courses on pelvic pain in Europe and London and I am now a listed specialist at 'International Pelvic Pain Society and included in Tatler's 'Britain's 250 Best Private Doctors'.
In the last two years, in addition to increasing numbers of people from all parts of the UK and world with coccydynia, coccyx fractures, dislocations, arthrosis, coccygeus muscle spasm & fibrosis, I have successfully diagnosed and treated many difficult cases of referred pelvic pain:
'Pudendal Nerve Entrapment (PNE)' and pelvic neuralgia, where nerves become compressed or inflamed near the ischium or "sitting bones" area of the pelvis with referred pain into the perineum, abdomen and buttocks. Many patients had pain on sitting, usually one-sided with burning, numbness and parasthesia in the pelvis near the sacrum and coccyx which can radiate to the perineum, vulva, inner thighs, lower abdomen and groins.
Misalignment or fixation of the sacroiliac joints, pubic symphysis, spine or coccyx was often causative or a perpetuating factor and was treated using manipulation, myofascial connective tissue techniques, acupuncture and exercises to reduce nerve compression, muscle spasm and inflammation. I have also treated many cases of 'abdominal wall myofascial pain' seen often after caesarian section.
My chiropractic colleagues Robert Griffiths and Chris Berlingieri are also very experienced in coccyx treatment and our computed digital x-ray system has proved really invaluable to patients with its close-detail, x-ray imaging of the spine, pelvic and coccyx joints.
My real and increasing concern is the number of coccyx and pelvic pain patients I see who are "out of it" on a cocktail of painkillers and NSAIDs, muscle relaxants and Pregabalin (Lyrica) from pain clinics. Because of these drugs they feel woozy and tired, cant work and their social life and interests disappear . Many lie around and become obese, fibromyalgic and depressed. Then antidepressants and stronger Morphine-based painkillers are prescribed ensuring that most will never work again ( 95% of people off work for 12 months will never work again!)
Rather than long waits for pain clinics and orthopaedic referrals for cortisone injections, these sufferers need to ask their GPs to refer and ideally fund them quickly to specialised chiropractors, osteopaths and physical therapists to properly diagnose and to help maintain them at work with physical treatment, ergonomic advice and exercises. This way, most patients will do well while the few needing surgery could be referred on quickly to experienced coccyx surgeons.
I was elected 'Fellow of the Royal Society of Medicine' in 2010 and I am now studying for an MSc in Performing Arts Medicine at University College London Medical School. Whilst studying part-time at UCL, I plan to write research papers for medical journal publication on coccyx pain utilising our large collection of digital computed x-ray images of coccyx injuries at Sayer Clinics.
I attended the unique and brilliant course on ''Pelvic Pain and Dysfunction'' with Dr Rhonda Kotarinos at St Georges Hospital, London in September 2011. Rhonda is the leading expert in physical therapy treatment of pelvic floor dysfunction and urogynaelogical pathology and teaches practical, hands-on techniques to help patients suffering acute and chronic pelvic pain syndromes. Her evaluation procedure assessed external myofascial tissues in the abdomen, legs, low back, pelvis and buttocks in accordance with current research findings which confirm a correlation between these external tissues and pelvic floor dysfunction and pelvic pain. Rhonda's coursework focussed on assessment of the health and function of abdominal and pelvic floor muscles with pelvic examination and treatment using physical myofascial tissue manipulation and acupuncture to resolve dysfunction and pain.
More patients with referred pelvic floor and vulvar pain related to coccyx and sacro-iliac dysfunction travel to us for treatment from around the globe and achieve symptomatic success and resolution of dysfunction at Sayer Clinics: Kensington.
We successfully treat ever increasing numbers of coccyx pain sufferers who act on the message not to delay so many months and years before making the simple step to independently obtain a proper diagnosis, logical physical treatment, freedom from pain and renewed happiness.
I will present a whole-day Workshop to 60 consultants on Coccyx, Sacroiliac, Pelvic Pain Diagnosis & Treatment at the Eighth Interdisciplinary World Congress on Low Back & Pelvic Pain, to be held in Dubai, on November 2nd 2013. This unique conference is held every three years around the globe. Previously held in Los Angeles in 2010 and Barcelona in 2007.
I am still working full-time, treating coccyx and pelvic pain patients as well as all the more usual problems such as back pain and neck pain at Kensington W8. I also plan to conduct further research into sacroiliac and coccyx joint treatment.
For the first time I will be practising a short clinic in the City at our beautiful new practice, after its first 25 years at Broadgate EC2, now recently reopened at 80, Coleman Street, EC2 near to Moorgate, Bank and Liverpool Street stations.
I have just completed my Masters in Performing Arts Medicine - specialist treatment of musicians and dancers and research thesis - MSc at University College London - UCL.
I have accepted the offer of a 7 year MPhil / PhD place at UCL Institute of Orthopaedics & Musculoskeletal Science, Stanmore RNOH , working with the Institute of Child health (ICH), Great Ormond Street Hospital from December 2013 to research stimulation and equalisation of long-bone growth in children with leg-length-difference before cessation of growth to minimise compensatory scoliosis progression of Adolescent Idiopathic Scoliosis.
Outlook on research: Using the system that I have just perfected during my MSc research I will accurately measure the leg-length of growing children with LASER & Ultrasound, which avoids use of x-rays. My future research plans will involve (monthly) measurements of children's leg-lengths using this safe and accurate US/LASER to assess while actively accelerating and equalising growth in length of lower-limb long-bones of the significantly shorter leg by physical measures before cessation of growth. Current surgical shortening by stapling the long-bone growth plate of the longer leg or lengthening the shorter leg by Ilizarov apparatus (painful, risk of side effects and injury) or Dr Paley internal methods (effective but extremely high cost). PhD Supervisors: Professor Gordon Blunn - Director: Institute of Orthopaedics & Musculoskeletal Science, UCL, Mr Andreas Roposch FRCS - Paediatric Orthopaedic Surgeon and Epidemiologist, UCL, Professor Sandra Shefelbine - Department of Mechanical & Industrial Engineering, North Eastern University, Boston, USA.
The main change in the last year and a half has been the increasing proportion of pelvic pain patients from the UK, Europe and further afield who visit for treatment from all over the world. We have seen so many people in such agony and misery who have suffered for so long with coccyx and pelvic pain, so over-medicated that they have become bed-bound, depressed, muscle-wasted, miserable and lost! But we get them back to health!!!
We get even better results now with our expanded team of brilliant Masters pelvic pain Physical Therapists who treat our patients with such caring, thoughtful, gifted, hands-on bodywork and precise internal trigger-point and myo-fascial stretch therapy for pudendal neuralgia, female pelvic pain and coccygeal pain treatment.
I plan to follow up the Dubai Conference by giving further Coccyx and Pelvic pain workshops and lectures at various conferances and the World Congress on Low Back and Pelvic Pain in Singapore 2016. This year I was elected a Fellow of the Royal College of Chiropractors in addition to my Fellowship of the Royal Society of Medicine and I am now a Master of Science (MSc) in Performing Arts Medicine from UCL. A number of potential patients email to ask if I still treat patients due to my now 7 years of research at University College London (UCL), but to clarify, I still practise full-time, in addition to the part-time UCL research. I gave up alcohol, newspapers and TV for the last few years to allow time to do it all.
Our patients continue to fall into four clear groups:
But the UNIVERSAL problem is that everybody who has Coccyx dislocation or pain SITS TO ONE SIDE on chairs, sofas and in the car which creates constant pressure on the muscles on that side of the coccyx which become unilaterally or one-sidedly fibrotic, painful and highly pain-sensitive with perpetual 'coccyx-guarding spasm'. This gradually results in 'Pudendal Nerve Entrapment (PNE)' and pelvic neuralgia, where the nerves become compressed or inflamed near the ischium or "sitting bones" with numbness or altered sensation and pain via the nerve branches which supply the rectum, the pelvic floor, the vulva and vagina, the clitoris, inner thigh and the lower abdomen. We also treat many male patients who complain of pain or deep ache referred to testicles and penis which relates clearly to their coccyx pain but which rapidly resolves with specific manipulation of the sacrococcygeal and sacroiliac joints.
Sayer Clinics 'Pelvic Pain Teams' of chiropractors, osteopaths, acupuncturists and Physical Therapists are highly regarded by our patients as our unique knowledge and ability with efficient diagnosis, effective treatment and intelligent advice has become even more successful.
On 8th and 9th July 2016 I presented my neuromusculoskeletal coccyx and pelvic pain rationale and techniques over two days in beautiful Paris at the world's first Coccyx Symposium organised by Dr Jean-Yves Maigne and Professor Levon Doursounian.
It was wonderful to finally meet, discuss and exchange ideas with world experts practising many different approaches to coccyx and pelvic pain.
I spoke as specialist in coccyx and pelvic manipulation, physical therapy and intense exercise rehabilitation. My clear message was the need to regain pain-free pelvic and coccyx function while absolutely avoiding drugs which block healing.
I was pleased that Dr Maigne and many of the doctors, specialists and surgeons saw their approaches as the 'last resort' and concluded that an effective, drug-free, minimal-intervention manual approach should be the first choice. The reality is that there are so few experienced hands-on coccyx and pelvic manipulators in the world.
Jon Miles was the star of the Paris gathering for his eloquent presentations on the history of coccydynia and on his experience of dealing with chronic coccydynia. Jon's unstinting work via his coccyx.org website for fellow coccyx sufferers is the pivotal point which facilitated this exciting global Coccyx Symposium in Paris.
In the last year Sayer Clinics Coccyx and Pelvic Pain team of physical therapists, acupuncturists, osteopaths and chiropractors has confirmed our position as global leaders treating sufferers who travel from around the world for extended treatment stays finally to resolve their neuromusculoskeletal coccyx and pelvic pain conditions.
As always the message is don't delay in seeking active, manual treatment. Tailbone pain suffered for several years is much harder and takes longer to cure and rehabilitate than tailbone pain of weeks' or months' duration which is usually straightforward for us to treat.
Since my last update 3 years ago in 2016 my daily clinical focus is on diagnosing and treating patients suffering coccyx pain and dysfunction, sitting-related pudendal neuralgia and musculoskeletal pelvic pain with over half my patients travelling from abroad for a few days and returning at intervals, with good results.
In 2017 I completed the required 42 modules and was awarded the FIFA diploma in Football Medicine.
I was invited to lecture at the 2nd Symposium on Coccyx and Pelvic Pain Disorders, in Dordrecht, Holland in June 2018 on my manual treatment protocols for Coccyx pain, Pudendal Neuralgia and pelvic pain which are very closely interlinked in many cases.
I really loved meeting and sharing ideas with old colleagues as well as excellent, highly-trained and like-minded Dutch pelvic physiotherapists and felt for the first time that I had finally found my 'family' of practitioners. I lectured on complex coccyx and pelvic pain connections and how to manually treat them, as I had learned hands-on from the gurus of pelvic pain; Drs' Amy Stein, Rhonda Kotarinos and Stephanie Prendergast. My presentation was well received and referred to as 'inspirational' by the Physical Therapists I so admire.
I have been consulted by many more patients with coccyx dislocation after childbirth, particularly with Ventouse. I was approached by a major London hospital to advise on why there are increasing numbers of coccyx fractures and dislocations during forceps and Ventouse-assisted childbirth. My advice and the solution lay in improving operators poor Ventouse technique relative to sacral and coccyx anatomy with use of less force and the correct angle of traction at different stages.
Squatting Childbirth is safer, quicker, less injurious with the 'mother in-control'. Childbirth is more challenging in the 21st Century because women are generally far older at childbirth than during the 1960s, 70's and 80's and more overweight and less physically fit, with stiffer joints and ligaments.
In hospital, expectant mothers are not generally enabled to squat, kneel or move around (which is central to natural childbirth) due to the 'stranded beetle' supine position required for monitoring in medically-controlling childbirth. Watch any TV programme about childbirth and we see a woman lying on her back with painful, slow, completely medicalised labour which increasingly ends in exhaustion and too frequently a Caesarian section or forceps, ventouse or episiotomy with varying degrees of trauma to mother and child.
The problem with lying on your back or sitting semi-reclined on your sacrum and tailbone is that the birth canal opening, the pelvic outlet, is reduced by as much as 30%. We, Homo sapiens, uniquely have very large-brained offspring relative to size of pelvic outlet compared to all other primates. Overlapping of the cranial bones at the fontanelles helps but without gravity, reclining means 'nothing to push against'. Modern women at childbirth in their late thirties are often physically disconnected, weak and unfit, overweight, can't push, find labour psychologically stressful and are quickly exhausted. Maximising the pelvic pathway for the baby's birth is just common sense. There is no good, practical medical reason for giving birth on your back - and every reason to give birth in a safer position that works with gravity, female anatomy and physiology.
Supported squatting or kneeling on all fours gives the pubis, sacroiliac joints and sacro-coccygeal joints freedom to stretch apart under the influence of the hormone relaxin and lets the unrestricted coccyx move backwards as the baby passes through the birth canal. This always happened with all mammals - except for women in the last 200 years in the 'civilised' western world since Emperor Louis XIV decided on supine childbirth for his courtiers to witness the birth of his heir, and it has been the fashion since.
Lying on your back narrows the birthing canal and increases the risk to the baby of:
and increased risk for the mother of:
A healthy flexible tailbone should extend backwards as the baby's head descends. Forceps or ventouse during childbirth can cause backwards dislocation of the coccyx, with extreme ongoing pain after the birth until manipulated by an experienced expert in joint manipulation back to a normal range of movement.
My study and experience of sacroiliac movement in squatting childbirth lead me to the following logical mechanism:
The mother's body weight acts down through the hip joints which in tandem with the loosening of the sacroiliac and pubic symphysis ligaments, act to flare the lower pelvic outlet. As delivery nears, the mother squats lower with her legs wider apart until the large thigh adductor muscles strongly stretch apart the symphysis pubis. Simultaneously the inferior sacrum glides posteriorally relative to the ilia under the pressure of the engaged foetal head bearing constantly down with gravity and maternal contractions. This further increases the outlet, the cervix dilates fully and effectively delivers the baby's head. The whole process of hormonal release and cervical dilatation is complex and finely tuned with body movement, gravity and soft-tissue stretching.
This delicate process is disrupted by lying supine with an epidural, often followed by injection of syntocinon to kick-start contractions which are slow (due to supine position) against a cervix which hasn't yet dilated sufficiently, causing increased intrauterine pressure, resulting in maternal exhaustion, foetal hypoxia and distress, leading to emergency Caesarian with increased risk of post-surgical infection. This is often followed by mastitis and then antibiotics. This disastrous cascade of intervention limits the exhausted mother's ability to bond with and breast-feed her baby. This is all considered normal in the West and, progressively, most countries now follow the medical practice of supine childbirth.
It is NOT normal and needs a total rethink based on tens of thousands of years of upright, squatting childbirth. Midwives need to be well-trained and confident in natural childbirth with the necessary back-up of modern emergency medicine.
I have long been fascinated by the genetically/geographically-related range of connective issue laxity and joint mobility in my patients from all over the world over four decades of clinical practice and I recently studied at University College London with Professor Rodney Grahame, the world expert on hypermobility. Collagenous ligaments, tendons and joints lose flexibility progressively with age which accords with my experience in treating pregnant women suffering sacroiliac subluxations, coccyx dislocation and fracture after forceps and ventouse births. It is also clear that mothers at childbirth are much older now than ever before in the history of womankind. 21st century older mothers in their late 30's and early 40's are less flexible and their sacroiliac, pubic and coccygeal range of movement is significantly reduced in comparison with mothers in their teens and early twenties which had always been the norm through millennia until the 1960's. The big change followed the advent in the late 60's of 'The Pill', widely available contraception, which gave women the freedom and the opportunity to delay starting a family and to enjoy a career. Many women who are sedentary at desk jobs with administrative computer and office work from school and college days until first maternity in their mid-to-late 30s and are often unfit, overweight and stiff jointed.
Add to this the comparatively recently concept of giving birth semi-reclining or supine and there you have the reason for a continuing rise in rates of Caesarian section, c. 30% of UK births, especially in more hypomobile Northern Europeans.
However, most of the world's people: Indian, Arab, African and Chinese, are at the more flexible or hypermobile end of the spectrum of tissue and joint mobility and many in rural areas give birth squatting. Northern European caucasians, celts, Germans, Scandinavians as well as peoples from mountainous regions like Northern Pakistan and Japan are ranged generally towards the less flexible or hypomobile end of the spectrum ... making childbirth, particularly in now much older mothers, far more challenging. All the more reason to encourage squatting for safer, quicker, less injurious 'mother in-control' childbirth with freedom to constantly move upright with gravity helping move the baby safely through the birth canal.
In 2018 I was listed as a specialist with The pelvic Partnership to treat women suffering pelvic girdle pain (PGP) who experience ongoing pain for months or years after their baby is born.
PGP is simply and swiftly treatable with expert manual therapy and many women with PGP are not diagnosed, or referred for treatment. The Pelvic Partnership offers support and information to women via their website at https://pelvicpartnership.org.uk/
I have recently invested in a new, super-advanced digital x-ray system which is extremely high-definition and low-dose specifically for pelvic and coccyx patients' standing and sitting x-rays. I now also use diagnostic Doppler Ultrasound for muscle, ligament, tendon and soft tissue examination and diagnosis.
I have completed the research for my 7 year (part-time) PhD in long-bone growth in children, leg-length-difference and scoliosis and I am writing-up prior to my final viva examination in 2020.
Michael Durtnall DC, Dip Roent, MSc, FRSM, FRCC
Chairman : Sayer Clinics, www.sayerclinics.com, email to firstname.lastname@example.org