Pain on direct coccyx area pressure: coccydynia or nerves? What to do?

[Frankie913]

In January 2017 a condition that I hypothesised to be coccydynia spontaneously occurred.
**The key symptom is that if I sit on a hard surface such as the floor putting direct pressure on the coccyx area, it is very painful.**

Also, sitting in a firm chair in such a way as to put direct pressure on the coccyx area also makes it sore, though the more padding in the chair makes it sore more slowly and less sore. Sitting leaning forward, putting my weight on upper hamstrings, is always fine. Laying on a hard surface such as the floor on my back or side is not a problem either, as there is only acute pain when I sit on the floor at like a 45 degree angle which puts the pressure directly onto the tailbone.

In February 2017 I went to see my regular physiotherapist who is a back specialist. He began a treatment program of pressing on the left and then right sides of the coccyx. His pressing hard with his thumb into the side of tailbone was excruciatingly painful at the moment, but not lasting pain—I felt fine when he was done. The degree of soreness on the right side went down, and he concluded after say 6 sessions in total that there was nothing else he could do for me. He was amazed that the condition hadn’t arisen from a fall on my coccyx, but he did say to me it seemed like coccydynia. I emphasise that it was idiopathic origin, and not caused by acute trauma such as a fall.

However, eleven months later, the coccyx has not recovered fully, and still gets sore in those situations. Though some would say it is only a mild condition at this time, and does not interrupt my functioning, except I am careful to avoid sitting in a way that puts pressure on the coccyx, I am getting tired of this chronic problem and sought a fresh perspective on diagnosis and treatment.
Last week I visited another physiotherapist. His evaluation is that actually the coccyx is well-seated and is fine. His diagnosis, based on pressing on my left and right SI Joints, is that the left SI Joint is springy and normal, but the right SI Joint is rigid (and tender to me). Therefore he concluded that my butt pain problem originates from right SI Joint pressure on the ano-coccygeal nerve He also thought there was likely to be neural sensitivity or neural over-reaction after all these months of tenderness in that area. He started me on a program of SI Joint mobilisation exercises: Bridge-up (glute bridge) from laying on my back, and also prone Single Knee to Chest. However, still no relief yet.


Yet, I already do pelvic mobilisation exercises such as rocking, squats, hip hinging, bird dog, and ASLR (active straight leg raise)—if I can do all that, with no soreness, why don’t I have a healthy pelvis?
Any advice on diagnosis and treatment? Also, I’m not even sure who to see for advice? The problem doesn’t seem serious enough to see a medical doctor. I can’t find a physiotherapist listing coccydynia as a special interest, nor can I find a pelvic specialist physiotherapist in my area.

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[Frankie913]

Update. I have read about a nerve condition, "pudendal neuralgia", which can be one sided, and my tenderness was a bit one sided, but mine doesn't feel like I would think nerve pain feels (i.e., electric, wired). Instead, my pain feels like tenderness in broad area of the coccyx, and not just a "point of pain". Also from the book "Tailbone Pain Relief Now!" by Dr Patrick Foye is mentioned dynamic instability of the tailbone verterbra, but I'm usually generally described as rigid and tight, not loose. My personal training progam is focused on improved movement, as a result of my result of my score on the Functional Movement Screen. It also doesn't feel like arthritic pain, another type of tailpone pain the Dr Foye. In sum, it feels like bone ache from soreness and tenderness, and I can't see a clear fit to the conditions mentioned in Dr Foye's book. But then again, I may be overfocused on the pain spot, and the pain may be caused by problems elsewhere (e.g., nerves). In sum, the thing that stands out is that this is chronic for almost a year now, and is not healed by a general fitness program and general good health.

[physiobob]

HI Frankie, thanks for your post.

Reading between the lines your issue seems like hypersensitivity to the coccyx region. i.e. nothing wrong with the coccyx itself nor the joint between it and the pelvic bones. I would say it is mostly caused by prolonged sitting on a hard or narrow surface, perhaps in combination with generalised, age related, degenerative joint changes. My wife for example suffered from this for over a year simple due to sitting on the same saddle chair for several years that fixed her lumbar position for hours on end. Eventually connective tissue became 'annoyed' and sensitivity arose.

The important thing to take on board here is that episodes insidious onset coccygeal pains are a long time in the making (much like many many shoulder impingement issues) and they only become painful at the end. So reversing it also takes a loooong time. And you and your therapist need to look for the source of the provocation, likely to be a chair or perhaps a car seat if you drive a lot. If your chair has a tilting seat section you could look to modifying the seat angle just a few degrees to see if that helps. If there is a long back on it that would allow for a lumbar support to help change the lumbopelvic position in sitting then that too could help. Ideally an assessment of your desk/chair height too if you are still working in that way.

Performing ALSR exercises is not something I would prescribe for this condition. Squats might help however deep lunges in several variations would be a lot more specific. In my experience people need some flexion in their spines (excluding people with canal stenosis) and also a lot more lumbar (low back) rotational release exercises. Instead of paying for physiotherapy I would be more inclined to take a course of at least 10 Pilates Studio based exercises in a one-to-one environment. Having access to an exercise regimen called 'Gyrotonic' would also be very useful.

Physiotherapy/Osteopathy/Chiropractic would of course be good to help release any pelvic asymmetries but those would be one or two sessions only. From there you need to get on to the whole body movement rather than pretty simple, static type exercises that you might currently be doing. Your overview looks to me some things that won't really hurt you but at the same time won't help.

Do feed back with your comments and I can add more information as required.

Best regards

PB

[Frankie913]

PB, thanks for your response!

Thank you for the new hypothesis that I wasn't aware of: hypersensitivity of the coccyx.

Thank you the explanation of the possible causality of this thing, probably by long time sitting patterns.

Thank you for addressing "prognosis", which is that this thing takes a loooong time to go away.

I've finally found a physiotherapist in my area "with 25 years of clinical experience and particular expertise in the management of hip, groin and lumbo-pelvic pain and dysfunction" (from website). I will mention to look for pelvic asymmetries. I expect there will be an overall pelvic musculoskeletal assessment and overall pelvic musculoskeletal fitness recommendations. I have to wait another six weeks before this appointment.

If I could ask one question, it would be: is there any stretch, mobilisation movement, trigger point therapy, or strengthening exercise that I could do at home as part of my fitness routine. Even if we can't be exactly sure of what will help, I'd welcome to know the types of things that often may help. If you give me a name of something, I will websearch it to get a more detailed description of how to do it. By the way, I am now doing glute trigger point therapy as part of my fitness routine, as recommended by my personal trainer, which sitting on a large trigger point ball starting with "outer, upper back pocket area" and then to middle side of glute. I am finding significant tension in these glute areas.

Frankie

[physiobob]

Hi again Frankie

I would have suggested the same exercise/release actually, perhaps with a foam roller too as it is a little less aggressive and could be used in addition to the ball version. Also a simple stability exercise while you are there. Often it is the opposite (to the painful side) buttock area that needs the release. You might find some sort of 'plough' based yoga exercise to strengthen the abdominals and hip flexors in an eccentric fashion might help too. A pilates studio or gyrotonic exercise class would address those in depth. However as a general comment an online assessment and comment is somewhat limited as the physical examination and observation in the clinic is important. So I am just providing some ideas to investigate.

regards

PB