Coccyx pain - Lig. sacrotuberous?

Background;
- 25y male, no earlier problems at all, highly active on sports.-- Paraglider accident 1y ago. Coccyx pain starting not long after that.
- Accident included; compression fracture T12, L1, L2 and burst fracture L4. Surgery; Posterior lumbar interbody fusion using pedicle screws, collectors. L4-root compression on the right side - included hip-rotators (out/in) - trendelenburg gait and drop-foot.
- Now; Osteosyntesis-metal was removed 5w ago. Almost back-pain free.
- He has little or no sign of the paresis (but strength is not full for none of the affected muscle-groups). Tendency of m. tibialis posterior cramps (functional pes planus with valgus).
- Coccyx pain is still persisting 1y after the accident and that's bothering him most (the pain lowered the first 2 months, stable since then - aggrevated by prolonged sitting (and standing).

Treatment given;
- Initally (1y ago); specific stabilizing exercises for the back and hip, hydrotherapy, training of the dorsal-flectors of the foot. Home-exercises and advices - specially on stability, and balance - terrain-walking and more. Stretching of the hamstring muscle group and hip flexors were not done - as the flexibility has increased as the stability of the back and hip was increased.

- The coccyx pain still persisting. The pain is purely localized on the 2nd coccyx bone (counting up) and over to the start of the sacrotuberous lig (left side - opposite to the paresis).

- Initially I thought the pain was due to strain on the sacrotuberous lig. because of either malalignment (the fixated L3-L5) or because the L4 paresis of the right side. Now to paresis is almost gone - and the pain's still there. Have tried deep stretching the sacrotuberous lig. and tried deep frictions of the ligament. Have not tried coccyx manipulation.

Also tried 1 month of not sitting at all (used diary and more), less pain that month, but it came back afterwards.

....

So? ... Suggestions? tips? any good explanations?

...

Best regards,
Øystein, Norway

Hi!

Good post - good luck!

Form Closure questions:
What is the status of his pelvis - SIJ, pubic symphysis, L5/S1, etc. Does he have alignement issues / aysmmetry of his sacrum or innominates? Did he fall onto his coccyx / ILA of sacrum causing a shear of the sacrum?

Force Closure / Motor Control Questions:
How are his core stabilisers? Are his posterior pelvic floor stronger than anteriorly? is his coccygeous muscle overactive? Is he a "butt-gripper"? Does he have good lumbo-pelvic / thorax dissociation? Is there fascial / soft tissue imbalance? Also, what is the current status of his hamstrings? How are his load-transfer tests (ASLR +/- compression at ASIS, Pub Symph, PSIS, Ish Tub)?

It sounds like a nasty accident so I would be checking the above - only since you did not mention them...

The sacrotuberous ligament has attachments to biceps femoris - and sometimes the hamstrings don't even attach to the Ischial Tuberosity but go to the STL. It is continuous with the dorsal long ligament up to the iliolumbar ligament, whose main function is holding L5 onto the sacral base. Coccygeous is often overactive and can also be causing the pain. Just some thoughts...

Again, good luck!

Antony

Aha - you didn't include the headaches in this section of your post (which is interesting).

The headaches and tension could also be related to dural tension since there are fascial connections from the sacrum all the way up to the brain.

The back pain and headaches could be related...

Detailed is good, thanks.

I only have 2 min. before I gotta go, but I'll write more later.

You are absolutely right about the neural tension - He is facing radiating pain down his left leg when sitting for a long time (30 min++, especially on couch or other soft chair etc). I don't know much about this neural tension thing - But would be glad if someone could brighten me up (post links etc?) - I was wondering about buying "The sensitive nervous system". How could one soften tension-problems like this one then?

One more thing; There was a loose bit of L4 torn into his spinal chord. It was pushed back as good as possible during surgery. I have seen the x-ray pictures from the day of accident, 3 month later and 6 months post-trauma. The dislocated bit of L4 seems to have been "reabsorbed" and at 6 months x-ray postop the L4 is slightly more anterior than L3 and L5. The radiating pain down his feet was most evident 2-4 mths post-trauma, and now only at stressful days sitting more than 30 min.

The coccyx pain seems pretty local as it is palpable in the sacrotuberous lig. and on the coccyx. Wierd thing: Pressing anterior on the coccygeal vertebraes gives no pain. Pressing anterior and inferior (down) gives no pain. Pressing anterior and superior arouses pain. Could this be due to sitting (and then sliding slowly downward - pulling the skin upward?)... The pain is clearly associated with tension to the soft-tissue as I can see it.

By the way; both SI-joints seems non-painfull, have normal joint-play. Pubic-joint too.

I will write more.

(sorry for writing clumsy english and not knowing the english words for all anatomy etc).

/øystein, Norway.

Much to be concerned about here. A mid line disc bulge at the thoraco-lumbar region and several segments below can cause coccygeal pain. Any post-op imaging to evaluate canal, discs - such as Ct or MRI?
Check the lateral allignment of the ischial tuberosity on both sides in relationto the midline gluteal crease. Check the ischia with respect to A-P, P-A relationships. Also test mobility with medial to lateral, lateral to medial at ischial tuberosity, P-A just above the ischial tuberosity on the ishium (bilaterally). If positive, contact me via my e-mail. There are 4 unilateral pattern that could be at work here, but invariably both sides require treatment. You will not find these described in the literature, someday I will publish.
The coccyx needs to be evaluated mechaically for forward/backward motion dysfunction and side-bending also.
It is relevant to palpate the sacrotuberous ligament. Open your palms fully so that thumbs are nearly 90 degrees away from digits. Bring thumb tips and tips of index fingers together so that they form a triangle. Place the tip of index fingers on the coccyx and the thumbs should then be on the creaes on top of the thighs. The index fingers then lie on top of the sacrotuberous ligaments. Now with tip of thumbs push into the ligament, you willhave to depress the gluteal fat ans muscle several centimeters. You can strum the ligament like aguitar string or simply depress it - just like taking up the slack and performing a mobility test at a joint. Compare the tone side to side. Asymmetry of tone coupled with bony palption and passive mobility testing should be informative, and can guide treatment.
Itwould be worthwhile to read up on Dr Maigne who has some excellent work on thoracolumbar junction mobility dysfunction. More often than not T12-L1 are in hyperextension and a foam roller placed below it with progressive flexion to isolate force at the junction is helpful, say for at least 5 minutes. Becreative, there areseveral ways to accomplish this. More details upon request.
Sitting on rolled towelsinfrontof the ischial tuberosities will unweigh the coccyx, helpful if it is suffering from sitting compression. Mulligan has a sitting wedge, though I was making these in 1983 (Albuquerque, New Mexico, USA), just never did market properly. Best Regards Jerry Hesch, MHS, PT [email protected]

Wow! Sounds like a nasty accident!

I specialize in pelvic PT, and have seen many with coccyx pain. This typically begins after a fall on to the buttocks, and if he didn't sustain this in the accident he may previously have and this accident was the final straw. Be sure to check his pelvic symmetry (inominant rotations, sacral rotations, etc). I don't advise mobilizing for this, as you don't want to gain movement but instead want to gain symmetry. Therefore the best is repositioning techniques (muscle energy techniques). Also, a good stabilization program is imperative here that incorporates the pelvic floor, transversus abdominis, and eventually the gluts. Another forerunner to check is pelvic floor tension (if the patient is open to this, as it will have to be rectally) and especially hypertonicity of the obturator internus (which is an external exam). Release of this muscle (the obturator) is a must. I would recommend more of a "John Barnes" style for release versus the typical stroking massage. I follow this with high volt stim to the coccyx area (with four leads, bifurcation of two if necessary depending upon your unit) or NMES at 80 pps, 300-400 volts (for reduction of spasm--research backed for internal pelvic floor stim but I find it equally effective for obturator spasm) and moist heat (may use ice if more relief with it, but typically heat does the trick although everyone is different). A warm Sitz bath is advised for home management with use of donut pillow (inflatable) if the patient can purchase one.

My patients typically have instant relief (or symptom decrease) with the obturator release.

Good Luck and keep us all posted!


aletta

Hi
Great discussion - veery informative and knowledgeable. I agree that a spinal MRI should be undertaken, including Tx & Cx - to exclude other areas of potential compression. The neural tensioning is the biggest hint - I agree that a slump or tilt in sitting could be aggravating symptoms. Thoracic spine is a likely area to look for neural compromise.

What are the erector spinae muscles like? If unevenly tensioned, a subtle apparent leg shortening can occur with a hitched pelvis. The muscle tensioning this can cause will impact pelvic sitting dynamics. Assess by using a measuring tape on bony prominences, in supine.

Try low level provocation tests to determine whether neural tethering may be at play here. Tethering can occur a considerable distance from the demonstrated symptoms, and can occur above and below eg headache and sacral pain.

Try erector spinae stretches, dural stretching etc.Trigger point dry needling is effective if muscles will not relax sufficiently - will not assist if tethering has occurred within the spinal canal.

Just a few extra thoughts to throw into the mix.Good luck - sounds like you have done welll so far, and the other posts should be helpful.
MrPhysio

Here is some poor x-rays to look at. I have ordered the CT scans and will probably get them this evening, and probably post some of it after downsizing some of it for inet usage.

http://larsen.cd/oystein/normal_image3.jpg

There are a lot of good ideas and tips here, some more relevant than others, and again some are unusable as I don't understand all abbreviations and the english used.

Regarding neural tension:
- Neural radiating diffuse pain after prolonged sitting and stressful days. Somedays even a little burning pain in the skin over m. tib. ant. on left leg (not the leg with most paresis).
- Slump test; gives no pain, but neural tension. Hamstring tension is a little variable - (Straight legs then fingers to floor distance is 10 - 20 cm). Sitting like doing slump test ("potato-bag" - thoracic flexion) and then flexing neck gives discomfort in upper cervical, and at about Th5-6 and also a little pain about L3-4.
- Paravertebral muscles in thoracic spine (also cervicothoracic junction) are frequently tensioned with a numb feeling in the skin (during stressful days and in running on higher speeds) mobilisation is then useful.

Regarding Coccyx:
- After a more thorough/detailed palpation of the coccyx I find the following: Seems to be aligned equally from the tuber ischii. But: The ligaments on the right side of the coccyx are by far more firm than on the left side. After palpating some minutes the local pain disappear in the sacrotuberous lig., but applying pressure to the tip of coccyx is still painful. Could the sacrotuberous lig. be sprained? .. what about injections, could this be helpful? prolotherapy? ..
- Aletta; could you explain how to release the m. obturatorius internus? ... and also "john barnes" technique in brief?

Regarding muscle length of erector spina:
- Can not find any special signs of differences between the sides.
- But; quadratus lumborum is constantly under tension. And trying to let go of the quadratus (sitting on one tuber ischii, then lowering the other) on the left side gives immediate pain deep in the muscle (QL), but seems to be referred from the spine (low L5-S1..). Trying the same on the right side does not elicit pain.

Gotta go..

/øystein

Whoops, a lot of writing errors..

To release the obturator, have the patient in sidelying (I would recommend right sidelying as it is easier to get to the lower side for me, but you will probably need to release both sides). With the patient in right sidelying, keep the right leg straight (in neutral) and flex the left hip and knee to 90 degrees and rest on a pillow in front of patient. Now, you'll have to palpate the length of the coccyx, and place your hand (fingers extended, using the tips of digits 2-5 to apply pressure) between the most inferior prominent portion of the coccyx and the anal opening. If the muscle is severely spasmed, it may be hard to tell the difference between the bone and tissue. So, to verify, ask your patient to roll his right knee and press into the mat (external rotation) and you should feel the contraction (or an increased hardness). Move to where the contraction is, again between the coccyx and anus. To help in your biomechanics and safety, keep you elbow/wrist/hand in a straight line, angling down at 45 degrees in relation to the mat or table your patient is on. Then, apply pressure to the muscle. This is what I mentioned as being a "Barnes style" but I know it is not exclusive to him. The main thing is to not do any "stroking" massage here. So, apply sustained, direct pressure, and wait for the muscle to release (time, not pressure or frequency of stroking, is the factor here). You will feel the muscle release (like sticking your hand through jell-o). This can take anywhere from 2-10 minutes, so don't worry if it seems too long, it's probably not, just focus on how the muscle feels. Once you have released this side, repeat on the left. Have the patient remain in right sidelying, and resist external rotation done by your hand at his knee. Once you find the left muscle, sit and drop your elbow to the mat, so this time your arm is angling up from the mat, at 45 degrees.

Sometimes pelvic floor tension can be felt externally when doing this release (once the obturator is relaxed) and a little closer to the anus. I find that this can be felt and released a little externally, but is not as efficient or beneficial as an internal release. However, a hypertonic obturator does not guarantee a hypertonic pelvic floor, so I'll keep my fingers crossed for this guy.

Of course, you will want to wear gloves when doing this.

It seems from everything you have written that so musch has been ruled out. That is typically the case with this. In fact, I have a new client who, as I found out today, has had all these tests and they of course were negative. I know his injuries are extensive, but he also has an ideal mechanism for coccygodynia. Have you found any information specific to this condition? I don't believe there is much unless you have attended or study courses specific to the pelvic floor. Internet is limited on this and discusses surgical removal of the coccyx (not recommended, usually ends up causing more problems).

Please keep me posted! Good luck with this and let me know how the release goes!

Also, I wanted to let you know that my coccyx patients with hypertonic obturator have radiating pain to ant tib, which is also usually decreased after the muscle release. I have one patient now who can determine the state of her obturator by this symptom, and now she is able to gain full relief of the ant tib pain when I release the obturator. Interesting sidenote!

Plus, Sitting increases the pain associated with coccygodynia, so his symptoms will likely increase with sitting (part of the reason it is prudent to rule out discal origins of pain). Stress can increase the pain too. We all know, that patients can manifest their stress in specific areas (i.e. chronic cervical or lumbar pain patients have increased pain in these areas when they increase their stress). Pelvic patients are not exclusive of this. These patients are unaware of tightening and of the spasms of their pelvic muscles, and it becomes almost natural for them to tighten during increased stress levels. Believe me, I see it all the time and it is one of the hardest changes to facilitate, as itis behavoiral.

OK- I think I have now written everything I wanted!

aletta

Sounds like you should consider direct coccyx mobilsation? Don that rubber glove... 8o

Cocyx pain can come form a dic bulge-large midline at any lumbar segment, maybe higher. The sacrum and cocys do respond to forces going through the ilium, the SI joint and especially (underscore this one) the symphysis pubis. I would never just treat the cocyx without screening all else. Wish I could help, my apporach to this region is much more thorough than I can express in this paragraph.
[email protected]
regards
jerry hesch mhs pt
the hesch method