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Coccydynia Pain in the vicinity of the coccygeal bone Associated Symptoms • Dyspareunia • Dyschezia • Dysmenorrhea Causes • Trauma from a vertical blow • Difficult vaginal delivery Pathologic features • Dislocated sacrococcygeal fracture • Ligamentous damage • Most cases the tip of the coccyx is subluxed or hypermobile Anatomy • Fibrous sacrococcygeal joint connects the sacrum to the one to four bone segments of the coccyx • Joint is reinforced by sacrococcygeal ligaments which encloses the s5 nerve root • S4,5 make the coccygeal plexus Anatomy • Levator ani and coccygeal muscles attach to and support the coccyx during childbirth and defecation • Gluteus maximus also attaches to the lateral coccyx Anatomy Prevalence • 5x greater in women • Female coccyx is more posterior in location and larger • 3x more frequent in obese women, maybe be related to the decrease pelvic rotation during sitting Symptoms • Pain • Dull and achy • Sensation of pressure • Increased pain with prolong sitting or sitting on hard surfaces Levator ani syndrome and proctalgia fugax are variants of coccydynia What is levator ani syndrome? Levator Ani Syndrome • Dull ache or pressure senation in the rectum • Worse during the day • Tenderness on palpation Pelvic Floor Muscles – Tension Myalgia Proctalgia Fugax Proctalgia Fugax • Sudden onset of anal pain that last a few minutes or seconds • Spastic muscle contractions of the pelvic floor muscles • Five times per year or more Physical exam • • • • • Tender over the coccyx Pelvic symmetry LE neuro exam Rectal exam Check lymph nodes Functional limitations • Driving • Avoid social situations • Equestrian • Sexual X-rays • Subluxation and fx Physiatric Prescription • Pain control measures? Pain relief • • • • Ice Warm sitz baths Ultrasound Galvanic stim Pain relief • Soft sitting surfaces – donut holes? • Pelvic floor relaxation exercises • Pelvic floor massage • Massage • Injections What is Thiele’s massage? Thieles Massage What is sacral sitting? Posture • Sitting Sacral Sitting Sacral Flexion Motion • Anti-lordotic exercises – Williams exercises • Hip extensor strengthening What is Williams Exercises? Williams Exercises Alignment/Adjustment – Muscle Energy • • • • Sacral Flexion Sacral extension Sacro iliac Unilateral or Bilateral Pelvic floor and gluteal relaxation Other measures • Botox • Prolotherapy • Surgery Activity modification • No prolong sitting • No sitting on hard surfaces
