Coccygeal pain

Fortunately coccygeal pain (coccydynia) is a rare presentation to Sports Physicians. Unfortunately, it can be one of the most difficult to treat.
Science on its treatment is a little bit haphazard and developing a treatment algorithm often comes down to clinical experience.

In my mind, I divide coccygeal pain into those with a mechanical cause for problems and those without.
There is little doubt that most cases start with a mechanical component, but his often dissipates with time, leaving a more inflammatory or chronic pain type of pattern.
The commonest cause by far is trauma and the commonest trauma by far is a fall onto the tail bone. Initial pain levels vary from mild to severe.

In the early phases of an injury, ice, the use of a ring cushion and anti inflammatories may reduce symptoms and allow healing.

Unfortunately, many patients do not seek help at his stage.

As the duration of pain progresses, compensations begin to occur in the muscles and ligaments of the pelvic floor, resulting in further and ongoing overload of the coccyx and sacrococcygeal joint.

My approach to this pain is to throw my net wide. Initally, NSAIDS for 4-6 weeks, combined with a ring cushion as much as possible and a pelvic floor physiotherapy to address muscle and ligamentous tightness can be effective.
It is quite common for the sacrotuberous and other ligaments to be tight and scarred. As you will remember, many of the pelvic floor muscles insert into these ligaments and are often then reflexly higher in tone, resulting in further unbalanced pull on the coccyx.
Teaching the patient to be aware of this pelvic floor tone is imperative in the longer term.

Should that approach not work, guided corticosteroid injection may help. These can be done to the sacrococcygeal joint or to the paracoccygeal tissues. Patients may need 2-3 of these at 6-8 week intervals and may need some neuromodulation medications to reduce pain flares in response.
Radiofrequency denervation procedures may be contemplated, but, again, literature is sparse.

Recalcitrant cases can consider surgery (coccygectomy). This is not a popular option due to the risk of nerve damage, with resultant continence issues, but as a last resort, does have a pretty good strike rate for pain relief (around 70%).