Referred coccygodynia

It is well known that coccygodynia can arise from a lumbar disc lesion, usually as the result of extrasegmental reference.¹ Coccygodynia may also arise from irritation of lower pelvic structures (neoplasms of rectum or prostate).² The history and clinical examination can easily distinguish referred pain from a local disorder. In referred coccygodynia from a disc lesion, pain arises not only during sitting but also during lumbar movements. Coughing is also painful. Physical examination additionally shows pain during lumbar movements, and straight leg raising often increases the discomfort. However, palpation does not assist in diagnosis because local tenderness is to be expected, whichever variety of coccygodynia is present. Tumours or other causes of inflammation affecting the sacrum should be suspected if the pain is not relieved by lying down or if there is nocturnal discomfort. In case of doubt, epidural local anaesthesia can be useful.

Local coccygodynia

True coccygodynia nearly always affects women and the most common cause is traumatic. Usually, a direct contusion during a fall in the half-sitting position is responsible. Because the coccyx usually lies 2 cm above the two ischial tuberosities it can only be contused when the body is tilted backwards during a fall on the buttocks. Alternatively, in a fall onto a narrow object, the force may strike the coccyx rather than the ischial tuberosities.

In ‘idiopathic’ coccygodynia, no particular injury is noted. It has been suggested that certain anatomical variations of the coccyx predispose to repeated microtraumas, which then cause chronic irritation. A coccyx with a sharp forward angle seems to be more prone to painful stretching.³