Most of us spend our day sitting and do not think about the position of our ilia, sacrum, or coccyx during the change from standing to sitting. Weight-bearing through a tripod of bilateral ischial tuberosities and a sacrum that should have normalized form closure should be easy and pain-free.

The coccyx typically has minimal weight bearing in sitting, about 10%, just like the fibula, however, it can be a major pain generator, if the biomechanics of the ilia, sacrum, and femoral head positions are not quite right. A lot of patients will state “My pain is worse with sitting” which can mean thoracic pain, low back/sacral pain, and even lower extremity radicular pain.

Scanning the literature for coccyx treatment does not always yield the best results for physical or occupational therapists. Most literature states what the medical interventions can be, and physical therapy is never at the forefront. However, as we are musculoskeletal and neuromuscular specialists, this is no different in our thinking patterns relating to coccyx pain or painful sitting.

During sitting, the coccyx has normal flexion and extension moments that will change or become dysfunctional once mechanics above and below that joint change. A simple ankle sprain from 2 years ago can result in chronic knee and sacroiliac pain that can lead to coccyx pain over time. Even the patient who has long-standing TMJ (temporomandibular joint) and cervical dysfunction, now has a thoracic rotation and your correction of their coccyx deviation cannot maintain correction.

Coccydynia and Painful Sitting is a course that provides a spark for your orthopedic mindset and encourages clinicians to evaluate the coccyx more holistically.

• What are the joints doing?
• How does it change from sitting to standing?
• Standing to sitting?
• What is the difference from sitting upright to slump activities?

Working through the basics and the obvious with failed results takes you to the next step of critical thinking within this course. How does the patient present? What seems to be lacking and how to correct them biomechanically to achieve pain-free sitting? Related coccyx musculature and nerve dysfunction can seem like the easiest to treat, but what happens when those techniques fail?

In Coccydynia and Painful Sitting, we look at the entire body, from the cranium to the feet, to determine the driver of coccyx pain and dysfunction. A better understanding of ilial motion, with accompanied spring tests (Hesch Method) normalizing spinal mechanics and lower extremity function is highlighted in this course. Internal vaginal and rectal release of pelvic floor muscles can lead to normalized coccyx muscle tension that is supported via coccyx taping.

To learn more, join Lila Abatte in her next Coccydynia remote course scheduled for July 13, 2024.

AUTHOR BIO

Lila Abbate, PT, DPT, OCS, WCS, PRPC

Lila Abbate, PT, DPT, MS, OCS, WCS, PRPC is the Director/Owner of New Dimensions Physical Therapy with locations in Roslyn, Long Island, and the Noho Section of New York City. Dr. Abbate graduated from Touro College in Dix Hills, NY with a Bachelor of Science (BS) in Health Sciences and a Master of Arts (MA) in Physical Therapy in 1997. She completed her Advanced Masters in Manual Orthopedic Physical Therapy (MS) at Touro College, Bayshore, NY in 2003 and continued to pursue her Doctor of Physical Therapy (DPT) at Touro in 2005. Dr. Abbate is a Board-Certified Specialist by the American Physical Therapy Association in Orthopedics (OCS) 2004 and Women’s Health (WCS) 2011. She obtained the Certified Pelvic Rehabilitation Practitioner (PRPC) from the Herman & Wallace Institute in 2014. She is a Diane Lee/LJ Lee, Integrated Systems Model (ISM) graduate and completed the New York series in 2012.

Dr. Abbate has been an educator for most of her physical therapy career. She has experience as a full-time faculty at Touro College, Manhattan Campus from 2002 to 2006 teaching the biomechanical approach to orthopedic dysfunction and therapeutic exercise as well as massage/soft tissue work that highlighted trigger point work, scar management, and myofascial release.

She is currently on faculty as a Lecturer at Columbia University teaching the private practice section Business & Management course (since 2016) along with the Pelvic Health elective (since 2012). She teaches nationally and internationally with the Herman & Wallace Pelvic Rehabilitation Institute teaching advanced courses of her own intellectual property: Orthopedic Assessment for the Pelvic Health Therapist, Bowel Pathology Function, Dysfunction and the Pelvic Floor, Coccydynia & Painful Sitting: Orthopedic Implications. She was a co-writer for the Pudendal Neuralgia course and teaches the Pelvic Function Series and the Pregnancy and Postpartum Rehabilitation courses. She has written two book chapters in 2016: Pelvic Pain Management by Valvoska and Healing in Urology: Clinical Guidebook to Herbal and Alternative Therapies by Chughtai.

She is a member of the American Physical Therapy Association, the National Vulvodynia Association, the American Urogynecology Association, and the International Pelvic Pain Society. Dr. Abbate is also a Senior Physical Therapy consultant for SI Bone, a sacroiliac joint instrumentation company.

Lila Abbate, PT, DPT, MS, OCS, WCS, PRPC is a Board-Certified Specialist by the American Physical Therapy Association in Orthopedics (OCS) 2004 and Women’s Health (WCS) 2011. She has obtained the Certified Pelvic Rehabilitation Practitioner (PRPC) in 2014. She is a Diane Lee/LJ Lee, Integrated Systems Model (ISM) graduate and completed the New York series in 2012. Dr. Abbate is Senior Faculty with Herman & Wallace and can be found instructing the Pelvic Floor Series as well as her own courses Coccydynia and Painful Sitting and Bowel Pathology and Function.

Pain with sitting is a common complaint that patients may present to the clinic with. While excess sitting has been shown to be detrimental to the human body, sitting is part of our everyday culture ranging from sitting at a meal, traveling in the car, or doing work at a desk. Often, physical therapists disregard the coccyx or tailbone as the possible pain generator, simply because they are fearful of assessing it, have no idea where it is, or have never learned about it being a pain generator in their education.

Coccydynia is the general term for “pain over the coccyx.” Patients with coccydynia will complain of pain with sitting or transitioning from sitting to standing. Despite the coccyx being such a small bone at the end of the spine, it serves as a large attachment site for many important structures of interest that are important in pelvic floor support and continence:¹

• Anterior Tip: Iliococcygeus and pubococcygeus, Sacrococcygeal ligament
• Lateral: Coccygeal muscles which runs parallel with the sacrospinous ligament
• Posteriorly: Fibers of gluteus maximus and sacrotuberous ligament

Along with serving as a major attachment site for the above structures it provides support for weight bearing in the seated position and provides structural support for the anus. However, the coccyx is only 10% weightbearing, so what seems to go wrong that this bone is taking the brunt of the weightbearing? Women are five times more likely to develop coccydynia than men, with the most common cause being an external trauma like a fall or an internal trauma like a difficult childbirth.^1,2 In a study of 57 women suffering from postpartum coccydynia, most deliveries that resulted in coccyx pain were from the use of instruments such as forceps delivery or vacuum-assisted delivery. A BMI over 27 and having greater than or equal to 2 vaginal deliveries resulted in a higher rate of coccyx luxation during birth. ³ Other causes of coccyx pain can be non-traumatic such as rapid weight loss leading to loss of cushioning in sitting, hypermobility or hypomobility of the sacrococcygeal joint, infections like a pilonidal cyst, or pelvic floor muscle dysfunction.¹ When assessing a patient with coccyx pain, it is also of the utmost importance to rule out red flags, as there are multiple cases cited in the literature of tumors such as retro rectal tumors or cysts being the cause of coccyx pain. These masses must be examined by a doctor to determine if they are malignant or benign and if excision is necessary. Quite often, these masses can be felt as a bulge on rectal examination.^4,5

A multidisciplinary approach including physical therapy, ergonomic adaptations, medications, injections, and, possibly, psychotherapy leads to the greatest chance of success in patients with prolonged coccyx pain.¹ Special wedge-shaped sitting cushions can provide relief for patients in sitting and help return them to their social activities during treatment. Physical therapy includes manual manipulation and internal work to the pelvic floor muscles to alleviate internal spasms and ligament pain. Intrarectal coccyx manipulation can potentially realign a dislocated sacrococcygeal joint or coccyx.¹ Unique taping methods demonstrated in video by Dr. Abbate, can be used as a follow-up to coccyx manipulation to help hold the coccyx in the new position and allow for optimal healing. Often coccyx pain patients have concomitant pathologies such as pelvic floor muscle dysfunction, sacroiliac or lumbar spine pain, and various other orthopedic findings that are beneficial to address. When conservative treatments fail, injections or a possible coccygectomy may be considered.

Luckily conservative treatment is successful in about 90% of cases.¹ Join Lila Abbate in her upcoming Coccydynia and Painful Sitting remote course on March 31st. By learning how to treat coccyx pain appropriately, you will be a key provider in solving many unresolved sitting pain cases that are not resolved with traditional orthopedic physical therapy. 

References:

1. Lirette L, Chaiban G, Tolba R, et al. Coccydynia: An overview of the anatomy, etiology, and treatment of coccyx pain. The Ochsner Journal. 2014; 14:84-87.
2. Marinko L, Pecci M. Clinical Decision Making for the Evaluation and Management of Coccydynia: 2 Case Reports. JOSPT. 2014; 44(8): 615
3. Maigne JY, Rusakiewicz F, Diouf M. Postpartum coccydynia: a case series study of 57 women. Eur J Phys Rehabil Med. 2012; 48 (3): 387-392.
4. Levine R, Qu Z, Wasvary H. Retrorectal Teratoma. A rare cause of pain in the tailbone. Indian J Surg. 2013; 75(2): 147-148.
5. Suhani K, Ali S, Aggarwal L, et al. Retrorectal cystic hamartoma: A problematic tail. J Surg Tech Case Rep. 2104; 6(2): 56-60.

Coccydynia and Painful Sitting

Course Dates: March 31, June 17, September 22, and December 10  

Price: $175
Experience Level: Intermediate
Contact Hours: 5.5

Description: Coccyx pain is a common, frustrating condition for the patient who often has difficulty sitting, one of the most important tasks necessary for daily activity. Patients who find help from a pelvic rehabilitation provider have often experienced pain near the tailbone for long periods of time, leading to chronic pain in addition to neuromusculoskeletal dysfunctions. This one-day, remote continuing education course allows the therapist to focus on this vital, sensitive area to learn and refine skills in assessment and treatment. Anatomy, pathology, and palpation skills of the coccyx region are instructed. 

This course includes a video lab on both internal and external neuromuscular taping techniques which can immediately be applied in the clinic. This course also includes a review of seating options to reduce pain. 

Fun fact: Did you know that the pelvis fans and folds just like the hand and foot?
Ischial tuberosities change position and move medial to lateral and back based on the functional task. Pelvic floor muscles length and fascial integrity and its ability to conform to demands become an important factor in treating painful sitting.

The one-day course gives you a basic anatomy review and discusses the biomechanics of sitting and the difference of quadruped and its assessment. External coccyx treatments are explained and reviewed through video format along with a discussion to assist patients in making good decisions using sitting relief pillows. You will learn 5 basic tips to know if your patient has true coccydynia or if the pain is being driven from elsewhere up or down the chain. A review of the literature and how the medical community views basic coccydynia and which medical interventions can assist patients with long-standing sitting pain.

Most people spend their days alternating between sitting and standing, changing positions constantly. How many of us take the time to think about the position of our coccyx, ilia, or sacrum? The coccyx typically is minimally weight-bearing in sitting, about 10%, just like the fibula. However, it can become a major pain generator if the biomechanics of the ilia, sacrum, and femoral head positions are not quite right.

Coccydynia and Painful Sitting is a course that can be related to all populations that physical therapists treat. A lot of patients will state “my pain is worse with sitting” which can mean thoracic pain, low back/sacral pain, and even lower extremity radicular pain.

Coccyx pain patients often have more long-standing pain conditions than other patient types. For the most part, the medical community does not know what to do with this tiny bone that causes all types of havoc with patient pain levels. Lila shares that "Sometimes treating a traumatic coccydynia patient seems so simple and I am bewildered as to why patients are suffering so long - and other times, their story is so complex that I wonder if I can truly help."

Lila Abbate discussed this in her past blog, Case Studies in Coccyx Pain. She wrote that "The longer I am a physical therapist, the more important the initial evaluation has become. Our first visit with the patient is time together that really helps me to create a treatment hypothesis. This examination helps me to put together an algorithm for treatment.

I hear their story and repeat back their sequence of events in paraphrase. Then I ask if there is any other relevant information, no matter how small or simple, that they need to tell me? Some will say, I know it sounds weird, but it all started after I twisted my ankle or hurt my shoulder (or something like that). I assure them that we have the whole rest of the visit together and they can chime in with any relevant details."

Determining the onset of coccyx pain will help you gauge the level of improvement you can expect to achieve. Coccyx literature states that patients who have had coccyx pain for 6 months or greater will have less chance for resolution of their symptoms. However, none of the literature includes true osteopathic physical therapy treatment, so I am very biased and feel that this statement is untrue."

The remote course Coccydynia and Painful Sitting is very orthopedically-based which takes Lila Abbate's love of manual, osteopathic treatment and combines it with the women’s health internal treatment aspects so that practitioners are able to move more quickly to get patients back on the path to improved function and recovery. The course looks at patients from a holistic approach from the top of their heads down to their feet. In taking on this topic, the course hones basic observation skills, using some of Lila's favorite tools: the Hesch Method, the Integrated Systems Model, and traditional osteopathic and mobilization approaches.

This course is designed to spark your orthopedic mindset, encouraging the clinician to evaluate the coccyx more holistically.

• What are the joints doing?
• How does it change from sitting to standing? Standing to sitting?
• What is the difference from sitting upright to slump activities?

Working through the basics and the obvious with failed results takes practitioners to the next step of critical thinking about how the patient presents, what seems to be lacking, and how to correct them biomechanically to achieve pain-free sitting?

This remote course provides 5.5 contact hours and the registration fee is $175. The 2022 scheduled course dates are:

• April 9
• June 5
• October 16
• December 3

Practitioners who have taken Sacroiliac Joint Current Concepts, Bowel Pathology, Sacral Nerve Manual Assessment and Treatment, Yoga for Pelvic Pain, or Ramona Horton's Mobilization of the Myofascial System courses may be interested in attending this course.

Lila Abbate PT, DPT, OCS, WCS, PRPC is the creator and instructor of Bowel Pathology, Function, & Dysfunction and Coccydynia and Painful Sitting. She also co-wrote the course Pudendal Neuralgia and Nerve Entrapment with fellow H&W faculty member Pamela Downey. 

Often pelvic health physical therapists are nervous about treating patients with bowel dysfunction and constipation. Lila Abbate's mentor, Elise Stettner, is proud to be a PT who treats bowel conditions. “Any PT can treat urinary symptoms. The patients who are really suffering are those with bowel dysfunctions.” She passed this passion on to Lila, who is the creator and instructor of the Bowel Pathology, Function, & Dysfunction scheduled next on November 13-14, 2021.

Bowel dysfunctions and constipation are often embarrassing for those who suffer from them and thus are often under-reported, which may lead to statistical underrepresentation. The statistics that we do have show that the average prevalence of constipation worldwide in adults is 16%, and for adults over the age of 60 is over 33.5%. (1) Everyone has a different normal for bowel habits which makes it hard to define a normal frequency. Constipation can generally be defined as less than three bowel movements per week and can present as infrequent bowel movements or difficult passage of stools that lasts for several weeks.

There are many potential facets to pelvic floor muscle problems concerning constipation. Lila shares that she recommends that therapists provide a muscle activity assessment in a sitting position, and can even utilize computerized-biofeedback, with the patient's hip and knees at different heights can help determine the best position for muscle relaxation during defecation. At times, it can also be useful to incorporate abdominal massage in resolving a patient's constipation. Abdominal massage for bowel function is useful in motivating peristalsis in the gut, plus there are no known side effects. This is a safe and non-invasive way to manage constipation and can be taught to the patient for them to perform on their own as needed.

In the Bowel Pathology, Function, & Dysfunction Remote Course Lila focuses on teaching registrants about the details of normal gut motility, bowel function, medical tests, and medications relating to diagnosing and treating the medical side of bowel dysfunction. Some of the highlighted lectures are about fecal incontinence, chronic constipation, and abdominal pain and how they relate to pelvic floor muscle dysfunction and physical therapy interventions. 

Also commonly encountered in pelvic rehabilitation practices are patients with coccyx pain. You may not think of constipation when treating coccydynia. However, defecation is one of the functional complaints that can be present. The coccyx can interfere with defecation as documented in a case study by Salar et al. They reported that the patient presented with an anteverted coccyx, and complained of "worsening rectal pain developing an hour before defecation and lasting for several hours afterward.” (2)

Lila Abbate also instructs the Coccydynia and Painful Sitting Remote Course. This course is a 1-day deep dive into treating patients who complain of coccyx pain with sitting and defecation. Lila shares that "The coccyx course is orthopedically-based and. I take my love of manual, osteopathic treatment, and combine it with the women’s health internal treatment aspects so that we can move more quickly to get patients back on the path to improved function and recovery." 

When asked about the approach she took in creating the course, Lila explains, "this course looks at patients from a holistic approach from the top of their heads down to their feet. In taking on the topic of coccydynia, I focused on honing basic observation skills and using some of my favorite tools in my toolbox. These include the Hesch Method, integrated systems model, traditional osteopathic, and mobilization approaches mixed with internal vaginal and rectal muscle treatment skill sets."

Join faculty member Lila Abbate this November at her upcoming course  Bowel Pathology, Function, & Dysfunction scheduled for November 13-14, 2021, or plan ahead and register for the Coccydynia and Painful Sitting Remote Course scheduled for February 4, 2022.

1.  Forootan, M; Bagheri, N; Darvishi, M. Chronic Constipation: A review of the literature. Medicine (Baltimore) 2018: May. PMID: 29768326 PMCID: PMC5976340 doi:10.1097/MD.0000000000010631
2. Salar et al.: Defecation pain and coccydynia due to an anteverted coccyx: a case report. Journal of Medical Case Reports 2012 6:175. doi:10.1186/1752-1947-6-175