A 21-year-old man presented to our office with chief complaints of coccydynia for the past 10 years. The patient said that his pain initially began 10 years ago at the age of 11 after a playground accident in which he went down a slide and hit the ground on his coccyx. He stated that he blacked out and did not remember what happened, but his parents, who accompanied him during the current visit, said that he was not taken to the emergency department or to any other physician at the time. Throughout this extended period, he managed his pain by walking, stretching, practicing tai chi, and engaging in overall activity. He had not previously tried physical therapy or used pain medications, but occasionally applied heat and ice therapy. The patient had a noncontributory medical, surgical, family, and social history. 

Over the past 2 to 3 years, his pain seemed to intensify without any additional traumatic events. He went to see his primary care physician after his pain became unbearable, and he was referred to an orthopedic spine specialist, who ordered x-ray imaging of the pelvis and sacrum. The radiograph showed a type III coccyx with severe sclerosis as shown in Figure 1. The patient's orthopedic spine specialist wanted to perform a positron emission tomography scan and possibly order a corticosteroid injection. However, the patient sought less invasive therapies, and he was referred to our office by a friend. 

He noticed increasing pain and decreased cognition, and he stated that sedentary periods typically exacerbated his pain. He regularly used a donut seat cushion to help alleviate his symptoms. He described that during a pain exacerbation, the pain started at the right superior part of the sacral base and then radiated to his lower back and posterior thighs bilaterally. He stated that on his best day, his pain was a 2/10, but during exacerbations, it escalated to 8/10. During his initial visit to our office, he rated his pain as 5/10. 

A 12-point review of systems was completed, and the patient denied urinary incontinence, rectal incontinence, weakness, and paresthesias of the lower extremities. The patient did admit to feeling depressed, to having a lack of focus that affected his work, and to experiencing unintentional weight loss of 20 lb over the past 1 to 3 years (body mass index [BMI], 14.94). The patient's only preexisting condition was a longstanding history of attention deficit/hyperactivity disorder. All pertinent physical examination findings are shown in Table 2. 

Findings from the osteopathic structural examination showed cranial flexion dysfunction, right anterior innominate, and bilateral sacral flexion (Table 2). We applied osteopathic manipulative treatment (OMT) to address these dysfunctions. Compression of the fourth ventricle (CV4) was used to accentuate extension after the still point. We also treated the patient with vault hold with balanced membranous tension, occipitoatlantal muscle energy, thoracic high-velocity low-amplitude, lumbar muscle energy and high-velocity low-amplitude, innominate muscle energy, sacral rocking, and sacral muscle energy. 

In addition, we applied the tenets of osteopathic medicine and looked beyond our patient's injury and chief complaint.² We addressed the patient's weight loss and used active listening with counseling to create a plan for the patient to increase his BMI. We encouraged the patient to eat a balanced diet containing 3 meals per day with protein, essential nutrients, and vitamins to gain a healthy amount of weight to reach normal BMI. We explored the patient's history and discovered that he strongly believed his coccydynia has been a significant factor in his inability to focus on school and work. 

At his first follow-up visit 3 weeks later, the patient gained 7 lb, and his BMI improved to 15.84. He stated that his pain and mood were significantly improved. The patient said that he could anticipate exacerbations much better and could move to alleviate symptoms before they occurred. We conducted similar OMT as in the first encounter. During his second follow-up visit 4 weeks later, he had gained an additional 7 lb, which brought his BMI to 16.82. He reported that his pain level was reduced to 3/10 in severity, and we performed similar OMT as in the prior 2 appointments. He chose to forgo appointments with his orthopedic spine specialist because of the improvement in his mood and level of pain. 

Several articles^4,7,11 have outlined the treatment options for patients presenting with coccydynia. In acute scenarios, patients are usually offered simple conservative treatments such as nonsteroidal anti-inflammatory drugs, nonopiate analgesics, hot baths, seat cushions, stool softeners, sitting less, and OMT.⁴ Eight weeks of the stated regimen is usually enough to resolve symptoms in most patients. In patients who do not respond to conservative treatment, radiographic imaging, including dynamic x-ray and magnetic resonance imaging, should be ordered.⁶ Studies have shown that dynamic x-ray imaging, in which images are obtained in both standing and seated positions, offers a more accurate diagnosis and can detect an abnormality in 70% of patients.⁷ Magnetic resonance imaging has been deemed more useful in detecting coccygeal edema, neoplasms, and abscesses.⁷ 

More invasive techniques may be used, such as bimanual manipulation of the coccyx under anesthesia, ganglion impar block, radiofrequency ablation of ganglion of impar, corticosteroid injections, and pelvic floor massage.^4,7,12-14 Studies report that the combination of bimanual manipulation of the coccyx and corticosteroid injections provided more relief synergistically than either of them individually.^12,13 If these options fail, then coccygectomy is the last line of treatment.⁷ Studies on the efficacy of the procedure in addressing symptoms of coccydynia were shown to have 80% to 90% good and excellent outcome.^11,13,15 

The patient in the present case had not been prescribed a conservative treatment regimen and was not specifically monitored. The patient was already using a seat cushion and engaging in activities of movement when OMT was added to his treatment. We chose not to prescribe NSAIDs and sought other options. We considered performing bimanual manipulation of the coccyx; however, this technique is usually performed closer to the time of the initial injury. We also considered corticosteroid injections; however, the patient wanted to postpone injections until after a trial of OMT. Coccygectomy would be an invasive option that was not advised given the patient's neurologic stability and the procedure's risk. Treatment of this patient was difficult because of the remoteness of the patient's injury. The coccyx had reossified during the 10-year period of self-management. The patient's pain was exacerbated by the 20-lb weight loss and underweight BMI. 

We addressed his weight loss first because low weight is a risk for increased coccydynia. One of the most important factors in the patient's symptom improvement was advising a balanced diet and discovering the origins of what the patient believed to be a cause of his depression. We were able to meet our patient's needs because of our osteopathic philosophy in treating the whole person—body, mind, and spirit.² 

In addition to his diet, the patient was treated with OMT. The cranium and the coccyx are linked together by the dura and the filum terminale.¹ To help fix the cranial flexion dysfunction, we conducted the CV4 cranial technique. In a cranial flexion dysfunction, the basiocciput and basisphenoid are restricted in the cephalad position while the occipital squama and the wings of the sphenoid are restricted in a caudad position.¹⁶ The CV4 technique was used to encourage the movement of the basisphenoid and basiocciput during cranial extension and resist cranial flexion by applying a bilateral medial force.¹⁶ The CV4 technique normalizes the PRM and promotes cerebrospinal fluid drainage and flow.¹⁶ We also focused on the more distal attachments of the meninges and performed a sacral rocking technique to create a synchronous and symmetric nutation and counternutation of the sacrum with the PRM.¹⁶ Sacral rocking normalizes sympathetic tone, and we believe that the technique normalized the sympathetic outflow from the ganglion impar.^2,16 The patient's sacrum also had a bilateral sacral flexion in which hypertonic pelvic floor muscles pull the coccyx forward and place the sacrum in a counternutated position. The bilateral sacral flexion also affected the PRM and his cranial dysfunction because the sacrum attaches to the dural membrane at the level of the S2 sacral vertebra.¹⁶ We used bilateral sacral muscle energy technique to relax and loosen the patient's hypertonic pelvic floor muscles to allow for improved PRM and to alleviate stress on the coccyx.¹⁶ 

The patient's improved mood may have been associated with our manipulation of the cranium, sacrum, and coccyx. A pilot study¹⁷ showed that women with depression who received OMT plus pharmacotherapy reported significantly more normal psychometric evaluation results than a control group. In comparison, pregnant women with depression who received massage to the head, neck, back, arms, and legs were shown to have decreased symptoms of depression and anxiety.¹⁸ Although massage therapy is not OMT, techniques such as myofascial and soft tissue techniques are similar. Research is needed to better understand the effects of these techniques on patient outcomes. 

Major depressive disorder and attention deficit/hyperactivity disorder have been associated with increased brain inflammation.^19-21 It is also postulated that several OMT modalities, including balanced membranous tension, have anti-inflammatory effects on the brain by improving lymphatic flow and decreasing the number of inflammatory cells and cytokines that induce these pathologic changes.^21-23 Thus, we theorize that our patient's mood and concentration improvements were likely related to the specific OMT techniques we performed on him during his office visit. More research into the potential benefits from OMT on neuropsychiatric disease could aid many people. 

Osteopathic principles and practice allowed us to evaluate and treat our patient holistically by addressing malnourishment, weight, and mood. Also, we were able to effectively perform OMT to improve the patient's pain. This case exemplifies the importance of the osteopathic approach in the general practice of medicine and demonstrates how OMT can be effective in managing chronic coccydynia.