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Case Report  |   June 2019
Osteopathic Approach to the Treatment of a Patient With an Atypical Presentation of Coccydynia
Author Notes
  • From Rowan University School of Osteopathic Medicine in Stratford, New Jersey. 
  • Financial Disclosures: None reported. 
  • Support: None reported. 
  •   Address correspondence to Karlbuto Alexandre, OMS IV, Rowan University School of Osteopathic Medicine, 42 E Laurel Rd, Stratford, NJ 08084-1354. Email: alexandrk2@rowan.edu
     
Article Information
Neuromusculoskeletal Disorders / Osteopathic Manipulative Treatment / Pain Management/Palliative Care / Psychiatry
Case Report   |   June 2019
Osteopathic Approach to the Treatment of a Patient With an Atypical Presentation of Coccydynia
The Journal of the American Osteopathic Association, June 2019, Vol. 119, 395-400. doi:https://doi.org/10.7556/jaoa.2019.069
The Journal of the American Osteopathic Association, June 2019, Vol. 119, 395-400. doi:https://doi.org/10.7556/jaoa.2019.069
Abstract

A 21-year-old man with atypical coccydynia that radiated bilaterally to his thigh and lower back came for treatment 10 years after coccyx trauma. Pertinent review of systems showed unintentional weight loss of 20 lb over the past 1 to 3 years, a body mass index of 14.94, significant depression, and poor concentration. In addition to treating his pain, we addressed the weight loss and depression that he was experiencing by advising a balanced diet, discovering the origins of what the patient believed caused his depression, and using osteopathic manipulative treatment. The patient was treated with osteopathic manipulative treatment to alleviate somatic dysfunctions diagnosed in the head, cervical, thoracic, lumbar, and sacral regions. At follow-up visits, the patient described a reduction in his pain symptoms from an initial 5 out of 10 to 3 out of 10 on his third visit. This case report outlines the importance of using a holistic approach when treating patients and advocates for using osteopathic manipulative treatment as a viable treatment option for patients with coccydynia.

The coccyx is a small bone that consists of 3 to 5 fused vertebrae and serves as an attachment site for the pelvic diaphragm muscles (coccygeus, iliococcygeus, and pubococcygeus) and several ligaments (sacrospinous, sacrotuberous, sacrococcygeal, and longitudinal ligaments).1 The filum terminale, a fibroligamentous extension from the conus medullaris, also attaches to the coccyx and connects it with the dura and the primary respiratory mechanism (PRM).1,2 The PRM is described as the inherent motility of the brain and spinal cord, the fluctuation of the cerebrospinal fluid, the mobility of the intracranial and intraspinal membranes, the articular mobility of cranial bones, and the involuntary mobility between the sacrum and ilia.2 The coccyx is innervated by branches of the coccygeal plexus, which provides sensation over the skin of the coccyx and contributes to pain in coccygeal injury.1 The ganglion impar is a caudal convergence of the sympathetic trunks that begins at the sacrococcygeal joint and ends at the tip of the coccyx and plays a significant role in the pain produced in coccyx injury.3 
A patient with a typical presentation of coccydynia has pain at the coccyx that is exacerbated by sitting for prolonged periods, leaning backward, and rising from a seated position.4 A patient with an atypical presentation of coccydynia has pain that radiates in different parts of the pelvis and lower back.5,6 The most common causes of coccydynia are trauma (50% of cases),6 extensive weight loss, extensive weight gain, degenerative joint disease, pelvic floor muscle spasm, herniated lumbar disk, pilonidal cyst, fistula, perianal abscess, and neoplasm.4,7 In our review of literature, we found no reported incidence rate of coccydynia.4,7 
Patients who are obese are predisposed to coccydynia because excess weight adds more pressure and force on the coccyx during periods of sitting and standing.4,7 Paradoxically, extensive weight loss causes a loss of adipose tissue and fibrous cushioning around the coccyx and thus exposes the coccyx to more mechanical force, which leads to coccydynia.4 The literature4,7 shows coccydynia to be 5 times more likely in women than in men, primarily due to mechanical changes to the muscles of the pelvic diaphragm that attach to the coccyx during childbirth. 
Patients with longstanding coccydynia can have chronic pain and depression, which is the most common mental illness seen in patients with chronic pain.8 Empirical studies have shown that patients with concurrent depression and chronic pain have decreased function, more inadequate response to treatment, and exacerbated disability compared with patients who have depression without chronic pain.7,8 Determining whether a patient's depression is caused by chronic pain is challenging because many variables, such as pain tolerance, socioeconomic factors, and age, make a direct comparison difficult.8,9 However, the possibility that one causes the other cannot be ruled out either because pain causes physical restriction (musculoskeletal immobility and decreased functionality), which can strain relationships and cause fatigue, decreased sleep, and decreased activity, which increase the risk for depression.9 
The coccyx has been shown to be a dynamic structure that can glide anteriorly and posteriorly between 5° to 25° in its normal range of motion.7 Postachhini and Massobrio10 founded the classification scheme describing the degree of flexion between the coccyx and the sacrum at resting position as defined in Table 1. In this article, we describe the case of a 21-year-old man with chronic coccydynia from an accident 10 years ago that resulted in a type III coccyx discovered on radiography. 
Table 1.
Classification and Description of Coccyx Flexion
Classification Description
Type I Coccyx pointed downward and caudal (normal)
Type II Flexed less than 90°
Type III Flexed to 90°
Type IV Flexion surpassing 90°
Table 1.
Classification and Description of Coccyx Flexion
Classification Description
Type I Coccyx pointed downward and caudal (normal)
Type II Flexed less than 90°
Type III Flexed to 90°
Type IV Flexion surpassing 90°
×
Report of Case
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. 
Figure 1.
X-ray results showing a type III coccyx with severe sclerosis
Figure 1.
X-ray results showing a type III coccyx with severe sclerosis
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. 
Table 2.
Pertinent Objective Findings from the Physical and Osteopathic Examinations
Examination Pertinent Objective Findings
Vital signs Height, 72 in; weight, 110 lb; body mass index, 14.94; blood pressure,100 mm Hg
General Nonacute distressed, emaciated
Head Normocephalic, atraumatic
Musculoskeletal 5/5 muscle strength in L2-S1 and C5-T1 bilaterally; paravertebral spasms of thoracolumbar spine with tenderness
Extremities Tenderness on left pelvic floor; no clubbing, edema, or deformity; normal range of motion of all joints; negative finding on straight leg test bilaterally
Neurologic +2/4 reflexes in patella and Achilles bilaterally; sensation intact to light touch in L2-S1, no focal deficits; CN 2-12 grossly intact with normal sensation, reflexes, coordination, muscle strength, and tone; normal unassisted gait
Psychological Alert and cooperative, normal mood and affect; normal attention span and concentration
Osteopathic Cranial flexion dysfunction, OA ERRSL, T5-6 NSLRR, L4 ERLSL, right anterior innominate, bilateral sacral flexion

Abbreviations: CN, cranial nerve; ERLSL, extended, rotated left, sidebent left; ERRSL, extended, rotated right, sidebent left; NSLRR, neutral, sidebent left, rotated right; OA, occipitoatlantal.

Table 2.
Pertinent Objective Findings from the Physical and Osteopathic Examinations
Examination Pertinent Objective Findings
Vital signs Height, 72 in; weight, 110 lb; body mass index, 14.94; blood pressure,100 mm Hg
General Nonacute distressed, emaciated
Head Normocephalic, atraumatic
Musculoskeletal 5/5 muscle strength in L2-S1 and C5-T1 bilaterally; paravertebral spasms of thoracolumbar spine with tenderness
Extremities Tenderness on left pelvic floor; no clubbing, edema, or deformity; normal range of motion of all joints; negative finding on straight leg test bilaterally
Neurologic +2/4 reflexes in patella and Achilles bilaterally; sensation intact to light touch in L2-S1, no focal deficits; CN 2-12 grossly intact with normal sensation, reflexes, coordination, muscle strength, and tone; normal unassisted gait
Psychological Alert and cooperative, normal mood and affect; normal attention span and concentration
Osteopathic Cranial flexion dysfunction, OA ERRSL, T5-6 NSLRR, L4 ERLSL, right anterior innominate, bilateral sacral flexion

Abbreviations: CN, cranial nerve; ERLSL, extended, rotated left, sidebent left; ERRSL, extended, rotated right, sidebent left; NSLRR, neutral, sidebent left, rotated right; OA, occipitoatlantal.

×
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. 
Discussion
Several articles4,7,11 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. 
Conclusion
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. 
References
Woon JT, Stringer MD. Clinical anatomy of the coccyx: a systematic review. Clin Anat. 2012;25(2):158-167. doi: 10.1002/ca.21216 [CrossRef] [PubMed]
Chila AG, Carreiro JE, Dowling DJ, et al.   Foundations of Osteopathic Medicine. 3rd ed. Philadelphia, PA: Wolters Kluwer/Lippincott Williams & Wilkins; 2011.
Oh CS, Chung IH, Ji HJ, Yoon DM. Clinical implications of topographic anatomy on the ganglion impar. Anesthesiology. 2004;101(1):249-250. [CrossRef] [PubMed]
Lirette LS, Chaiban G, Tolba R, Eissa H. Coccydynia: an overview of the anatomy, etiology, and treatment of coccyx pain. Ochsner J. 2014;14(1):84-87. [PubMed]
Awwad WM, Saadeddin M, Alsager JN, AlRashed FM. Coccygodynia review: coccygectomy case series. Eur J Ortho Surg Trau. 2017;27(7):961-965. doi: 10.1007/s00590-017-1947-3 [CrossRef]
Origo D, Tarantino AG, Nonis A, Vismara L. Osteopathic manipulative treatment in chronic coccydynia: a case series. J Bodyw Mov Ther. 2018;22(2):261-265. doi: 10.1016/j.jbmt.2017.06.010 [CrossRef] [PubMed]
Sarmast AH, Kirmani AR, Bhat AR. Coccydynia: a story retold. Austin J Surg. 2016;3(3):1091.
Holmes A, Christelis N, Arnold C. Depression and chronic pain. Med J Aust. 2013;199(6 suppl):S17-S20. [PubMed]
Herr KA, Mobily PR. Chronic pain and depression. J Psychosoc Nur Ment Health Serv. 1992;30(9):7-12.
Postachhini F, Massobrio M. Idiopathic coccygodynia. analysis of fifty-one operative cases and a radiographic study of the normal coccyx. J Bone Joint Surg. 1983;65(8):1116-1124.
Grosso NP, van Dam BE. Total coccygectomy for the relief of coccydynia: a retrospective review. J Spinal Disord. 1995;8(4):328-330. [CrossRef] [PubMed]
Wray C, Easom S, Hoskinson J. Coccydynia: aetiology and treatment. J Bone Joint Surg. 1991;73(2):335-338. [CrossRef]
Emerson SS, Speece AJ III. Manipulation of the coccyx with anesthesia for the management of coccydynia. J Am Osteo Assoc. 2012;112(12):805-807.
Reig E, Abejón D, del Pozo C, Insausti J, Contreras R. Thermocoagulation of the ganglion impar or ganglion of Walther: description of a modified approach. preliminary results in chronic, nononcological pain. Pain Pract. 2005;5(2):103-110.
Capar B, Akpinar N, Kutluay E, Mujde S, Turan A. Coccygectomy in patients with coccydynia. Acta Orthop Traumatol Turc. 2007;41(4):277-280. [PubMed]
Nicholas AS, Nicholas EA. Atlas of Osteopathic Techniques. 2nd ed. Philadelphia, PA: Wolters Kluwer/Lippincott Williams & Wilkins; 2012.
Plotkin BJ, Rodos JJ, Kappler R, et al. Adjunctive osteopathic manipulative treatment in women with depression: a pilot study. J Am Osteopath Assoc. 2001;101(9):517-523. [PubMed]
Field T, Diego MA, Hernandez-Reif M, Schanberg S, Kuhn C. Massage therapy effects on depressed pregnant women. J Psychosom Obstet Gynaecol. 2004;25(2):115-122. [CrossRef] [PubMed]
Yrondi A, Sporer M, Péran P, Schmitt L, Arbus C, Sauvaget A. Electroconvulsive therapy, depression, the immune system and inflammation: a systematic review. Brain Stimul. 2018;11(1):29-51. doi: 10.1016/j.brs.2017.10.013 [CrossRef] [PubMed]
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Figure 1.
X-ray results showing a type III coccyx with severe sclerosis
Figure 1.
X-ray results showing a type III coccyx with severe sclerosis
Table 1.
Classification and Description of Coccyx Flexion
Classification Description
Type I Coccyx pointed downward and caudal (normal)
Type II Flexed less than 90°
Type III Flexed to 90°
Type IV Flexion surpassing 90°
Table 1.
Classification and Description of Coccyx Flexion
Classification Description
Type I Coccyx pointed downward and caudal (normal)
Type II Flexed less than 90°
Type III Flexed to 90°
Type IV Flexion surpassing 90°
×
Table 2.
Pertinent Objective Findings from the Physical and Osteopathic Examinations
Examination Pertinent Objective Findings
Vital signs Height, 72 in; weight, 110 lb; body mass index, 14.94; blood pressure,100 mm Hg
General Nonacute distressed, emaciated
Head Normocephalic, atraumatic
Musculoskeletal 5/5 muscle strength in L2-S1 and C5-T1 bilaterally; paravertebral spasms of thoracolumbar spine with tenderness
Extremities Tenderness on left pelvic floor; no clubbing, edema, or deformity; normal range of motion of all joints; negative finding on straight leg test bilaterally
Neurologic +2/4 reflexes in patella and Achilles bilaterally; sensation intact to light touch in L2-S1, no focal deficits; CN 2-12 grossly intact with normal sensation, reflexes, coordination, muscle strength, and tone; normal unassisted gait
Psychological Alert and cooperative, normal mood and affect; normal attention span and concentration
Osteopathic Cranial flexion dysfunction, OA ERRSL, T5-6 NSLRR, L4 ERLSL, right anterior innominate, bilateral sacral flexion

Abbreviations: CN, cranial nerve; ERLSL, extended, rotated left, sidebent left; ERRSL, extended, rotated right, sidebent left; NSLRR, neutral, sidebent left, rotated right; OA, occipitoatlantal.

Table 2.
Pertinent Objective Findings from the Physical and Osteopathic Examinations
Examination Pertinent Objective Findings
Vital signs Height, 72 in; weight, 110 lb; body mass index, 14.94; blood pressure,100 mm Hg
General Nonacute distressed, emaciated
Head Normocephalic, atraumatic
Musculoskeletal 5/5 muscle strength in L2-S1 and C5-T1 bilaterally; paravertebral spasms of thoracolumbar spine with tenderness
Extremities Tenderness on left pelvic floor; no clubbing, edema, or deformity; normal range of motion of all joints; negative finding on straight leg test bilaterally
Neurologic +2/4 reflexes in patella and Achilles bilaterally; sensation intact to light touch in L2-S1, no focal deficits; CN 2-12 grossly intact with normal sensation, reflexes, coordination, muscle strength, and tone; normal unassisted gait
Psychological Alert and cooperative, normal mood and affect; normal attention span and concentration
Osteopathic Cranial flexion dysfunction, OA ERRSL, T5-6 NSLRR, L4 ERLSL, right anterior innominate, bilateral sacral flexion

Abbreviations: CN, cranial nerve; ERLSL, extended, rotated left, sidebent left; ERRSL, extended, rotated right, sidebent left; NSLRR, neutral, sidebent left, rotated right; OA, occipitoatlantal.

×