Coccygodynia—Diagnosis and Treatment

Background: Patients with coccygodynia have chronic pain in the area of the coccyx that is worse on sitting. The prevalence of this condition is unknown, but women are affected much more frequently than men, in a 5:1 ratio.

Methods: In this narrative review, we present the relevant diagnostic techniques and conservative, interventional, and surgical treatment options.

Results: The mobility of the coccyx is assessed with dynamic x-rays in the seated and upright positions. Although there have been a number of small-scale randomized therapeutic trials, the evidence concerning the treatment of coccygodynia is derived mainly from observational studies. Manual therapies such as pelvic-floor training, the use of elastic therapeutic tape, analgesic drugs, and sitting cushions have reportedly yielded mixed results, with limited to clinically relevant efficacy. Interventional techniques, including local steroid infiltration, ganglion impar block, and radiofrequency therapies, can markedly improve symptoms for many patients. In intractable cases, surgical removal of the coccyx (coccygectomy) is an option. In a meta-analysis, 84% of patients obtained relief of pain and 76% returned to work. After at least 36 months of follow-up, the mean degree of pain relief was rated at 5.4 on a scale of 1 to 10. Wound dehiscence arose in 5% of patients, and 3% underwent repeated surgery.

Conclusion: Coccygodynia requires special diagnostic evaluation, including dynamic imaging and interdisciplinary pain assessment. Patients with coccygodynia are at risk for pain chronification. In such cases, multimodal evaluation is indicated. Conservative treatment should be tried first, potentially including interventional methods of reducing pain. Coccygectomy should only be considered in intractable cases with demonstrated instability.

Cite this as: Benditz A, Thoma R: Coccygodynia: Diagnosis and treatment. Dtsch Arztebl Int 2025; 122: 638–44. DOI: 10.3238/arztebl.m2025.0154

Sir James Simpson first described coccydynia (also referred to as coccygodynia) in 1859 as a painful condition affecting the coccyx, often aggravated by sitting and rising from a seated position (1). Coccygodynia is still commonly overlooked, even 166 years after its first reported occurrence (2). Drawing on their experience, the present authors note that those affected often complain of not being taken seriously. This review aims to contribute to a better understanding of this clinical disorder. A PubMed search of the literature (eBox) yielded 469 hits dating back to 1890, of which 145 articles were published between 2019 and 2025.

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Anatomy

Anatomically, the coccyx is the triangular-shaped bone at the end of the spine, usually comprising two to five vertebral segments. Its rudimentary intervertebral discs show marked variability and, with the exception of the first one, are commonly fused. Disc spaces may also function as joints with cartilaginous elements, leading to abnormal movement (3). The first coccygeal bone is always connected to the sacrum (5^th sacral vertebra [S5]) via rudimentary (facet) joints. The sacrococcygeal region and the coccyx are innervated by the ventral rami of the fourth and fifth sacral nerves and the coccygeal nerve (4). In recent years, the sympathetic ganglion impar has gained significant importance as a target structure for diagnostic and therapeutic blocks. It can be accessed via a transdiscal approach (5, 6). The coccygeal plexus innervates the ischiococcygeus muscle, the subdermis and dermis of the anococcygeal region, as well as the periosteum and ligaments of the coccyx (7). From a biomechanical viewpoint, the coccyx may be regarded as a tripod that, together with the ischial tuberosities, stabilizes the sitting position.

Incidence and etiology

The exact incidence of coccygodynia is unknown. The women-to-men ratio is 5:1, which is supposedly due to natural births (9). Obesity and rapid weight loss have been reported as risk factors when adipose tissue loses its shock-absorbing effect (10). Coccygodynia is rare in children.

Trauma is reported as the underlying cause in adults in 50 to 65% of cases (11). A latency period between the traumatic event and onset of symptoms is typical. The authors consider this to be best interpreted as a “normal” reaction of patients who, after a fall onto the buttocks, initially regard their symptoms as plausible and so rarely seek immediate medical attention. They only consult their primary care physician if the pain has not resolved after several weeks.

Histology reveals degenerative changes in the rudimentary intervertebral discs or signs of osteoarthritis in the joints that develop in their place (12).

A dorsal spur, or osteophyte, at the most caudal segment can cause localized pain by direct tissue irritation when sitting. Rare causes, such as tuberculosis, chordomas, or osteoid osteomas, must not be overlooked (13, 14).

Patient history

After the initial description in 1859, it was not until 1963 that Thiele first presented a detailed report of the clinical symptoms of coccygodynia (15).

Patients report that the primary pain develops while sitting and worsens during reclination and change of position, especially on standing up. In contrast, the pain rarely occurs when walking or lying down. Most patients prefer to sit on a soft surface. Many of those affected feel they are not being taken seriously and yet are significantly limited in their quality of life. Depending on the degree of instability, patients also report pain increasing on standing up, during bowel movements, or during sexual intercourse. Based on the authors’ experience, the pain must be localized at the tip of the coccyx or over the mobile segment of the bone; otherwise, it is not a case of coccygodynia in the true sense of the condition. Complex pain scenarios in which the pain radiates deep into the gluteal region or extends down the leg or into the lower back require a multidisciplinary diagnostic workup to differentiate them from other possible underlying causes. Our experience is that patients report numerous medical consultations without ever receiving a proper diagnosis. Many have undergone urological, gynecological, or coloscopic examinations, all without pathological findings. Some patients report failed pilonidal surgery, while others have received pain therapy and psychotherapy.

From a pain therapy perspective, this medical history is typical of the progressive chronification process of this type of pain (16).

Interdisciplinary multimodal evaluation

As with all chronic pain, coccygeal pain carries the risk of developing chronification, which has so far not been assessed. The risk factors for chronification of low back pain, on the other hand, have been well explored and have been integrated into clinical practice as “yellow flags” (17, 18). Risk factors include clinical factors (poor subjective health), lifestyle/environmental factors (socioeconomic disadvantage with respect to education and income), workplace factors (dissatisfaction, stress, extreme physical demands), and psychosocial factors (pain catastrophizing, anxiety avoidance behavior, somatization, depression, and stress). They moderately increase the risk of symptoms becoming chronic (odds ratio [OR] = 1.5–2.5); previous pain experience has a medium risk (OR ≥ 5) (19).

In a prospective study involving 60 patients diagnosed with coccydynia, Güler and Ünal showed in 2024 that 78.3% of patients suffered depression, 81.6% anxiety symptoms, and 76.6% sleep disturbance, which deteriorated as a result of the disability secondary to coccygodynia (20).

Interdisciplinary multimodal pain therapy (IMPT) is indicated where there is an increased risk for pain chronification. This treatment is usually provided either as a day-clinic program or as full inpatient treatment (21). IMPT may also be applied to detect the risk of chronification at an early stage (22). It involves an interdisciplinary diagnostic pain assessment of biopsychosocial factors by a multidisciplinary team (23).

Clinical examination

The physical examination should begin with observing the patient’s sitting posture, which is forward-leaning and non-weight-bearing. This is followed by a search for lesions, including signs of pilonidal sinus, fistula, or infection. Palpation of the overlying skin, coccyx, and the adjacent ligaments and muscles may reveal focal tenderness (11). It is important to palpate the painful region to distinguish the tender site from the cranial components of the sacrum. A typical feature is tenderness limited to the tip of the coccyx or to the unstable segment. Subluxation or instability may also be palpated.

Digital rectal examination (DRE) may palpate dorsal instability. In addition, it also provides information about the tone of the pelvic floor muscles and may detect muscle trigger points. Endometriosis in women and benign prostate hyperplasia in men should be included in the differential diagnosis.

Radiological evaluation

Conventional X-ray

Dynamic functional studies of the coccyx in the lateral standing and sitting positions, as described by Maigne et al. in 1994, are crucial for diagnosing coccygodynia (2, 24). First, an X-ray is obtained in the standing position, and then another after five minutes of sitting in a painful, reclined position. The radiographs are then superimposed to measure angular mobility; angular mobility of more than 25° or less than 5° is defined as abnormal.

Despite its high diagnostic value, dynamic imaging is still largely unknown. AP views only play a minor role in diagnosis and are not generally required for reasons of radiation protection. However, if physical examination suggests lateral axis deviation, AP radiographic verification is justified. Many patients have difficulty finding a radiologist experienced in performing functional studies of the coccyx, and problems persist even with a detailed referral. The authors’ experience is consistent with reports from other countries (25).

In the current digital era, the Benditz–König classification allows rapid, straightforward recognition of instability (26). A distinction is made between four types: Type I refers to a segment tilted in an anterior direction by more than 15°. Type II is the most common and is multisegmented. Types III and IV involve dorsal subluxations, with more than 50% of Type IV patients needing surgery, which is significantly increased in comparison with Types I and II (Figure 1a–d). A treatment recommendation is currently being developed based on the Benditz-König radiological classification.

Figure 1

Benditz-König Classification 1–4, reproduced from the original publication with kind permission of Springer Nature (26); a) Type 1; b) Type 2; c) Type 3; d) Type 4

eFigure

Coccyx Types I–IV in the standing and sitting positions. a) Type I; b) Type II; c) Type III; d) Type IV

The authors’ experience indicates that instability is evident on radiography in nearly all patients presenting the corresponding clinical features. However, it must also be borne in mind that not every instability is painful.

Magnetic resonance imaging

Given that the patient is lying down for the scan, magnetic resonance imaging (MRI) rarely reveals pathological findings. However, edema may develop in the affected disc space or in the adjacent bone. This is particularly the case after acute trauma or in the presence of a dorsal bony spur. The dorsal spur may be the cause, but also the result, of coccygodynia (27).

Computed tomography

Computed tomography (CT) is only indicated for coccygodynia after a traumatic event with suspected involvement of the sacrum. One study has shown considerable individual variation of sacrococcygeal and intercoccygeal joint fusion as demonstrated on CT (28).

Therapy

Conservative therapy

Conservative treatment includes drug therapy, physiotherapy, manual therapy, exercise therapy, biofeedback, extracorporeal shock wave therapy (ESWT), and interdisciplinary multimodal pain therapy (IMPT). During IMPT, we work with the patients to improve their understanding of their illness and establish realistic therapeutic goals. This includes functionality, quality of life despite pain, recognizing contributing factors, and reducing fear of their pain. However, the literature does not provide sufficient evidence covering the use of IMPT in chronic coccygodynia. Indeed, IMPT is a complex intervention whose efficacy depends on many contextual factors that cannot be determined solely by randomized clinical trials. Apart from the question of whether a particular intervention is effective, it is also crucial to understand why it works and under which conditions it is most effective. The German National Care Guideline recommends IMPT for patients with subacute and chronic, non-specific low back pain “when less intensive, evidence-based therapeutic procedures have proven insufficiently effective” and, in actual practice, this applies equally to patients with coccygodynia (23).

The literature includes no articles specifically addressing the medical management of coccygodynia. As with treatment of low back pain, non-steroidal anti-inflammatories (NSAIDs) are also prescribed for coccydynia. The guideline strongly recommends prescribing NSAIDs for the treatment of non-specific low back pain at the lowest effective dose and for as short a time as possible (23).

The evidence for other conservative treatment methods is presented in Table 1. The studies listed may be divided into three groups: manual therapy, exercise therapy (including biofeedback and elastic therapeutic tape), and ESWT.

Table 1

Evidence for conservative forms of treatment

Manual therapy

Several randomized controlled trials (RCTs), such as those by Maigne et al. and Mohanty et al., report significant improvements in pain with manual manipulations and/or combined mobilization and stretching techniques (29, 30). The success rates ranged up to 59.7%, with significant reductions in the visual analog scale (VAS) after six months. Prospective studies (Wu, Scott) also document significant improvements in function (e.g., the Oswestry Disability Index [ODI]) and pain reduction after manual therapy (31, 32).

Exercise therapy and biofeedback

The study by Ahadi et al. showed that pelvic-floor training, with or without biofeedback, is effective for chronic coccygodynia, although biofeedback did not provide any additional benefit (33). Mosaad examined various forms of conservative therapies combined with pelvic-floor exercises and elastic therapeutic tape (34). Significant improvements occurred across all groups for pain (numeric rating scale, NRS) and function (ODI), with the elastic therapeutic tape combination producing the most significant effects.

Extracorporeal shock wave therapy

Two prospective studies (Marwan, Lota) have confirmed the efficacy of extracorporeal shock wave therapy (ESWT) for coccygodynia, especially that of traumatic origin (35, 36). Pain intensity (NRS) was significantly reduced after 12 months, in some cases almost down to pain-free levels. Efficacy correlated with the number of sessions and duration of symptoms.

Overall, these studies provide a sound evidence base for the use of conservative measures in the treatment of coccygodynia. The choice of method should be tailored to the imaging results and clinical symptoms.

Interventional therapy

Injection therapies

If conservative treatment methods do not have the desired effect, then injections with local anesthetics and steroids may be applied (therapeutic blocks). Targeted injections under fluoroscopic control, with contrast material administration, are essential for the assessment of interventional procedures, such as intradiscal therapies or neuromodulation at spinal ganglia (diagnostic blocks) (37, 38). Image intensifier-assisted and CT-guided procedures, as well as ultrasound-guided injections, have been reported. Ahadi et al. showed that injections without imagery support were just as effective as ultrasound-guided injections (39). “Flooding” the painful area can be performed in a non-targeted fashion, whereas intradiscal injections require more precise placement (Figure 2a) (40).

Figure 2

Intradiscal corticosteroid injection in the lateral projection; transdiscal ganglion impar block in the lateral and AP projections

Ganglion impar blocks are performed with imaging assistance (CT, fluoroscope) (38, e1, e2). The ganglion is located anterior to the sacrococcygeal junction. It is identified either by a transdiscal approach (Figure 2b, c) or initially from a lateral approach using contrast medium (reversed C sign), which is then blocked with a local anesthetic.

Radiofrequency therapies

As shown in Table 2, studies involving radiofrequency therapy (RF) for chronic perineal and coccygeal pain have only moderate success rates. Gopal et al. reported sustained VAS reduction in 75% of patients, and Sir et al. found a significantly higher pain and satisfaction rate after six months of pulsed radiofrequency (RF) (71%) compared with a one-off block (48%) (e3, e4). Can et al. observed more than 50% pain reduction in 54% of participants and improved function in 66% after 12 weeks (e5). Overall, radiofrequency therapy achieves clinically relevant, and sometimes sustained, pain relief in around one-half to three-quarters of patients.

Table 2

Evidence for interventional therapies

Neuromodulation

Neuromodulation (NM) consists of spinal cord stimulation (SCS), with electrodes placed near the spinal cord to dampen pain signals, and DRG stimulation, which targets the spinal ganglia and is particularly effective against local neuropathic pain (e6). There are individual case reports on successful sacral nerve stimulation using burst SCS systems. These allow patients to sit for more extended periods (e7). Giordano et al. reported a case in which dorsal root ganglion (DRG) stimulation was successfully applied (e8). In their case series, Hunter et al. report that the spinal ganglia of S4 and S5 are the target structures for the treatment of coccygodynia (e9).

Operative therapy

If conservative or interventional methods do not help and bio-psychosocial factors are not foremost, then coccygectomy may be considered, i.e., the surgical removal of the coccyx.

The evidence for surgical treatment is summarized in Table 3. It contains only cohort studies, with success rates for coccygectomy ranging between 74% and 87%.

Table 3

Evidence for operative treatment

Hanley et al. report significant improvements in all SF-36 questionnaire components, the ODI, and VAS scores, with 70% achieving a successful outcome (e10).

Sagoo et al. document an average VAS reduction from 7.8 to 2.1 and a return-to-work rate of 76% (e11). Nagappa et al. and Kalstad et al. also report pain reduction in 85% and 71% of patients, respectively, after 12 months (e12, e13).

Hochgatterer et al. demonstrate a postoperative NRS of 0.68 and a return to activities of daily living after an average of seven weeks (e14).

The main complication is still postoperative infection, with infection rates varying between 2% and 11%. Kalstad et al. reduced the rate from 10% to 2% by prolonging the duration of prophylactic postoperative antibiotics (e15). Sagoo et al. report complication and reoperation rates of 8% and 3%, respectively (e11). Hochgatterer et al. observed only one superficial infection and one reoperation for persistent pain (e14). Mulpuri documented infections within the first 30 days in 9.2% of cases (e16). Careful patient selection is crucial for successful outcomes (40, e17). Prerequisites include prior conservative or interventional therapy for at least six months, IMPT for cases at risk for chronification or already in a state of chronification, significant clinical and radiological instability, and pain reduction of more than 50% after three therapeutic coccygeal infiltrations (e18). The authors believe that three preconditions must be met before considering surgery: tenderness localized directly over the coccyx, confirmed instability on functional imaging, and reproducible pain relief after local infiltration. Patients who have already received IMPT should be evaluated even more stringently before attempting surgery. They should be informed that the pain will not disappear immediately after surgery due to scar formation, and wound tenderness may persist for several months (Table 3).

Conflict of interest statement
RT states that conference fees and travel expenses were reimbursed by the German Society for Pain Medicine, and travel and accommodation expenses by the Algesiologikum Center for Pain Medicine.

AB declares that no conflict of interest exists.

Manuscript received on 5 May 2024, revised version accepted on 21 August 2025

Translated from the original German by Dr. Grahame Larkin.

Corresponding author:
Prof. Dr. med. Achim Benditz

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