Coccydynia

Procedure

Patient side-lying or prone, with consent and a chaperone offered. Palpate externally along the sacrum to the tip of the coccyx and the soft tissues either side. An internal (per rectal) examination should only be done by a clinician trained and permitted to do so, with specific informed consent.

Positive Finding

Tenderness that reproduces the familiar pain, located at the coccyx itself rather than the sacrum or surrounding muscles.

Interpretation

Point tenderness at the coccyx supports coccydynia as the source of pain. Pain on sitting that is not reproduced by coccyx pressure should prompt a look at the lumbar spine, sacroiliac joints and pelvic floor. New coccyx pain without trauma, with night pain or weight loss, needs medical assessment.

Procedure

Patient side-lying or prone. Stabilise the sacrum and apply a gentle glide to the coccyx externally. Internal assessment should only be performed by a clinician trained and permitted to do so, with specific informed consent.

Positive Finding

Reproduction of the familiar pain with movement of the coccyx, or clearly reduced or excessive movement compared with what is expected.

Interpretation

Reproduction of pain with coccyx movement supports a local source. Judging how much the coccyx moves by hand is unreliable; sitting-versus-standing lateral X-rays are used when an unstable coccyx is suspected.

Procedure

Patient supine. Lift each leg in turn with the knee straight and ask whether the familiar coccyx pain, or any leg symptoms, appear.

Positive Finding

Reproduction of the familiar pain, or radiating leg pain, during the leg raise.

Interpretation

Not a recognised test for coccydynia. A positive SLR with leg pain points to a lumbar nerve-root problem as a possible contributor to the pain. A negative test supports a local coccyx source.

Procedure

Patient seated on a firm surface. Ask the patient to lean forward and back, and to move from sitting to standing, noting when the pain appears.

Positive Finding

Pain when sitting down, when leaning back onto the coccyx, or on rising from sitting.

Interpretation

Pain on sitting and on rising from a chair is the typical pattern of coccydynia. This is an observation of pain behaviour, useful for monitoring; it does not measure coccyx movement.

Procedure

Patient side-lying with the hips bent. Palpate the ischial tuberosities and the soft tissue between them and the coccyx.

Positive Finding

Tenderness that reproduces pain on sitting, felt at the sitting bones rather than the coccyx.

Interpretation

Helps tell coccyx pain from pain at the sitting bones, such as proximal hamstring tendinopathy or ischial bursitis, which also hurt on sitting. Pain located here rather than at the coccyx points away from coccydynia.

Procedure

Patient prone. Palpate the posterior superior iliac spines and the sacroiliac region, and apply gentle posterior-to-anterior pressure over the sacrum.

Positive Finding

Reproduction of the familiar pain from the sacroiliac region rather than the coccyx.

Interpretation

A way of checking whether nearby structures contribute to the pain. Pain reproduced here rather than at the coccyx suggests a sacroiliac or lumbar source; the sacroiliac provocation tests are more useful than palpation for this.