Coccydynia (Tailbone Pain): Literally a Pain in the Butt

April 28, 2020

Why does my tailbone hurt when I sit on my once comfy couch? This question may become relevant for many of us during this COVID-19 pandemic.

We all have been on long car rides, meetings that go past their end time, and have watched a television series from start to finish in one sitting. Especially now, we may be taking the opportunity to catch up on shows and spend more time on social media to connect with those we cannot see in person. You might have noticed that these activities can be problematic for the area at the base of the spine.

The coccyx, otherwise known as the tailbone, is a small bone at the base of the sacrum made up of 3-5 fused segments. Although small, the coccyx has important functions and is a point of attachment for the pelvic floor and gluteal muscles. These muscle attachments facilitate movement of the coccyx through a small range motion. When the pelvic floor muscles contract and shorten, the coccyx flexes, moving forward toward the pubic bone. Relaxation of the pelvic floor and contraction of the gluteus maximus both move the coccyx backward into extension (Grassi et al, 2007). Despite its small size and range of motion, this segment can cause significant pain for people, but why?

Demystifying Coccyx Pain

Coccyx pain can present as tenderness to and around the coccyx as well as pain with the following activities: prolonged sitting, defecation, menstruation, sexual intercourse, and moving from sitting to standing (Mahmood, 2018). There are known risk factors for coccyx pain, but sometimes the onset of pain can be idiopathic (unknown in origin).

Risk Factors for Coccyx Pain

  • Obesity: People who are obese are more likely to have less movement of the pelvis which results in more pressure to the coccyx in the seated position.
  • Age: Adults are more at risk to experience coccyx pain than adolescents.
  • Sex: The female pelvis is characterized by a wider sciatic notch and greater ischial tuberosity distance compared to the male pelvis. These anatomical features place the coccyx at more risk of being injured for the reason that these qualities increase the backward inclination of the coccyx, leaving it prone to injury and increased pressure at the coccyx while sitting.
  • Injury: Injury can occur directly to the coccyx via a fall, sexual intercourse, and prolonged sitting or indirectly with common causes such as lumbar spine surgery, vaginal childbirth, and rectal surgery (Mahmood et al, 2018).

If no known injury has occurred, your pelvic floor and central nervous system could be to blame. Muscle spasms of levator ani, piriformis, coccygeus, and gluteus maximus are known to cause pain in the coccygeal area (Mahmood et al, 2018; Thiele, 1937). These muscles could be in spasm for any number of reasons but at the root, we can reasonably say that some neuromuscular deactivation and central nervous system dysregulation has occurred.

The muscles of the pelvic floor are innervated by a combination of sympathetic (fight or flight) and parasympathetic (rest and relax) fibers and are known to play a role in several pelvic pain disorders (Vodusek, 2004; Dunkley, 2016). If your body is in a constant state of stress and distress, your pelvic floor can respond by contracting and staying in a fight or flight response. The issue becomes if it does not come down from this response, the body will begin to find other ways to regulate movement and function that can lead to dysfunction and pain. Think about it: if the levator ani (the deepest layer of the pelvic floor known as the pelvic diaphragm) maintain an overly shortened state, then the coccyx will stay in an overly flexed position. Now when seated, the coccyx will be exposed to more pressure and potential irritation. In sum, the muscles may be firing too much, not enough, or at the wrong time. But how do you know which is occurring?

Physical Therapy Approach

At Activcore, I get to provide 1:1 individualized care in order to establish the root cause of your pain. As a pelvic health physical therapist, I have received advanced training in order to identify and treat the pelvic floor but also connect impairments in the pelvic floor such as coccyx pain to how your body is functioning on a global level.

Seeing a pelvic health physical therapist can help determine the source of pain as well as a treatment plan for long-term relief. Below are some of the treatments your pelvic health physical therapist may employ.

  1. Manual therapy: External and/or internal hands-on techniques to address tissue restrictions and pain.
  2. Neuromuscular re-education: Retraining of the pelvic floor muscles to contract, relax, and elongate at the right time.
  3. Physiological Downregulation/Upregulation: If your central nervous system is too amped up or too sleepy, your physical therapist can help your central nervous system relearn appropriate responses to stimuli.
  4. Whole Body Approach: Remembering that segments above and below have an effect on your pelvis, your physical therapist will assess and treat any mechanical abnormalities that can be contributing to your pain.

You can learn more about pelvic floor dysfunction by visiting our Pelvic Health page.

Disclaimer:  The views expressed in this article are based on the opinion of the author, unless otherwise noted, and should not be taken as personal medical advice. The information provided is intended to help readers make their own informed health and wellness decisions.

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Dunkley, C.R, & Brotto, L.A. (2016). Psychological treatments for provoked vestibulodynia: Integration of mindfulness-based and cognitive behavioral therapies. Journal of Clinical Psychology, 72, 637-650.

Grassi, R., Lombardi, G., Reginelli, A., Capasso, F., Romano, F., Floriani, I., & Colacurci, N. (2007). Coccygeal movement: Assessment with dynamic MRI. European Journal of Radiology, 61, 473-479.

Mahmood, S., Ebraheim, N., Stirton, J., & Varatharajan, A. (2018). Coccydynia: A literature review of its anatomy, etiology, presentation, diagnosis, and treatment. International Journal of Musculoskeletal Disorders, IJMD-109. doi: 10.29011/ IJMD-109. 000009.

Thiele, G.H. (1937). Coccygodynia and the pain in the superior gluteal region and down the back of the thigh: Causation by tonic spasm of the levator ani, coccygeus, and piriformis muscles and relief by massage of these muscles. Journal of the American Medical Association.

Vodusek, D.B., (2004). Anatomy and neurocontrol of the pelvic floor. Digestion, 69, 87-92.

Dr. Ashley Newton

Center Director | Physical Therapist
Ashley Newton is a Doctor of Physical Therapy and Evidence In Motion Pelvic Health Certified (PHC) practitioner with a special interest in adult pelvic floor issues and yoga-related injuries. She works at Activcore in Princeton, NJ, located just 2 miles from Princeton University.


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