Tailbone Pain (Coccydynia): Causes, Treatment and Cushions

The coccyx (tailbone) is the end of the spine, usually made of three to five small, often fused segments joined to the sacrum by a small, mobile joint. As described in the review by Lirette et al., despite its small size it has several important functions: it is the attachment site for many muscles, ligaments and tendons, and together with the ischial tuberosities it forms one leg of the 'tripod' that supports the body in the seated position.

This description explains why the pain worsens on sitting: when a person leans back, part of the weight is transferred to the coccyx. If it is damaged, overly mobile, displaced forward or surrounded by tense muscles, any load can provoke pain. The pain may also be related to the pelvic floor muscles that attach to the coccyx (including levator ani) — their excessive tension is regarded as one of the sources of symptoms and is the target of physiotherapy.

For many people coccydynia is at first hard to pin down: the pain is described as 'in the buttock', 'near the anus' or 'at the base of the spine'. Doctors therefore usually begin by establishing whether the pain really involves the coccyx (tenderness on pressure, pain on sitting), and then by excluding other causes, as discussed in later sections.

Reviews indicate that coccydynia usually has a clear mechanical cause or trigger, although in some patients none can be identified (idiopathic pain). The most often mentioned are: local injury (a fall onto the buttocks, especially onto a hard surface), childbirth (in women, because of pressure on and movement of the coccyx), prolonged sitting on hard surfaces or in a reclined position, and also excessive mobility or instability of the coccyx. According to Lirette et al., factors that increase risk include obesity and female sex; the incidence of coccydynia has not been precisely established.

It is worth remembering that pain in the region of the tailbone does not always originate from the coccyx itself. It may be a reflection of complaints from other areas, for example the lower lumbar spine, the sacroiliac joint, the pelvic floor, the anus or the pelvic organs. For this reason the examination covers the whole region, not just the coccyx.

Cushions with a cut-out at the back (U-shaped or 'ring' cushions), wedge cushions and other designs that offload the coccyx are among the most often recommended forms of self-help. The logic is understandable: they reduce pressure on the coccyx by shifting part of the weight to the ischial tuberosities and thighs. We must, however, be honest about what the studies show: in the databases we searched we did not find controlled studies assessing the effectiveness of cushions in coccydynia. Advice on sitting therefore rests on clinical common sense and descriptions in reviews, not on evidence from randomised trials.

In practice a cushion is treated as one element of a package of 'activity modification and ergonomics' that reviews recommend as part of treatment alongside drugs and physiotherapy. The advice that follows from the mechanics of the pain is simple: avoid hard surfaces, do not sit with the pelvis tilted backwards, spread the weight onto the thighs and ischial tuberosities, change position often and take breaks to stand. There is, however, no evidence that any particular model of cushion is better than another — the choice is often a matter of comfort and trial.

The quality of evidence in coccydynia is limited: most studies are case series and retrospective studies, and there are few randomised trials. The broadest systematic review gathered data from many sources and tried to compare methods, although the authors point out the difficulty of comparison because there was no single consistent outcome measure.

How should these numbers be read? They are average changes in pain before and after treatment in studies of very different quality, mostly without a control group, so they must not be treated as a direct comparison — a 'league table of methods'. Invasive methods (radiofrequency, injections, surgery) were usually studied in patients in whom conservative treatment had failed, i.e. a group with a more severe course, which further complicates comparison. It is important, however, that even conservative care alone brought an average improvement of about 1.7 cm on the VAS (a 0–10 cm scale), and the authors stressed that non-operative management brings relief to many patients.

The first stage of treatment of coccydynia is conservative: modification of sitting and activity, analgesic and anti-inflammatory drugs (for example non-steroidal anti-inflammatory drugs, the choice of which is decided by the doctor taking comorbidities into account) and physiotherapy. Lirette et al. describe conservative treatment as effective in about 90% of cases, and in resistant cases pelvic floor rehabilitation, manual manipulation and massage, transcutaneous electrical nerve stimulation (TENS), psychotherapy, steroid injections, nerve blocks, spinal cord stimulation and surgery are considered; the authors indicate that a multidisciplinary approach gives the greatest chance of success.

The evidence on physiotherapy is mixed. In the review by Howard et al. (Journal of Manual & Manipulative Therapy, 2013) seven papers were found (two randomised, five observational) of moderate to very low quality, and the authors could not name the most effective conservative intervention because of the small number of studies. A more recent review by Sidiq et al. (Archives of Physiotherapy, 2025), covering 10 studies (515 adults), indicates that physiotherapy — including shock-wave therapy, kinesiotaping with exercise, stretching or massage of levator ani, manipulation and muscle energy technique — brought significant improvement in pain and function in the short term, and stretching or massage of levator ani sustained the improvement in pain in the long term; the authors stress the need for high-quality studies with long follow-up.

When conservative treatment does not bring enough improvement, interventional methods are considered. They include injections (usually local anaesthetic with a steroid into the region of the coccyx), ganglion impar block, radiofrequency therapy and, as a last resort, surgical removal of the coccyx (coccygectomy). In the review by Andersen et al. coccygectomy proved to be the most thoroughly studied method and could be beneficial in resistant cases, but it is a surgical procedure with a risk of complications (including infection of the wound near the anus), so the decision is made after other options have been exhausted.

Why wait? Because in most patients the pain resolves without procedures, and invasive methods were studied mainly in groups with a severe, resistant course. At the same time, intervention should not be rejected in advance if the pain persists for months, significantly limits daily functioning and does not respond to properly conducted conservative treatment. The decision should be made after talking to a specialist (for example an orthopaedic surgeon or pain specialist), who will discuss benefits, risks and alternatives.

The diagnosis of coccydynia is usually clinical — based on typical pain on sitting and tenderness of the coccyx on pressure. Imaging is not needed in everyone. It is considered when a fracture or dislocation is suspected after injury, when the pain is resistant to treatment, when warning symptoms appear (discussed below) or when an intervention is planned. The choice of test depends on the clinical question: an X-ray allows assessment of the shape, fractures and position of the coccyx, and magnetic resonance imaging of soft tissues, bone marrow and any tumour or inflammatory changes. We write about the possibilities of these tests in our entries on X-ray and MRI.

As in other segments of the spine, abnormalities visible on imaging (for example degenerative changes, various shapes of the coccyx) are also present in people without pain, so the result of a test must always be set against the symptoms. From the sources we searched we do not know how often such changes occur in people without complaints in the tailbone region, so we do not give figures here. In selected centres X-rays are taken in sitting and standing positions to assess the mobility of the coccyx, but the diagnostic value of such tests in coccydynia remains a matter of debate in the literature.

Rare but important causes of pain in this area include fracture or dislocation of the coccyx, infections, pilonidal cyst and tumours (including rare tumours of the sacrococcygeal spine). Pain that does not have a typical character, is getting worse or is accompanied by general symptoms therefore needs medical assessment and possibly imaging. See a doctor (non-urgently) also when pain on sitting lasts longer than a few weeks despite changes to sitting and simple painkillers.

Tailbone pain is troublesome, but usually has a good prognosis with patient, graded treatment. The key is to distinguish typical coccydynia from rare, more serious causes and not to make hasty decisions about surgery. Honest knowledge of what is well proven and what rests on clinical experience helps in choosing a sensible path.