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Bumped and Bruised Bottoms: Coccyx Injuries

Kelly Heidepriem, MD

Hippo Education

The holidays may be over, but ‘tis still the season for slip and falls on the ice that result in tailbone and coccyx-area injuries. Coccyx injuries are a common chief complaint in Urgent Care during this wintery, icy time of year. Classic coccydynia (aka coccyx pain) is worse when sitting and can worsen when rising from a seated position. At first glance, this seems like a straightforward chief complaint, but it lends itself to opportunities for a more nuanced discussion with patients.

What not to miss

Make sure you do a thorough evaluation of the rest of the pelvis. Just because they slipped and their coccyx region hurts the most doesn’t mean they can’t have a concomitant fracture in the rest of their pelvis as well. Also, don’t let a slip-and-fall be a red herring – a thorough exam here usually means having the patient get undressed so you can visualize the skin. Inspection of the perineum and perianal area is essential to rule out other potential causes such as pilonidal cysts, hemorrhoids, or abscesses. A donut pillow won’t fix those!

Not all coccydynia is due to trauma

Minor trauma? Easy. No trauma? This becomes more of a head-scratcher. After a thorough evaluation has you convinced the pain is isolated to the coccyx without a surrounding infectious cause, you might need to broaden your history. Does the patient perform activities that may lead to repetitive microtrauma (think motorcycles or avid Peloton-ers)? The female sex, including recent childbirth, is at higher risk of developing coccyx pain. A higher BMI leads to reduced pelvic rotation while sitting and may predispose these patients to coccydynia. Other less common atraumatic etiologies include avascular necrosis, coccyx bone spurs, sympathetic nerve pain, pelvic floor dysfunction, bursitis, or malignancies. 

Not a simple X-ray

Sitting versus standing radiographs should be performed after 10 minutes of standing to make sure that the coccyx is in a neutral position. The sitting radiograph should be performed on a hard stool with the patient having a straight back and thighs horizontal (you might need a footrest), and the seated radiograph performed on a hard stool. When seated, the patient should start with a flat back, position thighs horizontal, and lean back to the point of maximum tenderness before the X-ray is obtained.


It’s best to advise patients that this is a slow and steady road to recovery – there is no magic healing overnight. While most of our Urgent Cares don’t carry donut pillows, I find it helpful to pull up a picture of what one looks like on the website of your friendly, local pharmacy or home medical equipment store, so patients know what to look for. UpToDate does recommend tramadol, but just as we’ve discussed in other segments, we would recommend NSAIDs and Tylenol as initial mainstays of treatment. Physical therapy may be helpful as well. Some spicier options have shown some benefit in the literature including trials of using a capsaicin patch at the area of pain.