Pelvic And Coccyx Pain
Contents
- Musculoskeletal disorders
- Update, 10th October 2004
- Update, 2nd July 2006
- Mobilisation
- Acupuncture
- My advice
- Update, 2007-05-27
- Update, 2009-11-29
- Update, 2009-12-27
Michael Durtnall, Chris Berlingieri and Robert Griffiths are experienced in spinal and sacrococcygeal manipulation, acupuncture and physical therapy at Sayer Clinics: London
Michael and Robert are listed under ‘Doctors & Specialists’ at www.coccyx.org/treatmen/docsuk.htm
Michael Durtnall is listed at http://www.pelvicpain.org/ for the diagnosis and treatment of musculoskeletal coccyx & pelvic pain.
Read the http://www.coccyx.org/ personal experiences of Anonymous, Lee, Becky, Mel, Monica,Kim (1), Chris, Kim (2), Pauline, Adam Pymble, Debbie Dale, Vijay, Alan, Amanda, Nicole, Katy,Maureen, Justin, Mary Caroline, Duncan, Lorette, Caroline, John McCarthy, Bethan , John’s experience , Caroline, Margaret, Sue, Eileen, Hunter, Galina, David, Edel, Clare, Laila, Virginia, Anonymous, Awais, Kerry, Generale , Lee, Anonymous
Causes of chronic & acute pelvic pain
Neuro-musculo-skeletal disorders
- Abdominal muscle pain (trigger points)
- Spondylolisthesis – forward slippage of one lumbar vertebra on another – treated by regaining mobility/normal function of surrounding joints and muscles to minimize strain on a spondylolisthetic joint and postural changes.
- Poor posture – associated with caesarian section, weak abdominals, overweight/obesity, sedentary occupation, computers, high heels.
- Mechanical low back pain – lumbar facet or sacro-iliac joint dysfunction, sciatic referred pain, athrosis , muscular spasm or joint locking.
- Sacrococcygeal syndrome – chronic or acute coccygeal pain – coccyx hypomobility (stiffness), minor dislocation or arthrosis causing muscular pain, spasm or weakness to coccygeus, gluteal, obturator externus/internus, piriformis, gluteus minimus, quadratus femoris muscle spasms as well as internal hip rotators: gluteus medius, adductor longus and brevis, pectineus, tensor fascia lata and medial hamstrings.
- Coccygeal, sacral or pudendal nerve referred pelvic neuralgia. Muscular strains and injuries. Fractures.
- PSD Pubic Symphysis Diastasis causing severe pain at the symphysis pubis in the latter stages of pregnancy.
- Piriformis syndrome
- Rectus Femoris tendon strain.
- Disc bulge / herniation.
- Compensatory Scoliosis associated with significant leg-length difference.
Help during Pregnancy
Sayer Clinic therapists are experienced in working with pregnant patients. We understand the demands placed on the body during the different phases of pregnancy. There are tremendous increases in blood volume and hormonal changes that can affect soft tissue structures. Many pregnant women experience neck pain, headaches, low back pain and leg pain or postural changes, sacroiliac and pubic symphysis joint dysfunction.
Symphysis Pubis Disorder – SPD. The Symphysis Pubis joint between the pubic bones at the front of the pelvis may become separated or twisted due to ligamentous laxity during pregnancy causing SPD with pain and difficulty on walking, climbing stairs, dressing, turning in bed and getting in and out of a car. Pain can be severe in the sacro-iliac joints and sometimes in the groin, inner thigh, hips or buttocks.
SPD can be surprisingly easily and rapidly improved by careful, experienced and skillful unlocking of the sacroiliac joints, thus instantly reducing the torsional strain at the pubis. Acute SPD patients, usually referred by their midwife or obstretician, often in tears, hobbling and supported by friends at their first visit to us, walk out smiling within the hour!
Our specialised treatment tables have adjustable abdominal sections for maximum comfort during treatment allowing you to lie face-down comfortably. Treatment with manual therapy eases painful muscles, decreases oedema and swelling and increases joint motion and flexibility. Post-pregnancy Core stabilisation, pelvic floor exercises and postural re-education are addressed.
Help with Musculo-skeletal causes of Pelvic Pain.
Pudendal Nerve Entrapment – PNE. The Pudendal nerve can become compressed or inflamed as it passes from the sacral and coccygeal nerve branches within self-perpetuating, deep muscle spasms close to the ischium or “sits bones” area of the pelvis. Chronic referred pain or neuralgia may be felt in the perineum, abdomen and buttocks. Many patients have increased pain on sitting which is usually one-sided but both sides can be involved. Symptoms may include pain, burning, numbness and parasthesia in the pelvis near the sacrum and coccyx which can radiate throughout the pelvic floor, inner thigh, lower abdomen and groin.
After a thorough evaluation to confirm your diagnosis we can use specific connective tissue techniques, acupuncture or myofascial release to try to reduce muscle spasm and nerve compression and, therefore, inflammation. Specific physical therapy techniques called ‘nerve tissue tension releases’ and neural mobilisation or acupuncture can help decrease and regain reduced coccygeal range of motion by internal mobilisation to reduce coccyx/spinal cord meningeal tension. Misalignment or fixation of the pelvis, sacro-iliac joints, facet or sacro-coccygeal joints and muscular spasms are usually interrelated factors. We may use acupuncture, manipulative techniques and exercises prescribed with instruction.
It is important to previously exclude, in consultation with your GP, urological and other potential medical causes of your pain.
Groin Pain in Sportsmen and women
The Groin is anatomically complex, highly mobile and vulnerable to significant stresses generated in sport through the legs, abdomen and pelvis.
Pain can originate from the lumbar spine, sacroiliac joints, hip joints and/or symphysis pubis.
Muscles involved include the hip adductors, hip flexors, gluteal, abdominal and lumbar extensors.
The obturator nerve, ilioinguinal nerve and genitofemoral nerve are potentially involved.
Diagnosis depends on a thorough history and examination of the complex interaction between them all with dysfunction of one structure leading inevitably with time to a multipartite dysfunction throughout the body. Leg-length differences of a centimetre or more can cause significant pelvic tilt and shearing forces at the sacro-iliac and hip joints which, in time, cause degenerative changes in the joints. We address this with graduated heel-lifts to balance the leg-length and spine.
Our aim is to give the athlete a realistic framework for rehabilitation and return to sport.
Adductor Tendinosis
Pain and inflammation at the insertion of the adductor tendons onto the pubic bones causes pain with running and kicking with tightness and tenderness on resisted adduction of the hip.
Adductor tendon injuries are treated with soft-tissue physical therapy, ultrasound or laser with gradual strengthening of the adductor muscles.
Osteitis Pubis and Pubic Symphysis Diastasis - PSD
The symphysis pubis joint at the front of the pelvis has adductor muscles attaching on either side and abdominal muscles attaching to the top of the pubic bones. The symphysis can shear with sudden and repeated changes of direction during running and kicking or especially if sacro-iliac joints at the back of the pelvis are immobile or there is a significant leg-length difference.
Pain typically radiates to the inner thigh and lower abdominal region often with clicking at the pubis.
Our digital x-rays may show degeneration at the pubic symphysis due to chronic inflammation of the joint.
Treatment includes mobilisation of the sacro-iliac joints and deep massage and acupuncture to the muscles of the pelvis, hips and lumbar spine.
Hip Labral Tears
The hip joint is a common source of groin pain. The labrum is the cartilage lip of the acetabulum or hip socket, adding stability to the joint. A labral tear can cause clicking and pain on flexion and rotational hip movements with pain at the front of the hip which may radiate to the front of the thigh.
Examination can show decreased range of abduction and of internal rotation with the hip flexed at 90° and positive grinding tests. There may be associated spasm and pain in Iliopsoas, piriformis, gluteal and lumbar spinal muscles.
Hip and groin conditions can sometimes cause knee pain due to somatic referral of nerve pain from hip to knee.
Treatment of hip labral tears may involve referral to an orthopaedic surgeon for MRI and arthroscopic surgery.
Pelvic Nerve Entrapments
Compression or irritation of obturator, ilioinguinal or genitofemoral nerves within a self-perpetuating, deep muscle spasm can cause intermittent and poorly localised shooting or burning pain in the pelvis or inner thighs aggravated even by light touch in the nerve distribution. Treatment with pelvic joint mobilisation, deep muscle trigger points and acupuncture, stretches and exercises may help to resolve nerve irritation .
Referral for surgery to release a trapped nerve is occasionally necessary.
N.B. There has been very limited large-scale, clinical research carried out in the physical treatment of coccyx and pelvic pain and therefore limited evidence of the efficacy or otherwise of manual and acupuncture treatment for these conditions.
Michael Durtnall – Acupuncture and Physical Therapy for Chronic and Acute Coccyx and Pelvic Pain. Listed since 2003 with the international www.coccyx.org
Original posting coccyx.org – 16th March 2003
As a chiropractor practising for over twenty five years in central London I have treated well over a hundred cases of coccygeal pain – many due to dislocation after a fall or during pregnancy or as referred pain from sacro-iliac or lumbo-sacral disc or facet joints. I have been successful in resolving symptoms of pain and disability using manipulation treatment aimed at restoring a normal range of movement and function to joints which are locked or dislocated/subluxated or reducing inflammation in hypermobile (loose or unstable) joints by core stability exercises and postural rehabilitation. Specifically, careful and skilled coccygeal manipulation is a crucial factor for good results.
Update, 10th October 2004
Most of the above cases were of relatively recent onset – up to twelve weeks – and most responded rapidly to treatment.
Since my listing on http://www.coccyx.org/ I have treated very many more people who have suffered coccyx pain of much longer duration (up to thirty years) and who have, in many cases, had multiple cortisone injections without longterm relief.
I have reviewed these cases and have concluded that approximately 70% reported improvement of 75-100% in symptoms.
I suspect that repeated cortisone injections can damage the coccygeal joint cartilage thus accelerating calcification and arthrosis of the joint and thereby minimising the chance of regaining normal pain-free joint function. Cortisone injections usually reduce the pain temporarily but without having regained improvement in joint mobility and or position.
The longer the delay in assessment and treatment after onset of pain or injury and the more cortisone injections tend to make the condition more difficult to treat effectively.
Many patients bring their x-rays and MRI scans from referring GPs which is very helpful – but frequently the MRI scans do not include the lower sacrum and coccygeal joints. Many patients have been prescribed anti-depressants and often have not had any examination of the actual area of pain.
In summary, when coccyx pain is of long duration and if coccygeal joints are completely fused, especially in extension (bent backwards) and more particularly if the person is thin (lacking padding), then the chances of improvement are reduced dramatically.
In these cases the last option is surgical removal of the coccyx.
I have received requests for help and advice from osteopaths, physiotherapists and chiropractors from all over the world via http://www.coccyx.org/ and have done my best to explain my treatment and techniques.
I am certainly still learning and I only wish I could have helped more of those suffering this painful and demoralising condition.
Update, 2nd July 2006
Over the last two years I have seen a higher proportion of overweight, very sedentary, typically ‘IT’/computer patients in their 30’s to 60’s with extended (bent backwards) and calcifying or osteoarthrotic sacro-coccygeal joints. There has typically been no significant history of traumatic injury.
This can be clearly shown on our Digital computed, standing , lateral coccyx x-rays which are VERY closely collimated (angled, narrowed down and lead shielded) to MINIMISE x-Ray dosage to the area being examined and avoid ovaries and testes.
Of course even these x-rays are not taken if there is any chance of pregnancy.
Patients have mainly been refused x-ray or MRI evaluation in NHS hospitals where standard x-rays (without extreme collimation) of the entire pelvis would have had to routinely be taken.
I have concluded that many of these cases of chronic coccyx pain have been caused by long-term leaning back and slumping in bad car, office, and home seating at the computer or TV where the pelvis slides forward against the frontal ridge of the depression in the middle of seat cushioning, pressing the coccyx backwards, gradually over months and years, into extension with arthrosis.
The higher the person’s BMI (BODY MASS INDEX) or more overweight they are, the greater this pressure on the coccyx.
I treat but also IMPORTANTLY help my patients to ensure their employer gets them a Swedish HAG Credo or HO4 chair WITH neck rest… (these chairs are fantastic but expensive)… which allows the chair to recline RIGHT BACK at a dramatic angle with a supporting neck rest for surfing the net, phoning and talking, BUT can then tilt far forward with the feet tucked under the chair & thighs tilted down at 25 degrees & ‘back straight’ to work on the keyboard… which takes all pressure off the coccyx and gives good working posture with no neck strain! I love them…all my clinic staff and family have had them over the last 20 years. We can help you find a HAG chair supplier so you can try them out as I have described.
When these coccydynia patients have been previously assessed or treated, in my opinion, they have often been diagnosed with the assumption that it is the more distal, flexed and supposedly hypermobile coccygeal joints which are the cause of the chronic and often extreme pain.
Sacro-coccygeal Manipulation / Mobilisation at the correct levels, patient exercises which I have developed, medical acupuncture to acutely focus the healing process and correct seating brings good resolution in most cases.
Acupuncture around the joint is designed to OVERWHELM the relevant hypersensitive brain areas linked to the chronic coccyx pain which are easily triggered by emotional upset and stress and which potentiate the onset and perception of acute pain.
I have received many more requests for help and advice from coccydynia and pelvic pain sufferers, osteopaths, physiotherapists doctors and chiropractors from all over the world thanks to http://www.coccyx.org/ and have done my best to liaise, train and explain my evolving treatment techniques and protocols.
This research and continuing re-evaluation of treatment protocols has been extremely useful in improving results in patient pain reduction and improved function in our practice. I have been heartened by positive reports via email from chiropractors and therapists around the world who are learning from my experience.
- Don’t leave it too long to improve your seating
- See Swedish HAG Credo or HO4 chair WITH neck rest
- Don’t harm your health by taking long-term anti-inflammatories, painkillers, or by repeated cortisone injections.
- Stop all processed, junk and fast convenience foods for you and your family from now on and lose weight if necessary.
- Start regular and enjoyable exercise, sports or dance.
- Take action sooner than later… NOW is a good time to start.
Update, 2007-05-27:
In April 2007 we installed and have seen the benefit of using the new Fuji Computed Digital x-ray system at Sayer Clinic, Kensington for very high quality x-ray imaging of the spine, pelvic and coccyx joints. We can now manipulate and magnify the images and more precisely show the coccyx sufferer the position and condition of the joints, make a clearer diagnosis and better explain the likely timescale for improvement of symptoms.
I have been seeing more sedentary, computer/IT patients suffering coccyx pain than ever and usually with associated postural problems affecting the whole spine.
More and more patients from all over the world are flying in to see me in London UK for a course of treatment.
Update, 2009-11-29:
Since my last update I have focused on and and attended courses on pelvic pain in Europe and London and I am now listed at the IPPS ‘International Pelvic Pain Society and included in Tatler’s ‘Britain’s 250 Best Private Doctors’, as one of two UK chiropractors listed.
In the last two years, in addition to increasing numbers of people from all parts of the UK and world with longterm and severe coccyx pain, coccyx fractures, dislocations, arthrosis, coccygeus muscle spasm & fibrosis, I have diagnosed and treated many difficult cases of referred pelvic pain:
Coccyx hypomobility causing pelvic floor tension pain and muscular spasm and ’Pudendal Nerve Entrapment (PNE)’ or pelvic neuralgia, with nerves become compressed or stretched near thecoccyx and ischium or “sitting bones” area of the pelvis and referred pain into the perineum, abdomen and buttocks. Many patients had pain on sitting, usually one-sided with burning, numbness and parasthesia in the pelvis near the sacrum and coccyx which can radiate to the perineum, inner thighs, lower abdomen and groins.
Misalignment or fixation of the sacroiliac joints, pubic symphysis, spinal facet joints or sacrococcygeal joints were often causative or a perpetuating factor and were successfully treatable using manipulation, myofascial connective tissue techniques, acupuncture and exercises to reduce nerve compression, muscle spasm and inflammation.
My chiropractic colleagues Robert Griffiths and Chris Berlingieri are also very experienced in coccyx assessment and diagnosis and our computed digital x-ray system has proved really invaluable to patients with its close-detail, x-ray imaging of the spine, pelvic and coccyx joints.
Update, 2009-12-27:
My real and increasing concern is the number of coccyx and pelvic pain patients I see who are “out of it” on a cocktail of morphine-based painkillers, NSAIDs, muscle relaxants and drugs like Pregabalin (Lyrica) from pain clinics.
Patients may feel woozy and tired, potentially leading to lengthening time off work with their social life and interests disappearing . Many become inactive and can become overweight and depressed. Then, in some cases, antidepressants and stronger Morphine-based painkillers are prescribed. Many sufferers off work for 12 months will not work again.
Rather than long waits for pain clinics and orthopaedic referrals for cortisone injections, in my opinion, these sufferers should ask their GPs to refer, and ideally fund, them quickly to experienced chiropractors, osteopaths and physical therapists to properly diagnose and to help maintain them at work with focussed physical treatment, ergonomic advice and gradually increasing exercise. This way, more patients will do well while the few needing surgery can be referred on more quickly to orthopaedic specialists who are experienced in coccyx surgery.
We are seeing an increasing number of women with posteriorally subluxated sacro-coccygeal joints and fractures following Ventouse (suction device) or forceps assisted deliveries in childbirth.
Michael Durtnall
Chairman : Sayer Clinics
N.B. There has been very limited large-scale, clinical research carried out in the physical treatment of coccyx and pelvic pain and therefore limited evidence of the efficacy or otherwise of manual and acupuncture treatment for these conditions.
These conditions have so far been researched by a few clinicians and with small patient numbers. However, Coccyx.org lists available research papers which are well worth reviewing at http://www.coccyx.org/medabs/index.htm
Read the http://www.coccyx.org/ personal experiences of Anonymous, Lee, Becky, Mel, Monica,Kim (1), Chris, Kim (2), Pauline, Adam Pymble, Debbie Dale, Vijay, Alan, Amanda, Nicole,Katy, Maureen, Justin, Mary, Caroline, Duncan, Lorette, Caroline, John McCarthy, Bethan,Caroline, John’s experience , Margaret, Sue, Eileen, Hunter, Laila, David, Galina , Edel ,Virginia, Clare, Anonymous, Awais, Kerry, Generale , Lee, Anonymous
Call Ines or Maggie – here to help you from 8am to 8pm
Email ines@sayerclinics.com or call 020 7937 8978
