Getting to the Bottom of Pelvic Pain: Part 1 — The Anchoring Role of the Coccyx

We’re excited you’re here for Sarton Physical Therapy’s very first (of many) blog posts! On our blog, we’ll aim to discuss, review, and even challenge the latest and greatest topics, trends, and theories in the world of pelvic floor physical therapy. Not to mention, bringing our own clinical experience and new ideas to the table.

If you missed The Pelvic Education Alliance’s Coccyx talk in February that Julie and Michelle gave in San Antonio at the APTA Combined Sections Meeting (CSM), you’ve come to the right place. Over the next few weeks, we will share some of the clinical pearls and highlights from our standing-room-only presentation, right here on our blog.

Hands down, our BIGGEST take-home message from our talk is that coccyx dysfunction is often a root cause for patients with low back or pelvic pain—whether or not they complain of coccyx pain! Upon discovering this, the way we perceived and approached tailbone pain completely switched. Whatever your experience with this region as it relates to the pelvis, we invite you to read more and learn about the various roles the coccyx plays in pelvic pain. 

“Unfortunately, the coccyx is a missing link with many pelvic and low back pain cases.”

It is interesting to note that at least 80% of patients with pelvic pain in our current practice have coccyx dysfunction as part of their root cause. In fact, it’s now one of the reasons we now routinely look at the coccyx with all pelvic patients. 

How does the coccyx affect the pelvic floor?

The coccyx is so influential due to the critical roles—yes, plural—it plays. The coccyx has 4 key functions, which include:

• Anchoring
• Movement
• Support
• Childbirth & Defecation

Each of these roles is important in its own right, but for now let’s start by breaking down the anchoring role. For such a small bone, a tremendous amount attaches to the coccyx. Muscles, fascia, ligaments, the sacrum, the dural tube, and viscera all anchor on the coccyx. That’s a lot of stuff merging onto such a small, but oh-so-mighty, base of our spine! Below is a detailed list of the anterior and posterior attachments:

Anterior Attachments to the Coccyx

• Levator ani, which is comprised of
• Pubococcygeus
• Iliococcygeus
• Puborectalis (attaches to tip of coccyx)
• Coccygeus
• Ano coccygealligament/raphe (positions the anus and is comprised of fibers of the levator ani group)
• Anterior sacrococcygeal ligaments

Posterior Attachments to the Coccyx

• Iliocostalis
• Longissimus
• Multifidus
• Thoracodorsal fascia
• Gluteus maximus
• Posterior sacrococcygeal ligaments

What is the clinical relevance? 

If the position of the coccyx is altered in any way, then this will affect one, or possibly all, of the structures above attaching onto it. Let’s take the dural tube for example. The dura, which is the “sausage casing” around the spinal cord extends from the cranium to the tailbone, creates a bridge between these 2 structures. It is composed of thick, dense, white, fibrous connective tissue. At the cranium level, the dura surrounds your brain and leaves through the foramen magnum of the skull, where it also attaches circumferentially and then makes it way down the around the spinal cord anchoring onto the coccyx. If the coccyx is flexed, extended, side-bent, or rotated, what happens to the dural tube? It is yanked and pulled on affecting every other area it attaches to. Can this affect the neck and the head? Absolutely! Can it affect the nervous system as a whole especially with patients who have CNS up-regulation? Most definitely!

The above clinical application is why we recently were able to successfully treat a headache patient by treating the coccyx and pelvic floor, thereby influencing the dural tube. This patient had been seen for intense manual therapy for her headaches elsewhere for over a year, and after her first treatment to correct her coccyx dysfunction and release tension exerted on it from her hypertonic pelvic floor, her headache lifted for the first time!  

Now, think about the pelvic floor muscles. What happens to those muscles if the coccyx is not positioned correctly? The same thing as the dura. The muscles are compromised. If the coccyx is too flexed, it shortens the distance of attachment of the lev ani form the pubis to the tailbone. This can be an underlying reason for pelvic floor muscle hypertonus that just won’t give, despite manual treatment to the muscles themselves. Likewise, if the coccyx is laterally deviated or sidebent, it will affect the muscles as they run from the pubis to the coccyx on that side by shortening the distance again promoting hypertonicity. The opposite side of muscles will of course compensate setting the stage for a nice muscular imbalance side to side. 

What about the viscera? The coccyx help supports the rectum and the anus. What happens if it the tip is too flexed again? It can restrict and prevent normal expansion of the rectum and defecation in turn is influenced. This can become restricted and feed into what is known as outlet constipation (the train arrives but it just can’t leave the station!). If the tip of the coccyx is pulled too far forward it can close off the outlet and a patient with compensate in 1 of 2 ways:

1. She/he will bear down excessively to use intra-abdominal force to push past this barrier which over time can lead to pelvic organ prolapse and pelvic floor muscle hypertonicity, or
2. She/he will compensate with the sacrum by taking it into a more nutated position, pulling the coccyx out of the way. A picture of this type of posture is seen below.

The Sarton Summary

What’s the take home message here? The position of the coccyx will affect everything that attaches onto it! Every patient with pelvic hypertonus should have their coccyx evaluated as part of their pelvic floor exam, whether or not it hurts. Likely, at some point in their past, they have sustained a fall which has influenced the position of the coccyx. Falls, followed closely by childbirth, are the #1 reason for coccyx dysfunction. Stay tuned as we explore the coccyx’s next vital roles in both childbirth!