By Jennifer Keesee, PT, DPT, PHRC Westlake Village
Michelle is a 39 year old patient who was referred to PHRC by her pain management specialist for evaluation and treatment of tailbone pain, known as Coccydynia. Her symptoms started one year after giving birth to her second child, and had continued off and on for about three years. Michelle did not know what caused the injury, but was working out a lot at the time of onset and thinks this may have contributed. For more on Coccydynia, see this blog post.
Michelle reported sharp pain around the tailbone, which sometimes radiated to the side of her hips. Her symptoms were aggravated by sitting (especially in the car or on hard surfaces) or arching her back and alleviated by standing. Using a cushion with a coccyx cut out and leaning forward helped improve sitting tolerance. Lastly, Michelle had experienced urinary leakage with running, jumping, and sneezing since delivering her two children. She enjoyed doing high intensity aerobic exercise and yoga classes but had stopped due to incontinence and pain.
An MRI several years ago showed a dislocated tailbone. Michelle had participated in several pelvic floor physical therapy (PT) sessions around the initial onset of her symptoms, however they mainly consisted of mobilizing the tailbone and were very painful. She stopped attending PT because she experienced relief with a corticosteroid injection. When her symptoms returned about a year later, she received another injection, however she only had pain relief for six months.
My first thoughts: Michelle had only briefly tried pelvic floor PT but had stopped because it was too painful. She had significant relief with past corticosteroid injections, however had never paired it with PT. I believed that the injections were helping with the pain in the short term, but did not address restrictions in the muscles and connective tissues so once the injection wore off, the pain would return. Due to the severity of her pain, Michelle and I decided it would be beneficial to receive one more injection to help her tolerate therapy, but I warned that it was important to continue with therapy even after the pain decreased to ensure long lasting results.
Examination: When I examined Michelle, I noticed that she shifted her weight from side to side and leaned back to avoid putting direct pressure on her tailbone. I found muscular restrictions throughout her gluteal muscles, hamstrings and deep hip flexors. I also found restrictions in the connective tissue of her abdomen, low back, posterior hips, posterior thighs, and perineum. I assessed Michelle’s pelvic floor muscles vaginally instead of rectally because of her previous painful experience in PT. I discovered that her pelvic floor muscles were tight and weak and she had difficulty relaxing them.
Plan: I suspected that due to Michelle’s hypermobile tailbone, her muscles became very tense to stabilize this joint. Some other things that likely contributed to her pain were the physical stress of two pregnancies and vaginal deliveries, intermittent straining to have a bowel movement, as well as altered posture and biomechanics resulting from the pain. For a double whammy, these tight muscles were not able to effectively contract when she sneezed, ran, or jumped, which caused urinary leakage, known as stress incontinence.
Together we decided to start with a weekly PT session. Our initial goal was to focus on decreasing restrictions in her muscles and connective tissue to allow the pelvic floor muscles to better relax and lengthen. Once this was achieved, we could start working on strengthening and motor control exercises for the pelvic floor to address Michelle’s urinary leakage. I provided education on proper mechanics when having a bowel movement to prevent straining which would make her pelvic floor muscles even tighter. For more details, check out What’s The ‘Right’ Way To Poop? I advised Michelle to start foam rolling her legs and hips and to perform several stretches at home to help relax the pelvic floor muscles and several of the other muscles that attach to the pelvis. She also performed diaphragmatic breathing exercises to help restore the natural movement of her pelvic floor muscles.
Michelle was very dedicated to her home exercise program and reported getting the most relief from foam rolling her glutes. She received a steroid injection between her second and third visits. Afterwards, she noted decreased pain when in the car and was able to sit more upright. At this point she was able to tolerate a rectal exam, during which, I found hypertension in the anal sphincter and and levator ani muscles (a group of muscles which starts at the pubic bone and circle around the vagina and rectum). Since directly mobilizing her tailbone had worsened her pain in the past, I decided to stabilize the tailbone and mobilize the sacrum and found that her muscles were better able to relax afterward.
Around the fifth and sixth sessions, Michelle was only having pain when she sat on very firm surfaces and her muscular and connective tissue restrictions had significantly decreased. In fact, she was sitting upright so much that her low back started to ache, thus it was time to get to work on strengthening her core muscles, which would also help with the incontinence. We added two exercises to get her abdominal, back, gluteal, and pelvic floor muscles working together. Some of these exercises can be found in No-Equipment Workout for a Happy Pelvis and Strong Core. Since Michelle was doing so well, after the fifth session, we decided to decrease treatment from weekly to every other week.
By the seventh session, Michelle had started doing cardio kickboxing classes and noticed that she had minimal leakage! Two weeks later she was able to perform jumping jacks without leaking. At her last session, we agreed that Michelle’s goals had been met so we went over how and when to progress her home exercises. I told Michelle that she should reach out if her pain or stress incontinence returned or if she was unable to progress her exercises as we discussed.
My take home message:
- Coccydynia can be a challenging diagnosis because it typically causes pain with sitting which affects so many activities of daily living. Be proactive like Michelle and get help as soon as you can! Early intervention can prevent worsening of symptoms, chronic pain, and enable you to continue with your active lifestyle.
- An interdisciplinary approach is important when dealing with pain, especially chronic pain. If your symptoms are significantly limiting your daily life, your PT may advise you to work with a pain management specialist. Finding the right intervention to control your pain can help you participate more fully in PT. As I mentioned above, it’s important to continue with PT even after you get relief to address the root cause of your pain.
- Be honest and open with your PT about what your goals are and what is or isn’t working for you. Michelle was very clear on her first visit that her primary goals were to 1) have less pain with sitting, 2) have decreased leakage with activity, and 3) return to her usual exercise routine. Each session we’d discuss what exercises were most beneficial and modify her home exercise program accordingly to meet those goals. Michelle was also very dedicated to performing her home program regularly, which is the primary reason she improved so quickly after having pain for three years.
Here’s what Michelle had to say about her story:
My experience at PHRC was vastly different from previous physical therapy experiences I had. At PHRC, there was a treatment plan in place, which included help from my physical therapist during the appointment, as well as various exercises I would do at home to help alleviate the pain. I felt very confident in Jennifer about her knowledge and expertise in pelvic floor issues, including tailbone pain. She never pushed me past any exercises that I wasn’t comfortable doing or that caused me to hurt. My past PT experiences were very hard–I even had one therapist pull at the tailbone itself, which caused a tremendous amount of pain.
I can dedicate my success to both PHRC for giving me excellent in-person therapy and myself for actually doing the provided at-home exercises. This, combined with a steroid shot, left me pain-free–something I hadn’t experienced in years. Throughout my treatment, Jennifer was always kind, supportive, and understanding of what I was experiencing.
Chronic pain is awful, and sometimes it takes us as the patient to be our own advocates for therapy. But places like PHRC can become advocates with you and are paramount in helping alleviate pain. I didn’t feel “weird” or alone at PHRC. I felt as though what I was going through was validated and that in itself was so very helpful. I’m so thankful I took that first step and called Jennifer. Together, we were able to come up with a unique plan that worked for me and my specific tailbone pain. I think that’s the biggest advice I would give to anyone going through this: you are not alone. Pelvic floor issues and tailbone pain are real. And PHRC is your advocate. They are there to stand by your side and give you the help you need for your pain.
Are you unable to come see us in person in the Bay Area, Southern California or New England? We offer virtual physical therapy appointments too!
Virtual sessions are available with PHRC pelvic floor physical therapists via our video platform, Zoom, or via phone. For more information and to schedule, please visit our digital healthcare page.
In addition to virtual consultation with our physical therapists, we also offer integrative health services with Jandra Mueller, DPT, MS. Jandra is a pelvic floor physical therapist who also has her Master’s degree in Integrative Health and Nutrition. She offers services such as hormone testing via the DUTCH test, comprehensive stool testing for gastrointestinal health concerns, and integrative health coaching and meal planning. For more information about her services and to schedule, please visit our Integrative Health website page.
Melissa Patrick is a certified yoga instructor and meditation teacher and is also available virtually to help, for more information please visit our therapeutic yoga page.
Do you enjoy or blog and want more content from PHRC? Please head over to social media!