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The Coccyx – Gonstead Chiropractic Analysis and Management. David Leach BSc, MChiro

Thursday 22, Mar 2018

The Coccyx – Gonstead Chiropractic Analysis and Management

David Leach BSc, MChiro

Gonstead Diplomate

GCS Australia, 2016

Introduction

Coccydynia is an extremely painful condition that Chiropractors have treated to varying levels of success. True coccyx problems are five times more common in women than in men; probably because of the female pelvis leaving the coccyx more exposed (1).

 

The patient with coccyx pain usually presents with a history of trauma to the coccyx area caused by a fall, car accident, pregnancy or childbirth. Insidious onset of symptoms can occur in response to an aggravation of a pre-existing coccyx injury or a referred pain syndrome. Pain is located directly around the coccyx area and may radiate into the buttocks or legs. Paraesthesia or numbness may occur around the saddle region or posterior thighs. The coccyx subluxation may also result in pain before or during a bowel movement, during intercourse, or around the time of a woman’s period. The pain of a true coccyx problem is characteristically worse on sitting, and gets worse the longer you sit. Pain can last for days after inappropriate sitting, particularly on hard surfaces. Pain is often aggravated when the patient rises quickly from the seated position.

 

Twenty separate cases are presented here to highlight the Gonstead systems analysis of the coccyx and Gonstead’s specific approach to correction.

 

 

Anatomical Review 

 

The Coccyx (os coccygis).  The coccyx (Fig. 1) is usually formed of four rudimentary vertebræ; the number may however be increased to five or diminished to three. In each of the first three segments may be traced a rudimentary body and articular and transverse processes; the last piece (sometimes the third) is a mere nodule of bone. All the segments are destitute of pedicles, laminæ, and spinous processes. The first is the largest; it resembles the lowest sacral vertebra, and often exists as a separate piece; the last three diminish in size from above downward, and are usually fused with one another (2).

 

Surfaces.  The anterior surface is slightly concave, and marked with three transverse grooves that indicate the junctions of the different segments. It gives attachment to the anterior sacrococcygeal ligament and the Levatores ani, and supports part of the rectum. The posterior surface is convex, marked by transverse grooves similar to those on the anterior surface, and presents on either side a linear row of tubercles, the rudimentary articular processes of the coccygeal vertebræ. Of these, the superior pair is large, and is called the coccygeal cornua; they project upward, and articulate with the cornua of the sacrum, and on either side complete the foramen for the transmission of the posterior division of the fifth sacral nerve (2).

 

Borders.  The lateral borders are thin, and exhibit a series of small eminences, which represent the transverse processes of the coccygeal vertebræ. Of these, the first is the largest; it is flattened at the posterior aspect, and often ascends to join the lower part of the thin lateral edge of the sacrum, thus completing the foramen for the transmission of the anterior division of the fifth sacral nerve; the others diminish in size from above downward, and are often wanting. The borders of the coccyx are narrow, and give attachment on either side to the sacrotuberous and sacrospinous ligaments, to the Coccygeus in front of the ligaments, and to the Gluteus maximus behind them (2).

 

Base.  The base presents an oval surface for articulation with the sacrum (2).

 

Apex.  The apex is rounded, and has attached to it the tendon of the sphincter ani externus. It may be bifid, and is sometimes deflected to one or other side (2).

 

Figure 1: The Coccyx Ventral and Dorsal Views

 

 

 

The Gonstead Coccyx Listings

 

The Gonstead listing system pertaining to the coccyx is reproduced here in Table 1 (3, 4, and 5). External trauma to the coccyx will usually misalign the coccyx in an anterior direction, listed as ‘A’. Although less common, the coccyx can misalign in a posterior (‘P’) direction. The coccyx may also deviate to the left or right side depending on the direction of trauma or impact. If the apex of the coccyx deviates to the right, a listing of AR or PR is assigned to the misalignment. If the apex of the coccyx deviates to the left, a listing of AL or PL is assigned to the misalignment.

 

The net effect of coccyx deviation is the creation of an AP wedge in the coccyx’s alignment to the sacrum, or between intercoccygeal segments. This opening of the joint surfaces will correlate to the area of greatest ligament trauma and joint swelling as detected by digital static palpation. The practitioner will observe that the greatest tenderness exists at the lateral aspect of the involved joint, synonymous with the existence of an AP wedge. The AP wedge will occur on the side opposite to the deviation – an AL listing will have an open wedge on the right side, while an AR will have a wedge on the left side.

 

In the case where no AP wedge exists (A or P coccyx listings), tenderness is usually most prevalent over the posterior surface of the coccyx segments. The author has observed a high correlation between the most tender coccyx segment being the portion where subluxation has occurred.  This must be verified on x-ray to confirm the joint misalignment.

 

Table 1: Gonstead Coccyx Listings

 

Coccyx Listings

A

P

AL

AR

PL

PR

       

 

In a previous GCS case study, variations to coccyx listings were presented, including coccyx fractures (6). The author maintains here that the practitioner needs to have awareness of which portion of the coccyx is misaligned – the entire coccyx, the proximal section or the distal section. This is important in order to apply the most appropriate corrective procedure and achieve the best resolution. Examples of x-ray listings are presented below.

 

 

Case History

 

Symptomatic coccyx presentations require a thorough understanding of the aetiology and characteristics of the pain. The practitioner must question the patient on all recent and previous traumas, aggravating and relieving factors, as well as any previous treatment interventions.

 

The asymptomatic coccyx is often discovered either through the case history if a previous trauma or episode was reported, or as an incidental finding on the patient’s x-ray when examining for other presenting complaints. If a coccyx misalignment is present on the patient’s x-ray in the absence of symptoms, it is important to re-question the patient about any previous trauma or episodes of coccydynia.

 

The presence of coccyx pain needs to be differentiated between being a primary coccyx subluxation or a referred pain syndrome. It is widely understood that the symptom of coccyx pain can arise from the coccyx, the sacrum, the sacroiliac joint, the L5/S1 disc, or the T12/L1 disc (6, 7). The flow diagram presented here may assist the practitioner in locating the historical source of coccyx pain (Figure 2).

 

 

 

 

 

 

 

Figure 2: Coccyx History Flow Diagram

 

Coccyx Pain

                                                                                                                   Yes

 

                           Acute Onset                                                                                                                                          Insidious Onset

 

                                                                                                                               

    Abrupt                                          Non-abrupt                                                                                      Past History          Referred            Pathology     

                                             

Subluxation                          Previous history/Subluxation

Dislocation                           Referred pain

Fracture                               Pathology (Primary or Secondary Tumour)

 

 

The history obtained from a patient with coccydynia involves details regarding the coccydynia itself and other underlying conditions that may refer pain to the coccyx region. Questions should relate to the following:

·         Localization of pain - The patient should be asked to indicate or point to the painful site or sites

·         Severity of coccyx pain - The patient should be asked to rate the level of coccygeal pain (Visual Analogue 0-10 scale) when it is at its best and at its worst and to indicate overall pain severity

·         Duration and onset date of coccydynia - The patient should be asked whether any identifiable traumatic incident occurred, recent or remote

·         Exacerbating factors - The patient should be asked whether there is pain associated with, for example, prolonged sitting or sitting on hard versus soft surfaces, as well as with sexual intercourse, standing up after sitting, or bowel movements

·         Sitting tolerance - The patient should be asked to quantify how many minutes of sitting can be tolerated before the pain mandates changing position

 

Other elements of the patient's history that should be obtained or screened for include the following:

·         Cushions tried - Such as donut cushions, which have a circular hole in the middle, or wedge cushions, which have a triangular wedge cut out posteriorly

·         All conservative treatment modalities tried including Chiropractic

·         Oral medications tried and response to these

·         Interventional pain management procedures and response to these - Such as caudal or other epidurals, local anesthetic blocks, and steroid injections, as well as whether these were administered blindly or guided fluoroscopically

·         Gastrointestinal (GI) symptoms – Constipation, diarrhea, bright red blood per rectum, melena (black, tarry stool), and fecal incontinence (any GI workup, such as GI consult, colonoscopy, or rectal exam)

·         Urinary symptoms - For instance, urinary incontinence or dysuria (urinary diagnostic workup, such as urology consult or urinalysis)

·         Female intrapelvic history - Such as uterine fibroids or ovarian cysts

·         Female obstetric history - Childbirth, vaginal or cesarean delivery, and any associated difficulties at the time

·         Female menopausal status - Premenopausal, perimenopausal, or postmenopausal

·         Lower limb neurologic symptoms - Such as radicular pain or lower limb numbness or weakness

·         Concomitant ischial bursitis - Such as unilateral or bilateral ischial buttock pain due to leaning to either side to avoid sitting with pressure on the midline/coccyx region

·         Body weight - Such as any significant increase or decrease in body weight preceding the onset of the symptoms

·         History of cancer - Especially colon, prostate, ovarian, cervical, testicular, or other intrapelvic malignancies

·         Risk factors for cancer - Blood per rectum, abnormal vaginal bleeding, unexplained weight loss, fevers, or chills (10).

 

 

 

Physical Examination

 

Visualisation

 

Direct visual inspection of the skin over the coccygeal region is important. An underlying pilonidal cyst may produce visible discharge, local rash, or a visible skin opening (fistula). In addition, inspecting for a local dimple/divot may be relevant, because in one study, 25 (83%) of 30 patients with a bone spicule at the distal coccyx had a "pit" noted in the overlying skin (8). A bone spicule is a term usually used to describe the bony matrix in the development of a new bone, and intramembranous ossification is an essential process during the natural healing of bone fractures including the coccyx (9).

 

 

 

Static Palpation

 

Sacrococcygeal palpation involves identifying and exerting digital pressure onto the sacrococcygeal junction and the coccyx segments, noting whether the presenting symptoms localize well to that site (ie, exquisite tenderness at the coccyx and/or sacrococcygeal junction, with only mild or absent tenderness at adjacent structures). Chiropractors are encouraged to palpate down the sacral tubercles until the apex of the sacrum is reached. From here, the sacrococcygeal junction and subsequent coccyx segments may be palpated directly or through a single layer of cotton underwear along the length of the coccyx and on both left and right sides. If the coccyx is a primary source of pain, the examination will reveal all tender aspects with emphasis placed on the most exquisite site of tenderness – this will help the practitioner list the subluxated segment as mentioned earlier in the Gonstead Listings section.

The author’s experience has been that it is important to note which section of the coccyx exhibits the most exquisite level of tenderness – the sacrococcygeal junction, the proximal coccyx segment, or distal coccyx segments. This information may be used to help the practitioner decide on the most appropriate form of correction, contact point, and where the focus of that correction needs to occur.

The presence of oedema and pain on the lateral sacrococcygeal ligament may be used to indicate lateral wedging of the coccyx. The side of open wedge will be most tender, indicating the apex of the coccyx has moved to the opposite side (e.g. an AL coccyx will display more tenderness on the right sacrococcygeal ligament, while an AR will be more tender on the left).

Some medical clinicians palpate the coccyx via an internal/external approach; using a gloved hand, they place 1 finger inside the rectum (anterior to the coccyx) and, with another 1 or 2 fingers, palpate externally (posterior to the coccyx). In this way, some clinicians also attempt to assess for increased or decreased sacrococcygeal mobility (10). Patients with severe coccydynia may have difficulty tolerating this examination, and it is beyond the scope of a routine Chiropractic examination.

Palpation of other non-coccygeal structures is an important aid in ruling out pain generators from other sources such as the ischial bursae, sacroiliac joints, lumbosacral joints, thoracolumbar joints and lumbosacral or gluteal muscles. The practitioner must examine for other potential sites of subluxation and referred pain scenarios.

 

Motion Palpation

The Gonstead system does not teach a reliable or tested motion palpation protocol for the coccyx. All motion techniques throughout the skeleton examine for fixation or abnormal motion patterns, and some information could possibly come from the detection of soft tissue movement/tension over the coccyx. It has been the authors’ experience that tissue tension can be felt while palpating the coccyx through cotton cloth while laterally flexing the patient from side to side in the seated position, and possibly while palpating the coccyx through the active movement of sitting to standing. These findings may be potential additional indicators that may or may not always be present.

The challenge for the practitioner could well be in differentiating between a hypomobile and hypermobile coccyx in the symptomatic patient. A functional radiological examination is likely to be the most reliable way of differentiating the two alternatives, helping the practitioner to manage the patient and treatment outcomes most successfully (11). This will be discussed further in the radiology and discussion sections of this paper.

Static palpation and the reproduction of pain when the patient performs the active sitting to standing movement have been historically the most reliable indicators of coccyx subluxation in the Gonstead system (7).

 

Instrumentation

It is well documented in the Gonstead seminars that the use of the Nervoscope gives valid information from the base of the occiput to the lumbosacral junction (7). While the Nervoscope will not help the practitioner locate a primary coccyx subluxation, it is extremely valuable in assessing the spine for other potential sites of subluxation that may refer pain to the coccyx region.

 

Further Examination

Other aspects of the physical examination include the following:

·         Neurologic examination - Strength, sensation, and muscle-stretch reflexes can be assessed throughout the bilateral lower limbs to evaluate for any lumbosacral radiculopathy

·         Motion palpation of the sacroiliac joints, lumbosacral joints and thoracolumbar joints, including documentation of pain with these motions, particularly if the presenting symptoms are reproduced

·         GI and gynecologic physical examination - Depending on the patient's history, abdominal, rectal and gynecologic physical examinations may require referral to a medical practitioner.

 

 

 

Radiographic Examination

 

Chiropractors can use radiography for several purposes following the identification of various history and examination findings. These include:

·         excluding underlying pathological cause (red flags)

·         confirmation of diagnosis/pathology

·         determining appropriateness of care, and

·         identifying contraindications or factors that would affect or modify the type of treatment/care proposed.

 

According to the guidelines of the Chiropractic Board of Australia, radiographs should only be obtained if there is sufficient clinical justification in an evidence-based context. Practitioners must weigh the risk against the benefit in deciding to undertake any radiographic investigation (12). The use of radiographic imaging would be justified in cases of recent or previous coccyx trauma, persistent and unresponsive pain, the presence of pathology risk factors, and spinal trauma in areas capable of referring pain to the coccyx region.

When assessing a symptomatic coccyx patient, the minimum radiographic examination should be an AP and lateral lumbopelvic series in the weight bearing position. Standard full spine standing Gonstead specific radiology films taken at 180-200cm have the added advantage of less patient exposure, reduced magnification, and the assessment of the entire spine for potential referral sites. Depending on equipment capabilities, weight-bearing spot shots of the sacrum/coccyx in the lateral and AP projection (with tube tilt 10° caudad and centered over the superior pubis) will give information that is more specific especially if fracture is suspected. The amount of mAs compared to the normal AP exposure would be reduced in consideration of patient size and coccyx density. If the lateral film shows a large degree of anteriority, then consider a 15° caudad tube tilt (14). Should the available films not be of diagnostic quality, then the practitioner should consider referral to a radiology practice for either plain films or an MRI study. MRI can be extremely helpful in assessing nondissociated sacral fractures, coccyx fractures, and pathology or tumors.

 

The lateral film is essential in determining whether the coccyx has misaligned in an anterior or posterior direction, giving the primary first letter of the listing. It also allows the practitioner to understand how many segments the coccyx has, and where the misalignment has occurred – at the sacrococcygeal joint (proximal coccyx), or between the coccyx segments themselves (distal coccyx). This helps the practitioner determine the best contact point and line of correction.

 

Assessing whether an individual coccyx segment has misaligned left or right poses a problem in most Gonstead practices given the x-ray exposure factors for a standard AP film are more considerate of lumbar and pelvic bone density than of coccyx exposure factors. Specific coccyx AP x-rays with tube tilt would be needed in most cases to gain radiographic evidence of laterality.  Reliable information can be gained from digital palpation of the lateral coccyx with more tenderness being palpated on the opposite side to lateral deviation (ie. on the side of open wedge), and should be used in conjunction with x-ray findings.

 

Functional radiographs of the coccyx should be considered if the patient is slow to respond to treatment and/or the practitioner suspects a hypermobility syndrome. Using the same projection factors for the erect lateral coccyx/sacrum, position the patient to sit on a flat surface (e.g. a folding plastic chair or similar) until the pain is reproduced. Expose the film in the seated lateral position once the beam has been centered over the mid sacrum area using the greater trochanter and sacral tubercles as landmarks.

 

The following x-rays represent typical findings in the assessment of the coccyx:

 

Figure 3. Normal Coccyx Alignment

 

Note this three-segment coccyx follows both concave anterior and posterior curves of the sacrum, with no interruption to this alignment. The intersegmental articulations and the sacrococcygeal articulation are uniform and opposing joint surfaces are largely parallel.

 

 

Figure 4. The Posterior Coccyx.

Note in this posterior 3-segment coccyx the interruption to the sacral curves with the entire coccyx moving towards the dorsal surface of the body. Correction would need to occur at the sacrococcygeal junction in this case.

 

 

Figure 5. Anterior proximal coccyx.

Note the proximal section of the coccyx is anterior to the apex of the sacrum with clear disruption to the anterior line of the sacrum. The two distal segments of the coccyx still appear in good alignment to the proximal or first coccygeal segment. Some remodelling of the sacral apex is noted in this case. Correction would occur around the sacrococcygeal joint in the presence of supportive palpation findings.

 

 

Figure 6. Anterior distal coccyx.

 

 

The two distal segments in this coccyx are anterior to the first coccyx segment, which still shows good alignment with the sacral apex. Uniformity is lost with the anterior margin of the sacrum. Correction of the anterior distal coccyx would occur around the first intercoccygeal articulation in this instance. An L5 spondylolisthesis is also noted in this x-ray.

 

 

Figure 7. Fractured proximal coccyx.

 

 

In this proximal coccyx fracture, the first coccyx segment is anterior to both the sacral apex and the second coccyx segment. This patient fell backwards onto the edge of a metal step. The alignment of the proximal coccyx at the sacrococcygeal joint and first intercoccygeal joint were addressed in this case. The proximal segment was deemed to be anterior to both the sacral apex and second coccyx segment.

 

 

Figure 8. The Hypermobile Coccyx.

A.   Dislocation of the coccyx (left: standing; right: seated).

Note the posterior translation of the entire coccyx at the sacrococcygeal articulation in the seated position, indicative of severe ligament damage. Functional x-rays are necessary to visualize these unstable coccyx presentations.

 

B.    Hypermobility of the coccyx (greater than 25-degree change of angle between standing and sitting). Images reprinted with permission from Jean Yves Maigne, MD (13).

 

Note the large degree of anterior movement of the distal coccyx when comparing the standing to the seated x-ray. This is likely to be due to ligament damage leading to instability (11).

 

 

Figure 9. Coccyx Pathology

 

 

Arrows indicate a primary carcinoid tumor creating pressure and irritation to the lower anterior branches of the coccygeal nerve, producing worsening coccydynia symptoms.

 

Note an anterior coccyx was found on the initial x-ray which initial treatment gave temporary relief. Further treatment gave no response, prompting the referral for MRI and medical assessment. A malignant carcinoid tumour seen here on MRI is related to a cystic birth defect triggered by menopause. The tumour was removed, along with the coccyx, S5, S4 and a portion of S3 as seen on the post-surgical x-ray above.

 

 

Coccyx Case Studies

 

The following table represents a series of coccyx presentations at the authors practice. Note that symptomatic and asymptomatic patients are included. Symptomatic patients include the method of correction used for a successful resolution of symptoms. No coccyx adjustments were administered to asymptomatic patients where the coccyx showed no signs of subluxation.

 

 

 

 

 

 

 

Table 2. Coccyx case presentations.

Age

Sex

X-ray

Listing

Anatomy

Cause

Technique

Contact

14

F

X

Normal

3Segment

T

AS

 

44

F

X

P

3

CB

AS

 

44

F

X

A-prox

3

T

AS

 

36

F

X + MRI

AR-dist, # Sac4

3

T

PB, Prone Hilo

Pisiform Lt First ICJ

24

F

X

A-prox

2

T

PB

Pisiform  over coccyx just inferior to SCJ

26

F

X

A-prox

3

T

AS

 

57

F

X

# A-prox

3

T

Internal

Ant mid finger distal phalanx over ant surface 1st Coccyx seg

44

F

X

A

2

T

AS

 

34

M

X

A-dist

3

T

AS

 

63

F

X + MRI

AL-dist

3

I, PY

PB, Prone Hilo, Surgery

PB- Pisi Rt First ICJ    Hilo- Thumb/Pisi   

46

M

X

A-dist

3

T

AS

 

15

F

X

A-dist

3

T

AS

 

24

F

X

A-dist

3

T

PB, Prone Hilo

Hilo- Thumb/Pisi over 2ndCoccyx seg

47

F

X

AR

3

R

PB Left Ilium

Pisi Ischial Spine

65

F

X

U

U

I

Coccygectomy

 

55

F

X

# A-prox

3

T

Internal

Distal Phalanx over Ant Prox Coccyx

33

F

X

A-dist

3

T

PB

Pisi over 2ndCoccyx seg, just inf to ICJ

35

M

X

P

3

T

PB

Pisi over 1stCoccyx seg, just inf to SCJ

42

M

X

AL-prox

3

T

PB, Prone Hilo, Internal

Internal ant 1stCoccyx seg Rt bias

59

M

X+MRI

AL

3

T

PB

Rt 1st coccyx, inf to SCJ

                   

Key: F = female, M = male, X = diagnostic x-ray, MRI = Magnetic Resonance Imaging; ICJ = intercoccygeal joint; SCJ = sacrococcygeal joint; # = fracture, U = unknown, T = direct trauma, CB = childbirth, I = insidious onset, PY = pathology, R = referred pain, AS = asymptomatic, PB = pelvic bench side posture move, Pisi = Pisiform contact.

 

 

Discussion

 

 

This sample of clinical cases supports the notion that coccyx misalignments are more prevalent in females (1). Misalignments at the sacrococcygeal joint compared to the intercoccygeal joint appear equally common. Listings around the sacrococcygeal joint usually responded well to the side posture correction on the pelvic bench. Subluxations involving the distal coccyx responded to both the pelvic bench and prone Hilo techniques. The author has observed that the more severe misalignments of the distal coccyx are more likely to require the prone Hilo adjustment with the pelvic piece wound up far enough to expose the patient’s coccyx. It would be acceptable in the author’s experience to commence treatment for the coccyx subluxation on the pelvic bench, and move to the Hilo and then the internal technique if the patient symptoms had not been resolved with the previous approach. The practitioner may vary this approach based on the size of the patient, the presentation, and listing on a case-by-case basis. It would be common to attempt external procedures prior to utilising an internal correction. The authors experience has been that only unresponsive cases and anterior fracture/dislocation presentations have required an internal correction.

 

Typically, a good audible setting will give some immediate changes if applied to the correct coccyx segment. Each patient presented here required a varying number of treatments to resolve their coccyx symptoms. As always, after good symptomatic response is achieved, it is imperative to spread the distance between the next follow up appointment to allow the body sufficient healing time. This reduces the possibility of the practitioner over adjusting the coccyx or interrupting the healing process. Once the patient achieves a pain free status, the Gonstead System’s approach would be to leave the coccyx alone to allow sufficient healing time (7). Consider readjusting the coccyx only if symptoms return. This approach has worked well with the cases presented here.

 

When a coccyx procedure is not producing results, the practitioner should move to a different procedure, recheck the patient for referred pain scenarios, and consider pathology. The pathology case of malignant carcinoid tumour presented here had an insidious onset that showed initial improvement to the adjustments, but with subsequent successful audible adjustments, the patient plateaued and then started to get worse. In fact, symptoms showed continued deterioration despite the patient avoiding known aggravating factors. Referral and surgical intervention were employed to remove the tumor and its compression of the distal branches of the coccygeal nerve, with successful resolution of her coccyx pain. The patient did return twice several months’ post surgery with a right sacroiliac subluxation that cleared with specific Gonstead adjustments to her ilium. The practitioner should remain open to all possible diagnoses in the unresponsive or deteriorating patient.

When the practitioner encounters a patient that is not responding as expected (in the absence of pathology), we need to expand our current thinking on the misalignment equating to fixation model. As seen here in Figure 9, seated x-rays can be very useful in understanding the difficult coccyx case. Dynamic lateral coccyx x-rays were developed by Jean Yves Maigne, MD, of France (13). A standing lateral coccyx x-ray is taken first, then have the patient sit on a hard surface for a couple of minutes, reproducing their typical pain, and then shoot a sitting lateral coccyx film. Compare the films, especially the angle of flexion at the sacrococcygeal junction and between the segments of the coccyx. The x-ray is examining for excessive or aberrant motion, as well as the coccyx position when symptomatic. Greater than 25 degrees of change in angulations of the coccyx segment on the sitting x-ray is positive for instability.

The seated x-ray may provide two significant findings. The first is dislocation: a coccyx that completely loses its normal relationship to the other coccygeal segments or the sacrum when sitting. In a dislocation, a segment of the coccyx has shifted or translated when compared to the erect film. The second is hypermobility: a coccyx segment that has more than 25 degrees of motion (usually into flexion), when comparing the standing film to the sitting film. Both of these findings represent excessive motion and support the theory that excessive ligament damage has occurred during injury, creating instability. Excessive mobility is the opposite of the previously mentioned fixation model, and can explain why a patient takes longer to respond, or is unresponsive to specific adjustments. Adjusting an unstable segment may give temporary relief, but will most certainly require time for stabilization and rehabilitation to occur. The author recommends the reader reviews Heller’s 2016 Dynamic Chiropractic article that is inclusive of approaches to rehabilitation in these difficult cases (11). It is likely that the use of dynamic coccyx x-rays will increase the practitioners understanding and facilitates management of the difficult case.

The Gonstead practitioner takes time to diagnose and understand the nature of a coccyx injury, including the joint in lesion. Equally, we must take care in performing the most specific correction possible that will elicit the best response. Adjustment procedures have an emphasis on speed and accuracy. Locating the contact point for those listings mentioned in Table 2 requires effort and concentration to ensure the doctors’ contact ends up in the correct position. In the case of an A coccyx, the doctor is using tissue slack pulled in an inferior to superior direction to end up just inferior to the joint around which subluxation has occurred. The line of correction (LOC) is a short amplitude, high velocity thrust in a further inferior to superior direction, using the skin to ‘drag’ the anterior coccyx posteriorly. The mechanics here are the same whether the adjustment is performed on the pelvic bench with a pisiform contact, or prone on the Hilo with a pisiform on thumb contact. As noted earlier, the Hilo may provide the doctor with better access to the coccyx when needing to correct anterior distal segments.

In the case where there is lateral deviation in the listing, the point of contact is on the side of open wedge, as close as possible to the lateral aspect of the coccyx segment and just inferior to the joint in lesion. Emphasis in finding the point of contact, dragging the tissue slack up to that point with the cephalad hand, and placing the pisiform or thumb pisiform contact specifically is paramount to a specific setting. The LOC for the AL/AR listings is inferior to superior, with the open wedge resolved by point of contact as the anterior component of the listing is corrected.

When dealing with a posterior listing, the practitioner contact point will again involve tissue pull in a superior to inferior direction to a point just inferior to the subluxated joint. The P coccyx is best corrected in the side posture position with a pisiform contact, and a LOC of posterior to anterior, and superior to inferior through the joint plane line. If the listing is PL or PR, then the contact point is varied to the side of open wedge, as close to the coccyx as possible and just inferior to the joint in question. It is important to remember that the primary direction of the misalignment is P, which necessitates the same LOC.

When the coccyx misalignment is not responding to external procedures and functional x-rays negate hypermobility or dislocation, then the practitioner may need to consider the internal procedure. Patient consent and clear discussion of the procedure must occur first, and practitioners should consider having an assistant in the room during the procedure. A gloved middle finger with suitable lubricant is guided through the rectum until the anterior portion of the coccyx is felt through the rectal wall. The case study above of the 42yo male who finally required an internal procedure was found to have tenderness over the involved coccyx segment when palpated through the rectal wall. While stabilizing the sacral apex with the secondary hand, the distal tip of the primary contact takes the contact to the point of tension through the rectal wall, and is then gently lifted in an anterior to posterior direction. This created an audible release, instant relief, and was repeated on two further occasions when symptoms returned until stability was achieved. The case presented in Figure 7 above of the fractured anterior proximal coccyx segment required a slightly different adjustive procedure. The practitioner needs to be conscious that there could be some splintering of bone fragments during fracture, and working on the anterior surface of the fractured segment presents a significant risk factor. To minimize the risk in this case, the anterior margin of the first coccyx segment was held lightly with the primary contact through the rectal wall – the pressure used here was gauged completely on the patient tolerance level in what was an extremely painful procedure. A secondary contact using the base of the first metacarpal of the cephalad hand over the apex of the sacrum gently thrusted the sacrum forward to meet the fractured segment. An audible release was achieved, and the procedure was repeated two more times before the patient was allowed 6 weeks for the site to heal. No further correction was felt on the final procedure, which leads to the decision to leave the segment alone. Post x-rays 3 months later showed a reduction in the anterior displacement and a resolution of the coccyx symptoms.

Conclusion

Coccydynia is a debilitating condition that can severely affect a patients’ quality of life. This paper represents a specific approach to analysis of the coccyx. Misalignment can be present on x-ray without the coccyx being symptomatic and alone does not represent a need for intervention. Signs of subluxation and symptoms must be present before coccyx intervention is considered.

In addition to the patient history, digital palpation, pain from sitting to standing, and x-ray analysis represent the most reliable indicators of coccyx subluxation. The site of most exquisite tenderness is often equated to the site of primary subluxation, and gives the practitioner valuable information on the location of a proximal or distal coccyx subluxation, and best point of contact for correction. The use of dynamic functional x-rays is also recommended for the resolution of difficult cases.

The practitioner should consider all possibilities in the origin of coccyx pain including local subluxation, referred pain syndromes from other sites of subluxation or injury, hypomobility vs hypermobility, and pathology.

The specific Gonstead analysis documented here has lead to the resolution of multiple cases of coccydynia.

 

 

 

References

 

1.    http://www.coccyx.org/whatisit/index.htm

2.    http://www.theodora.com/anatomy/the_sacral_and_coccygeal_vertebrae.html

3.    Herbst, Gonstead Chapters, p 47-48

4.    Plaugher, G. Williams & Wilkins, A Specific Biomechanical Approach, p185

5.    Dr Chris Hart, Gonstead Workbook, p 35

6.    The Coccyx – A Specific Approach, Gonstead Diplomate Recertification Paper 2009, by David Leach (GCS Diplomate).

7.    Gonstead Seminar of Chiropractic, Seminar Notes, 1993-2015.

8.    Maigne JY, Chatellier G, Faou ML, et al. The treatment of chronic coccydynia with intrarectal manipulation: a randomized controlled study. Spine. 2006 Aug 15. 31(18):E621-7. [Medline].

9.    Brighton, Carl T. and Robert M. Hunt (1991), "Early histological and ultrastructural changes in medullary fracture callus", Journal of Bone and Joint Surgery73-A (6): 832-847

10. http://emedicine.medscape.com/article/309486-clinical#b3

11. Marc D. Heller, Dynamic Chiropractic, Vol 34, Number 3, 2016 Treating Pain: The Hypermobile Coccyx.

12. http://www.chiropracticboard.gov.au/Codes-guidelines/FAQ/Conduct-performance/Chiropractic-diagnostic-imaging.aspx

13.  Maigne, JY. Management of Common Coccydinia 2002, as reprinted on www.coccyx.org, with description of dynamic coccyx X-ray procedure.

14. http://www.radtechonduty.com/2014/12/x-ray-of-coccyx-ap-axial-projection...