LONG CASE REPORT

Pat.Name: Kim, Duk Ye No.: Low Back 2

working/Dx.: Acute post-traumatic coccyx dysfunction (AL coccyx).

Dr's Name: Jo, kyung bok Clinician Sign:

Chief Complaint

A 53 years old female presents with severe coccyx pain of 1 weeks duration following a forceful sitting incident. The pain has been a constant intense ache aggravated by sitting and defecation and relieved by walking.

1. Humanistic Factors

Philosophical

This patient fits within the chiropractic paradigm as there are no contraindications to conservative management.

Psychological

Be aware that many patients with long standing coccyx pain demonstrate a major emotional component to their symptoms.

Sociocultural

Treatment of this intimate region requires consideration of the patients cultural background and traditions.

2. Functional Morphology

Anatomy

Coccyx is a small triangular bone composed of four fused rudimentary vertebrae.

The coccyx is directed downwards and anteriorly from the apex of the sacrum so that its pelvic surface is directed anteriorly and its

dorsal surface faces posteriorly.

Includes the anatomy of the sacrum and coccyx and their pelvic relations.

The coccyx is a delicate structure situated at the lowest point of the sacrum. Its position in the body leaves it vulnerable to trauma

from falls onto the buttocks, car accidents, childbirth (especially difficult deliveries) and scarring from abdominal surgeries such as hysterectomy and episiotomy. Physical or sexual abuse and chronic slumped sitting posture are other causes of persistent tailbone pain. In all of these situations, the coccyx may become anteverted, retroverted, or lateroverted (pushed too far forward, backward, or to the side). The result is frequently embarrassing and sometimes debilitating pain.

Chronic dyspareunia may be caused by adhesions following episiotomy or plastic repair of the vagina. Endometriosis, vaginitis, pelvic inflammatory disease and radiation therapy sometimes result in chronic painful intercourse due to adhesion formation at the round or broad ligaments, uterus or other structures.

sacrum (vertebrae sacrales I-V), sacral bone: five sacral vertebrae.

Coccygeal vertebrae (os coccygis), coccyx: Small, triangular bone at the lower end of the vertebral column, formed by the fusion of four rudimentary vertebrae and articulating with the sacrum.

Main part :

Ala of sacrum (ala sacralis): Lateral part of the base of the sacrum.

Base of sacrum (basis ossis sacri): Broad upper part of the sacrum (the first sacral vertebra).

Apex of sacrum (apex ossis sacri): The lower tip of sacrum for the attachment to the coccyx.

Auricular surface (facies auricularis): large ear-shaped articular surface for the ilium bone.

Sacral canal (canalis sacralis): The lower part of the vertebral (spinal) canal.

1. CHARACTERISTICS OF THE COCCYGEAL REGION

In most adults, four, small, fused vertebrae form the coccyx. The "intervertebral space" between Co 1 and Co 2 will persist the longest. All segments consist of a "vertebral body". Only Co 1 has additional feature worthy of mention.

Co 1 Features

1) Vertebral Body

Upper and lower surfaces may bear peripheral regions resembling the epiphyseal rim. Often the surfaces appear like fingerprints.

2) Coccygeal Cornuae

A bony process is found posterior and ksuperior to the vertebral body. It is thought to represent the superior articular process & facet of Co1 (perhaps some of the pedicle as well). These are the coccygeal cornuae

3) Transverse process

A pair of rudimentary processes extent laterally, these represent the transverse processes.

4) No vertebral foramen exists for coccyx.

2. THE SACRO-COCCYGEAL JOINT

A synovial joint is lacking in this articulation. The intervertebral disc is classified as an amphiarthrosis amphiarthrosis syndesmosis.

3. INTERVERTEBRAL DISC

Although this structure lies between the bodies of S5 and Co1 in the position of an intervertebral disc, its histology does not demonstrate the characteristics previously described. It is a true fibrocartilaginous joint.

4. VENTRAL SACRO-COCCYGEAL LIGAMENT

The ventral sacro-coccygeal ligament is the inferior continuation of the anteior longitudinal ligament. It attaches to the front of the vertebral bodies from about S3 to Co2 or Co3.

5. SUPERFICIAL DORSAL SACRO-COCCYGEAL LIGAMENT

This ligament will attach to the margins of the sacral hiatus and sacral cornuae superiorly and to the body of Co 1 posteroinferiorly. The superficial dorsal sacro-coccygeal ligament is the homolog of the ligamentum flavum and forms the posterior wall of the spinal canal.

6. DEEP DORSAL SACRO-COCCYGEAL LIGAMENT

A continuation of the posterior longitudinal ligament, the deep dorsal sacro-coccygeal ligament attaches to the vertebral bodies of the lower sacral segments and to the back of the body of Co 1 where it blends with the superficial dorsal sacro-coccygeal ligament fibers. Together, these two ligaments form the anterior and posterior ligamentous boundaries for the sacral canal.

7. LATERAL SACRO-COCCYGEAL LIGAMENT

This homolog of the intertransverse ligament is attached to the inferolateral margin of sacrum and to the short transverse process of Co 1.

8. INTERCORNUAL LIGAMENT

As its name implies, the intercornual ligament attaches the sacral cornu of S5 to the coccygeal cornu of Co 1.

It represents the capsular ligament of synovial joints.

Past surgeries may create or contribute to these conditions. Many women have undergone abdominal or pelvic surgeries for other conditions earlier in their lives. Unfortunately, even the most skilled surgeon cannot prevent the formation of adhesions after some surgeries. According a recent study in the British Journal of Surgery, 55% to 100% of patients will develop adhesions following gynecologic surgery. Surgeries such as episiotomy, C-section, abortion, hysterectomy, D. and C., and even lysis (removal) of

adhesions may cause additional adhesions to form.

Sacrococcygeal dysfunctions are often poorly defined and improperly treated. When encountered, the pain can be excruciating, frustrating and often difficult to treat. It occurs roughly twice as frequently in females as in males. Unfortunately, due to the intimate nature and relative inaccessibility of the coccyx it often gets overlooked and is left untreated as a cause of lower back pain and dysfunction.

Common symptoms of coccydynia and dyspareunia include painful intercourse, burning pain in the lower back and sacroiliac region, hip, buttock, and groin, inability to sit for long periods of time, frequent bladder infections, prostatitis, and hemorrhoids. Almost all of the soft tissues of the pelvis are attached to the coccyx. When the coccyx is displaced forward (toward the pubic bones), this relaxes the bladder and the rectum. This may result in urinary or fecal incontinence. Reproductive function can also be affected by this mechanism. Examples of problems can include inability to have an orgasm or difficulty maintaining an erection, decreased libido, and even infertility.

If the condition persists, swelling and inflammation occurs in and around the area. Compensatory postures to avoid pain in sitting can lead to low back or hip pain. If the situation is allowed to continue, small adhesions may form at the site, and the muscles and ligaments get tighter, creating a chronic situation. Medications may help reduce the pain or inflammation, but the situation will persist until the underlying cause of the pain is addressed. Bony pelvis bound posteriorly by the vertebral sacrum and coccyx and laterally and anteriorly by hip bones.

* Vertebral elements

* a. Sacrum

* 5 fused vertebrae

* pelvic surface is fused bodies

* lateral ala (fused transverse processes) articulate with the ilium to form the sacroiliac joint

* ventral rami of S1-S4 emerge from pelvic sacral foramina

* median sacral crest: fused spinous processes of sacral vartebrae

* sacral hiatus: lower sacral vertebral arches lacking, allowing caudal access to the vertebral canal

* b. Coccyx

* 3-5 fused bones joined to the sacrum by sacrococcygeal ligaments

* (no synovial joint)

* provides attachment for pelvic muscles and ligaments

* Hip bones (os coxae)

all 3 contribute to the acetabulum, the pelvic socket of the hip joint

* a. Ilium

* Iliac fossa and crest

* Anterior superior iliac spine (ASIS)

* Posterior superior iliac spine (PSIS)

may be marked by surface dimpling

* b. Ischium

* supports weight in a seated position

* bears an ischial spine and an ischial tuberosity

* ischial rami (superior and inferior) form lateral margins of the obturator foramen

* c. Pubis

* Symphysis pubis: midline cartilaginous joint

* Pubic rami (superior and inferior) form medial margins of the obturator foramen

* Pelvic notches

converted to foramina by specific pelvic ligaments

* Greater sciatic notch: between auricular process of the ilium and the ischial spine

* Lesser sciatic notch: between ischial spine and ischial tuberosity

* Pelvic ligaments

* Sacrospinous ligament: extends from the lateral margin of the sacrum and coccyx to the ischial spine

* Sacrotuberous ligament: extends from the sacrum to the ischial tuberosity

* Pelvic foramina

traversed by important nerves and blood vessels exiting or entering pelvic or perineal spaces

* Greater sciatic foramen

formed between the greater sciatic notch and the sacrospinous ligament

* Lesser sciatic foramen

formed between lesser sciatic notch and sacrotuberous ligament

* Obturator foramen

Formed by the union of ischial and pubic rami

Mostly closed by the obturator membrane

An obturator canal at the anterosuperior margin transmits obturator nerves and blood vessels (which supply the thigh)

* Pelvic boundaries

* False pelvis (pelvis major)

Lies between the iliac fossae but superior to the pelvic inlet

Part of the abdominal cavity proper; contains abdominal viscera

* True pelvis (pelvis minor)

Lies inferior to the pelvic inlet

Inferior boundary coincides with a line drawn between the tip of the coccyx and the inferior border of the pubic symphysis

Contains pelvic viscera

* Pelvic inlet (pelvic brim; superior pelvic aperture)

Bounded by symphysis pubis, sacral promontory, and iliopectineal lines

Coincides with a line between the sacral promontory and the superior border of the pubic symphysis

Shape varies with sex, race, and nutritional history

* Pelvic outlet (inferior pelvic aperture)

Bounded posteriorly by coccyx and sacrum, anteriorly by the inferior border of the pubic symphysis, and laterally by ischial tuberosities

* Pelvic cavity

space between the inlet and outlet

* Pelvic axis

a curved line joining the midpoints of the A-P diameters of the inlet and outlet

Classification of pelvis (by shape of the pelvic inlet):

conjugate (A-P) diameter: measured from the superior pubic symphysis to the sacral promontory transverse diameter: measured between iliopectineal lines at the widest point

* Gynecoid

Conjugate diameter exceeds transverse; wide inlet and outlet, straight walls facilitates vaginal delivery present in 43% females

(Caucasian and African American), few males

* Android

Transverse diameter exceeds conjugate; wide superior aperture but narrow inferior aperture

Present in 33% Caucasian females, 16% African-American females, most males

* Anthropoid

Conjugate diameter exceeds transverse

Found in 24% Caucasian females, 41% African-American females; common in males

* Platypelloid

Transverse diameter exceeds conjugate to a relatively extreme degree

Uncommon in either sex

Walls of the pelvic cavity

composed of the bones and ligaments of the bony pelvis, superficial muscles, and deep muscles and associated vasculature and nerves

* Posterior wall: the smooth, concave, anterior surface of the sacrum and coccyx

primary muscle is the pyriformis, which forms a muscular bed for the sacral plexus

* Anterior wall: pubis, pubic symphysis, pubic rami, obturator internus muscle, and fascia

* Lateral walls

bones are medial aspects of the ilium and the ischium

major features are the obturator internus muscle, its fascia, the obturator nerve, and blood vessels

* Pelvic floor

Formed by the pelvic diaphragm, a funnel-shaped sheet of muscles and connective tissue that supports abdominopelvic viscera Separates the pelvic cavity from the perineum Penetrated by rectum, urethra, and (in females) vagina

Muscles are the (ischio)coccygeus and divisions of the levator ani Pelvic diaphragm

a funnel-shaped sheet of muscles that comprises the floor of the pelvic cavity and the roof of the perineum

* Piriformis

Arises from the lateral margins of the sacrum Exits the pelvic cavity via the greater sciatic foramen to insert on the femur Sacral plexus forms on the pelvic surface and exits the pelvis with the muscle

* Obturator internus

Contributes to the lateral walls of both the pelvic cavity and the perineum

Arises from the medial surface of the obturator membrane and its bony margins

Has a broad, fan-shaped origin that tapers to exit the pelvis via the lesser sciatic notch as a narrow tendon

* Levator ani muscles

Muscle fibers originate from inner surfaces of the anterior pelvis and sweep posteromedially to converge on midline structures

May be morphologically sub-divided into iliococcygeus, puborectalis, pubovaginalis/levator prostatae, and pubococcygeus

* Iliococcygeus

Fibers originate on lateral walls (archs tendineus and ischial spine)

Medial attachments (coccyx, medial raphe) are posterior to the anus

* Puborectalis

Each muscle arises from the pubis, passes posteriorly, and joins with its partner to form a U-shaped muscular sling

around the anorectal junction

Maintains the anorectal flexure

* Pubovaginalis/levator prostatae

Medial fibers of puborectalis converge medially to insert into the perineal body

In females, some fibers insert into and re-inforce the walls of the vagina

In males, fibers from the two sides meet anterior to the anus to re-inforce the muscular floor beneath the prostate

* Pubococcygeus

Main part of levator ani

Each muscle arises from the pubis and arcus tendineus (a condensation of fascia extending across obturator internus),

passes posteromedially, and inserts into the coccyx and the anococcygeal ligament [a fibrous union of converging muscles]

Medial fibers converge onto midline structures

* Coccygeus (ischiococcygeus)

Assists the levator ani in supporting pelvic viscera

Triangular in shape; arises from the ischial spine and fans out to insert on the lateral borders of the lower sacrum and the upper coccyx

Gender

Coccydynia is more common in women.

3. Normal and Abnormal Function

Biomechanical basis

Coccyx (tailbone) pain, menstrual pain, pre-menstrual syndrome, PMS and pailful periods may all have a biomechanical cause. In many cases these conditions may be treated without drugs or surgery. Even with a diagnosis of endometriosis, the actual pain often comes from adhesions or scar tissue accompanying the endometriosis. These patients often respond quickly to our very unique,

non-surgical physical and massage therapy treatment.

Anterior and lateral displacement of the coccyx with associated piriformis hypertonicity and tenderness.

The Coccyx Defined as a Supposed Vestige Humans differ from most primates in that they lack a tail. The lower primates have tails, and the apes, which are believed by many to be our closest relatives, likewise are tailless. The human coccyx (also called the os coccyx) was viewed by Drummond (1903) as a rudimentary tail left over from our distant past and therefore vestigial. The coccyx bones were interpreted as remnants of a structure which strongly linked humans to the lower primates.

Both D. Morris (1985) and Pansky (1975) saw the coccyx as all that yet remains of our primate tail. Cartmill et al. (1987:186) asserted that the coccygeus muscle and sacrospinous ligament which attach to the coccyx are vestiges of a powerful muscle that acts to tuck the tail down in a dog body: Pinchot (1985:41) claimed that the coccyx is the only part of the skeleton without a function.

The coccyx and associated structures were and still are believed to be useless remnants of evolution.

The coccyx is composed of three to five (usually four) nodular pieces of fused vertebral bones at the lowest part of the vertebral column. There is some evidence that the coccyx in modern humans is one vertebra longer than it was in Neanderthals; but this difference may be merely a racial variation.

The coccyx is triangular in shape and attached to the bottom of the sacrum. Its name coccyx means cuckoo; it was named because of its resemblance to a cuckoo by Robert Walker (1987:253). Because it is not connected to the ribs, the coccyx does not have pedicles, lamina, or spinous processes that are present on certain other vertebrae. The coccygeal vertebrae have only three transverse grooves which provide an attachment to the ventral sacrococcygeal ligaments and the levatores aid, two broad thin muscles which form part of the hammock-like floor of the pelvis. These muscles function as a single sheet which extends across the middle line, forming the principal part of the pelvic diaphragm and support for the rectum. The coccygeus muscle also helps to support the posterior organs of the pelvic floor, especially during blocked forced expiration, as in elimination.

The coccygeus muscle can draw the coccyx ventrally to give added support to the pelvic floor against abdominal pressure. It draws the coccyx forward after defecation. This muscle is inserted by its base into the margin of the coccyx and into the side of the last section of the sacrum. The coccygeus muscle consists of the levator aid and the pyriformis which enclose the back part of the outlet of the pelvis.

In females, the coccygeus muscle draws the coccyx forward after it has been pressed back during parturition. Smith (1986:134) reported that the movements of the coccyx help to enlarge the birth canal during childbirth. The levator ani muscles constrict the lower end of both the rectum and the vagina, drawing the rectum both forward and upward- see Anthony (1963:411). Far from being remnants of muscles that pull the tail down in a dog, as Cartmill et al. (1987:186) and others claim, the small sling of muscles attached to the coccyx serves several functions.

On the left and right dorsal surfaces of the coccyx is located a row of tubercles called the rudimentary articular processes"

However, they are rudimentary only in the sense that they are smaller than the tubercles on the thoracic vertebrae. The larger first pair, the coccygeal cornua, articulate with the cornua of the sacrum and allow some movement. On the opposite side are the openings called foramina-openings for the transmission of the dorsal division of the fifth sacral nerve. The narrow borders of the coccyx receive the attachment of the sacrotuberous and sacrospinous ligaments laterally for support of the bones, the coccygeus muscle ventraIly, and the gluteus maximus muscle dorsally The oval surface of the coccyx base articulates with the sacrum. Cray (1966:130) pointed out that the rounded apex or lowest part of the coccyx is attached to the tendon of the sphincter ani externus and its movement can be bifid, meaning that it can be deflected to both sides, and thus make bowel movements possible. Also, Cray (1966: 130) discussed the anococ-cygeal raphe which is a narrow fibrous band that extends from the coccyx to the margin of the anus. Citing an anatomy textbook, Scadding (1981) concluded this very succinctly by stating that several muscles and ligaments insert on the coccyx. Walker (1987:253) noted that it is the coccyx ?.. to which certain anal and perineal muscles, Weischnitzer (1978: 285) reported that the iliococcygeus muscle is supports and raises the pelvic floor. He indicated that the iliococcygeus is inserted on terminal parts of the coccyx. Without the coccyx and its attached muscle system, humans would need a radically different support system for their internal organs which would require numerous design changes in the human posterior Concerning the coccyx and its importance, Allford concluded that: "The posterior surfaces [of the coccyx] serve as attachments for the gluteus maximus muscle and the sphincter and externus muscles. The gluteus maximus muscle is essential for defecation and labor during childbirth. The sphincter ani externus muscle is needed to keep the anal canal and orifice closed. These are obviously very important functions. The interior surfaces of the coccygeal vertebrae also serve as important attachments for muscles that aid in the containment of feces within the rectum . . . [as well as control of] defecation, and the expulsion of the fetus during labor. For these important reasons, the coccyx can never be classified as a rudimentary or vestigial rudiment of our ancestors. Aliford (1978:42) Franks dealt with coccyx malfunction as follows: "Individuals who injure the tailbone may develop a painful condition called coccydynia. Removal of the coccyx presumably because it is thought to be nonessential seems to be a poor operation. I counsel my patients with tailbone pain to resist removal of the coccyx if ever suggested" Franks (1988:24) The coccyx is not the only support system of the internal organs; the diaphragm and other muscles also help fulfill this role. If the coccyx is surgically removed, enough surrounding supporting structures exist in adults so one can live fairly normally. The three to five small bones are obviously part of a larger support structure consisting of bones, cartilage, muscle, ligaments, and tendons, all of which participate. Concerning surgery of the coccyx, Shute noted that the vestigial organ argument is not realistic: Take it away and patients complain; indeed the operation for its removal has time and again fallen into disrepute, only to be revived by some naive surgeon who really believes what the biologists have told him about this useless ꅻudiment: Shute (1961:40)Reno argued that the coccyx need not be classed as a useless remnant of evolution. become tails in many other species, the human tail stub only forms the basis of the human coccyx. Mankind does not travel up the trunk of the animal tree with each embryo. . ." . Smith (1986:118). Gould (1982:41) noted that at four weeks humans have a well-formed tail which is larger at that time than their legs. Shute (1961:40) added that although in its development, the human embryo appears tailed this is simply because there is disproportionate development of various parts of the fetal skeleton:

"There is something seemingly unhuman about the presence on a human infant of a taillike the tails found on other primates. It is incongruous; it violates our sense of anthropocentricity, and it raises issues that involve not only teratology and embryology but also our view of ourselves and our place in evolution. The human tail serves as an example of modern concepts of ontogeny and phylogeny and presents a striking clinical confrontation with the reality of evolution.

We do not intend to discuss the evolutionary concept that an individual retraces his evolution during his embryological development;

K. S. Thomson (1988) also asserted that the recapitulation concept has little if any meaning in modern biology; he viewed it to be a dead concept. In addition to demonstrating that Haeckel paradigm is totally inadequate, Rusch (1969) showed that some of Haeckel drawings purporting L. to demonstrate embryonic recapitulation were fraudulent. Even Gould (1982:41), the reviewer of Ledley paper, noted that M. N. Remine and an anonymous coauthor from the University of Minnesota analyzed Ledley findings shortly after the report was published. Their pointed critique of Ledley evolutionary thesis speaks for itself: Many evolutionists view the appendage as tail-like enough to be interpreted as evidence of man primitive evolutionary ancestry. This interpretation has two drawbacks. One drawback is that there are good reasons, as given above, why the appendage may not be interpreted as a true tail. Secondly, there is no well established genetic mechanism to account for the preservation of the structural elements necessary for tail formation in the human genome. Creationists may view the appendage as a structural variant of developmental origin rather than as a tail: ReMine (1982:8)

Ledley himself (1982) admitted that the so-called caudal appendage may be nothing more than a dermal appendage which by chance occurred in that position. Reno noted that one explanation of these abnormal caudal appendages is that each is merely a birth abnormality: "Could not this be the result of a deranged process taking place during embryologic development? The normal process is sometimes altered and as a result we see Siamese twins, cleft palates and harelips. No one would argue that these were once normal conditions in a remote ancestor. A "tail" could be such an anomally. Reno (1970:86)

The spinal configuration of all chordates determine each ones posture and mobility. Because of this, some various organisms can be classified taxonomically based on the length of their spine, the spine’s flexibility, its curvature, and many others. This is evident when one looks at the different types of hominoids. There are leapers (long spined), suspensory (relatively short spined), quadrupeds (short and thick), bipeds (medium length and flexible), et cetera. Because of this, many assume that the relative length of the spine is evolutionarily developed and each adaptation is based on how far along the evolutionary ladder the organism is presently at. Sufficient to say, such a notion includes the human spine.The human spine is made up of twenty-four vertebra and one hundred and ten joints (NASS, 1). It is further divided into five sections,

namely: the cervical spine, which is composed of five vertebra (of which the atlas and the axis is the most popular), the thoracic spine, which is made up of twelve vertebra and is where the rib cage articulates, the lumbar spine (the five largest vertebra which absorbs most of the pressure and impact in the spine), the sacrum, which attaches the whole structure to the pelvis, and the coccyx. This structure, which is also known as the vertebral column or backbone, is one of the primary support structures for the human skeletal system. Due to its immense articulation, the backbone allows for a wide degree of movement, flexibility, and increased locomotive capability. This is especially made possible by the presence of cartilage found in between each vertebra, which are appropriately named the inter-vertebral disks. These disks absorb most of the pressure the spine experiences as it performs an extensive range of movements (sometimes all at the same time). The human spine is the most unusual of all vertebral configurations because of its curvature.

The S-shaped curve of this structure is an intrinsic feature that can be found in humans alone. Because of such an arrangement, humans are enabled to stand in an upright position and walk in a bipedal manner. Some animals, such as most terrestrial apes, are also capable of walking bipedally but cannot sustain this manner of locomotion in any length of time. This is because their backbones are not configured for such behavior.

Theirs is shaped in a much shorter and straighter spinal arrangement hence greatly suited for quadrupedal locomotion. Therefore, their ability to move using their hind legs is merely a food gathering (and/or protection) technique, much like the elastic tongue of most reptiles and amphibians. such differences in vertebral arrangements, however, do not deter people from assuming that some ancestral apes did walk on hindlegs without the benefit of an S-shape curved spinal column. These people, obviously not very bright, presume that the laws of physics and geometry do not apply to such ancient species and that their over-all bone structures do not at all have anything to do with their modes of locomotion. In addition, some even get ahead of themselves by allegedly determining behaviors of different species without the benefit of a complete skeletal structure, much less a spine. Because of such drastic misconceptions, the different sectional functions of the human spinal column may be grossly misinterpreted.

The coccygeal process (or the tailbone), which is located at the caudal end of the spine, is defined in a variety of ways. The Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health does it in this manner, “the small bone caudal to the sacrum in man, formed by the union of four (sometimes five or three) rudimentary vertebrae, and forming the caudal extremity of the vertebral column.”(Miller, 273). Such a definition is the most common of all designations regarding the tailbone. This is because they state that due to the vertebrae’s small size and its fusion with other vertebrae, it is therefore conclusive that these structures are rudimentary in nature. In addition to this, one of the more interesting definitions regarding the coccyx is one supplied by the National Ankylosing Spondylitis Society. They state that, “the coccyx, or tailbone, is composed of from three to five rudimentary vertebrae....The articulation between the coccygeal vertebrae and the sacrum allow some flexibility in the coccyx, which is particularly beneficial in taking the stresses of sitting and falling. The coccyx is extremely susceptible to shock fracture....Furthermore, since a number of nerve pathways pass near this area, damage to the coccyx threatens damage to the nerves of the lower body...” (NASS, 4). In addition, NASS includes that the coccyx “helps protect the lower alimentary tract” (NASS, 1). One should notice immediately after reading the above statement that the NASS’s definition greatly contradicts itself. This is due to the fact that their sentence starts off claiming that the tail bone is made-up of vestigial (therefore useless) bones that are fused together, then the definition is terminated by enumerating a variety of functions that the coccygeal process performs and its importance to the nervous system (as can be seen if and when it is damaged). This is like saying that the cranium is a group of rudimentary plates fused together at the sutures and that although useless, it is “particularly beneficial” when you hit your head. Incidentally, it also houses the brain and therefore “a number of nerve pathways pass within this area” and because of this, it perhaps protects the brain.

How can anyone state that the coccyx is vestigial when all bones function the same way the tailbone does? According to the Encyclopedia and Dictionary of Medicine, Nursing and Allied Health, the skeletal system’s function is to: give support and structure to the body, protect delicate internal organs, make movement possible, attach with muscles, and many others (Miller, 1139). Correct me if I’m wrong, but isn't is what the coccyx is exactly doing? If the categories that automatically exclude any bones from being designated as vestigial are similar to the ones stated above, the coccyx, therefore, should not be considered rudimentary.

The above notion can be readily observed in a variety of ways. First off, when a person sits down, pressure is exerted on the coccyx. As a response, the tailbone moves forward to absorb most of the shock that sitting down entails (no pun intended) (The Coccyx, 1). This can (and should) be observed as an active reaction to stress the body is experiencing and is therefore a protective response by the “vestigial” tailbone. Another way to determine the importance of the coccyx is by looking at the different structures that are connected to it (since one of the main functions of the skeletal system is its connection with muscles and other formations).

The coccyx is cranially connected to the sacrum. According to NASS, the articulation between these two, help function as a “shock absorber” (NASS, 4). At its periphery, the coccyx holds (along with the pubis and ischial spine) a sheet of muscle called the pelvic diaphragm (Virtual Hospital, 1). The pelvic diaphragm includes, the levator ani, perineal body, perineal membrane, and other small muscles (Miller, 352). Hence, as can be observed, the coccyx holds in place a variety of structures that are important in locomotion and the protection of different internal organs.

In conclusion, many would like to think that the coccyx, or tailbone, is in fact the last vestige of our once long tails. Because of this, many dismissed the importance of this structure in the hopes that everyone would agree that there was a smooth progression from apes to man. However, in actuality, the coccyx is just like any other bone in the human anatomy. It functions similarly by giving protection, support, rigidity, a place to attach muscles, and many others. The only problem it had was that its location was where a tail would normally be present. That, however, does not qualify it as the rudiments of a tail. Furthermore, had the coccyx not been there, the sacrum would automatically be considered the vestiges of an ancestral tail regardless of what its other functions were. Hence, the alleged uselesness of the caudal end of the spine is more imagined that factual. This is because no matter how many times a person assumes that the tail bone is useless, the fact still remains that this structure functions just like any other bone in the human anatomy.

Circulatory factors

None apparent.

Hormonal and metabolic factors

None apparent.

Neurological factors

Discuss the pain mechanism involved.

4. Pathology

The relevance of developmental anomalies

Consider the possibility that this patient may naturally have an anteriorly and/or laterally placed coccyx.

The relevance of pathomorphology to management

To understand coccygodynia, one should know the anatomy that is involved in this very painful conditon and the mechanisms that are responsible for it's cause. The sacrum is the broad triangular bone below the lumbar vertebrae and is situated between the right and the left hip bones. The sacrum although a single bone is actually composed of five bones that have grown together.

At the very end of the sacrum is the coccyx, and is frequently referred to as the "tail bone". The coccyx is a tiny triangular bone, and like the sacrum is made up of four bones that have never completely developed.

Pain caused by anything that affects the coccyx is called "Coccygodynia". Coccygeal pain occurs with greater frequency in women. This may be due to the fact that it is more prominent in women than in men. Another distinct possibly is that the coccyx may have been injured or displaced during childbirth, and has been dormant until it has been further aggravated by another injury. Any injury that results from a direct blow to the coccygeal region, that might be sustained as in a direct fall on the buttocks, can cause the coccyx to be tipped anteriorly (forward), or deviated laterally, either to the right or left side. When this occurs, the coccyx may be found to be more freely movable than the norm.

When persistent pelvic pain occurs for no sufficient reason or cause, a pelvic examination should be made and an evaluation can then be made by the physician. If no apparent cause is found due to uterus (or adenia) in women, the coccyx should be palpated. This examination is performed rectally with the patient lying on their left side with the knees drawn to the chest. The doctor will perform the rectal examination by inserting the index finger with the thumb on the outside above it. The coccyx can be palpated in this fashion and a determination can be made as to how the coccyx is positioned, and whether it is movable.

If during the palpation of the coccyx, a severe pain occurs, that may be indicative that there is trouble about the joint or about the fascia or muscles. In addition to the pelvic exam an x-ray should also be taken to visualize the position of the coccyx. Even if a pelvic examination was not performed, an x-ray should definitely be taken.

Treating coccygodynia can be tricky at best. It will require a great deal of rest. The worst part of this condition is being able to sit without eliciting severe pain. Do not sit on a soft seat or pillow as this will increase the pain by causing too much pressure on the coccyx. The best way to alleviate this pressure is by using the RELAXO-BAK? COMFORT CUSHION. This cushion is specifically designed to relieve the pressure that is placed on the coccyx. It should be used on any chair that is used and when riding

in your automobile. Sitting for long periods of time is not advisable.

Get up and move about after sitting for awhile.

In addition to rest and using the Comfort Cushion, taking hot Sitz Baths, can soothe the painful area. Also the use of an analgesic gel such as BIOFREEZE™ can help in the alleviation of some pain. The patient should also try to maintain a normal bowel movement. Constipation that can cause straining during bowel movements can increase the pain. In very severe cases that are long lasting and unresponsive to treatment, may result in the surgical removal of the coccyx. Although the operation is relatively simple, it behooves the patient to try everything in their power to avoid this radical treatment. Using the above treatment suggestions, plus plenty of rest and patience can help you avoid this surgery.

Note that sometimes even surgical excision of the coccyx doesn't relieve the discomfort.

Contraindications

None apparent in this case.

Restricted indications

Work within the patients pain tolerance.

Risk factor

Patients may not be comfortable with the idea of a per rectal treatmetn.

The right to choose is the main ethical principle to apply:

- fully inform the patietn of what the procedure involves and obtain consent to proceed.

- explain what the patient may experience in terms of pain or discomfort.

- give the patient the option of privacy and having a 3rd party of their choice in the room.

5. Chiropractic Assessment

History

53 years old female with coccydynia following foreceful sitting incident.

Constant intense ache aggravated by sitting and defecation and relieved by walking.

Observation

Cautions when moving into a seated position and sits on either buttock.

Static palpation

edema and extreme tenderness over coccyx with a palpable anterior and left lateral displacement.

Motion palpation

Coccyx motion to the right was reduced and painful.

Muscle assessment

Bilateral piriformis hypertonicity and tenderness.

Orthopaedic assessment

The sitting test for coccydynia is positive indicating the coccyx is the source of pain.

Radiological assessment

Anterolateral (left) displacement of the coccyx.

Differential diagnosis

Sacroiliac joint dysfunction

Coccygeal dysfunction

Coccygeal fracture

Piriformis myofascial pain syndrome

Sacrococcygeal ligament sprain.

Diagnosis/working hypothesis

Acute post-traumatic coccyx dysfunction (AL coccyx).

6. Chiropractic Management Options

6.1 Adjustive techniques

List principles of technique which are important

· Each patient should be evaluated individually and the techniques should be tailored to the patient's needs.

· Acuity of the patient's condition. The more acute the patient is, the less osseous adjusting is indicated and the more specific should the adjustment be.

· Response to movement: Where the presenting syndrome is aggravated by minimal movement if signifies one or more of the following: acute inflammation, traumatic insult, pathology which may contraindicate chiropractic manipulative techniques.

List safety/risk factors

· Always make sure that the patient does not fall off the table at all times.

· Patient understanding of implementation of the techniques: proceed only after patient consent.

· An assistant or third party needs to be present during the implementation of the techniques to avoid accusation of sexual abuse etc.

· Always use a latex glove for and internal coccygeal adjustment. Fingernails must be very shout and smooth to avoid injuring the patient.

List and analyse technique options

Name of Technique and Reference

· External coccygeal

· Internal coccygeal

Method of application

1. External coccygeal: used to correct anterior and left lateral displacement.

2. Interanal coccygeal: there is more control using this method of implementation with very good results.

The patient is in the prone anti-gravity position for both technique implementation.

Clinical judgement is needed to decide when to adjust the coccygeal joint. The sooner the adjustment is made the quicker will patient response be.

6.2 Mobilisation techniques

List principles of techniques which are important

· Acuity of the patient's condition. The more acute the patient is, the less osseous adjusting is indicated and the more specific should the adjustment be.

· Response to movement: where the presenting syndrome is aggravated by minimal movement it signifies one or more of the following: acute inflammation; traumatic insult; pathology which may contraindicate chiropractic manipulative techniques.

List safety/risk factors

List and analyse technique options

Name of Technique and Reference

Not applicable.

6.3 Soft tissue techniques

List principles of technique which are important

· Each patient should be evaluated individually and the techniques should be tailored to the patient's needs.

· Selection and amplitude of techniques - the least traumatic techniques are employed first. All techniques should be applied gently and lightly.

List safety/risk factors

· Each patient should be evaluated individually and the techniques should be tailored to the patient's needs.

· Selection and amplitude of techniques - the least traumatic techniques are employed first. All techniques should be applied gently and lightly.

List safety/risk factors

· Only commence technique implementation after the oedema and inflammation has subsided.

· Always work within the patient's tolerance lovel.

List and analyse technique options

Name of Technique and Reference

·Nimmo therapy

Method of application

Nimmo therapy: elbow technique to the involved piriformis muscles to reduce triggerpoints and muscle spasm.

6.4 Non-force techniques

List principles of technique which are important

· Each patient should be evaluated individually and the modalities should be tailored to the patient's needs.

· Acuity of the patient's condition: The more acute a patient is, the less osseous adjusting is indicated and the more specific should the adjustment be.

· Response to movement: where the presenting syndrome is aggravated by minimal movement it signifies one or more of the following: acute inflammation; traumatic insult; pathology which may contraindicate chiropractic manipulative techniques.

List safety/risk factors

· Only implement technique after the inflammation and oedema has subsided.

· Patient understanding of the implementation of the technique.

· Always have an assistant of third party present when implementing the techniques.

List and analyse technique options

Name of Technique and Reference

Apex contact (3 minutes)

Method of application

1. Apex contact (3 minutes): on the sacrotuberous ligament to relax the ligament, gluteal and spinal musculature.

6.5 Mechanically assisted chiropractic techniques

List principles of technique which are important

· Each patient should be evaluated individually and the modalities should be tailored to the patient's needs.

· Acuity of the patient's condition: The more acute a patient is, the less osseous adjusting is indicated and the more specific should the adjustment be.

· Response to movement: where the presenting syndrome is aggravated by minimal movement it signifies one or more of the following: acute inflammation; traumatic movement it signifies one or more of the following: acute inflammation; traumatic insult; pathology which may contraindicate chiropractic manipulative techniques.

List safety/risk factors

· Drop piece (moveable) is inappropriate for the implementation of a coccygeal adjustment.

Method of application

Activator: use for and external coccygeal adjustment to correct anterior and left lateral displacement.

6.6 Physiological therapeutics

List principles of physiological therapeutics which are important

· Each patient should be evaluated individually and the modalities should be tailored to the patient's needs.

· All procedures need to be in keeping with a physiological therapeutic intent and reaction to promote healing and wellbeing for the patient.

List safety/risk factors

·Avoid burning the patient's skin with the cryotherapy.

·Ultrasound - pulsed: avoid cavitation. Apply only if tolerated by the patient in the sub-acute, chronic phase.

·The patient must sit as little as possible and use a ring cushion or two rolled towels when sitting.

· Avoid intercourse for 3-4 weeks (female).

List and analyse physiological therapeutic options

Name of Technique and Reference

· Cryotherapy

· Ring cushion

Method of application

1. Cryotherapy: This needs to be applied 2-3 times before the adjustment if possible.

The patient may start at home before going to the clinic to reduce the inflammation over the painful region.

2. Pulsed ultrasound 1w/㎠ for 5 minutes over the coccyx and adjacent region to improve circulation and promote healing.

3. Ring cushion: sitting on the cusion or rolled towels for approximately 2 weeks to relieve pressure off the coccyx.

6.7 Preventive chiropractic care

Home advice:

Cryotherapy 3 times a day for 2 days (10 minutes on; 10 minutes off; 10 minutes on).

Avoid sitting as much as possible for approximately 2 weeks, sit on a ring, or on 2 rolled towels - one under each ischial tuberosity to raise the level of the coccyx. Avoid intercourse for 3-4 weeks.

7. The Chiropractic Management Plan

Instruction to patient

* Apply ice to the sore area for 15 to 20 minutes each hour for the first 1 to 2 days. Put the ice in a plastic bag and place a towel between the bag of ice and your skin.

* After the first 1 to 2 days, you may apply heat to the injury to help relieve pain. Use a warm heating pad (set on low), whirlpool bath, or warm, moist towels for 15 to 20 minutes every hour for 48 hours. Lie on your stomach,

DO NOT lie on the heating pad.

* Sitting on a large rubber ring or a cushion may ease the pain. Some people feel more comfortable sitting on a hard surface.

* You may increase your activity as the pain allows.

* You may use over-the-counter medicines to ease the pain.

Take stool softeners if bowel movements are painful. Take all

medications exactly as directed by your doctor.

Discussion and explanation to the patient of diagnosis, prognosis and cost

The following can be utilised:

1. Cryotherapy.

2. Coccygeal adjustment - Refer to

3. Soft tissue therapy to the piriformis muscle.

4. Ultrasound pulse 1 w/㎠ for 5 minutes.

Advise the patient of the risk/benefit ratio and obtain consent before treatment commences. See the patient 3 times in the first 2 weeks and reassess.

Monetary matters need to be discussed before treatment commences.

8. Outcomes to Chiropractic Management

The management plan must be modified based on the patient's response to treatment.

If the patient improves after the initial treatment:

Continue with the proposed management plan.

If the patient does not improve after the initial treatment:

· Reassess the case

· Consider the possibility of the patient experiencing a reaction to treatment (this should have been explained to the patient prior to commencement)

· Consider referral for 2nd opinion (chiropractic or otherwise)

Prognosis with conservative care for the young adult is usually good with the patient becoming asymptomatic within 2 weeks.

If no response to treatment occurs and symptoms persist over a long period of time, surgical excision may be appropriate, however, surgical excision of the coccyx has a poor prognosis.

REFERENCE

1. Orthopedic physical Assessment 3rd edition by David J. magee

2. Differential Diagnosis for the chiropractor by Thomas A. Souza

3. Chiropractic technique by Thomas F.Bergmann, DC

4. Chiropractic Management of spine Related Disorder by Meridel I Gatterman DC

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