Nurse who suffers chronic tailbone pain

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I am a Registered Nurse who has suffered with tailbone pain for over 8 years. Like all chronic pain, it is essential that sufferers get the correct support, diagnosis and treatment appropriate for them as an individual. This blog follows my journey with chronic pain, it expresses my personal opinions and thoughts. It is not intended as a replacement for advice or treatment from your normal Healthcare Provider.

Monday, 6 April 2015

What is an unstable or hypermobile coccyx? Sit/stand X-rays and MUA's.

I have had several 'diagnosis' on my coccydynia over the years. Unfortunately I have lost some of the reports. I am very cross with myself- although ultimately I suppose it doesn't change anything for me.

I was just looking back on a couple- and even these seem to contradict each other.

In January 2014 a London Chiropractor told me that X-rays showed the "sacro-coccygeal joints to be fusing in the extended position, with the second joint slipped forward (anterolisthesis) and moderately calcified."

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I have been told by another 'specialist' (Dec 2014) that my X-rays show the lower part tilts backwards instead of forwards. So, already contradictions.

An orthopaedic consultant who did a Manipulation Under Anaesthetic (MUA) in 2009 told me the coccyx was hypermobile- one of the most mobile he had felt.

So, what do all these things mean?

The following are my thoughts on what an 'unstable coccyx' is- I have obtained information from several sources (see some of the links below), as well as my own history, and what I have been told.

Information from, An unstable coccyx (research paper), 'About tailbone pain' and Unstable coccyx -

The coccyx is normally mobile, it can flex or extend, this we know.

'Active flexion' is the result of flexing, (moving the coccyx in a forward direction), our levator ani and sphincter ani exturnus muscles- try it now- pull everything in, tense as if you are trying to stop having a wee and passing wind, this is what pelvic floor exercises feel like. This is 'active flexion'.

'Extension' of the coccyx is when we relax these muscles (moving the coccyx in a backward direction), pass wind/faeces and during childbirth. When we 'let go' after tensing them we are relaxing them.

Sitting can cause 'passive flexion' or 'passive extension' - we are not controlling our coccyx voluntarily. This will depend on your coccyx and how yours 'sits' anatomically. Everyone is slightly different. Sometimes it does not move, it may be 'ossified' or one solid piece of bone/vertebrae.

It baffles me therefore, that the NHS does not perform dynamic sit/stand X-rays when these would reveal so much. How do 'professionals' know exactly what they are dealing with, if they do not have a definitive diagnosis. I can only assume, because it is the NHS, it comes down to time and money- it takes longer to do obviously, thereby costing more both time wise, and x-ray wise.

How a sit/stand X-Ray should be done

Posterior luxation and subluxation:  (abnormal movement/slight misalignment or partial dislocation of the coccyx joint) is apparently found in 20-25% of cases where a sit/stand X-ray is performed. This should go as soon as the person stands. It always causes pain when sitting.

Hypermobility in flexion (unstable coccyx): Can be caused by trauma, weakening of the joint, anal intercourse, or pregnancy. Hypermobility is defined by flexion of the coccyx of more than 25-30 degrees in the sitting position. It is found in 20 to 25% of the cases. This is not always painful. I have found some reference to this being more common with those who have a coccyx slightly longer than normal, slightly more curved and with those with a higher body mass index.  A curved or elongated coccyx means it may position itself incorrectly-it will align itself parallel to the seat and cause passive flexion from the pressure of the seat. Apparently a higher BMI means we are less likely to sit correctly.
According to "It is not surpising that slippage of a joint like this, pulling or tearing the surrounding tissues, can cause inflammation and pain. Because normal life is impossible without sitting, the joint is repeatedly forced out of its normal position, and may not be able to heal properly. Sitting down with an unstable coccyx is like spraining your ankle, then forcing the ankle to bend more than normal. Repetitive strain from cycling or rowing has also been blamed for this condition. One of the medical papers says that anal intercourse can also be a cause. And in some cases there is no known cause, but the joint has become dislocated."

Coccygeal spicule: This is an abnormality in the form of a small bony bump or prominence on the dorsal aspect (the back) of the tip of the coccyx, involved in 15% of the cases of coccydynia. 

Coccyges without radiologic abnormality: In 40% of the cases there is no abnormality found in sit/stand X-rays. It does not mean you do not have a problem.

With this in mind, from what I have been told (above)- I have 'posterior luxation and/or subluxation' - my coccyx moves and partially dislocates when I sit, depending where and how I sit the pain varies. Added to this mine is 'hypermobile in flexion'- again, it causes pain when I sit. Everyone that I have seen agrees that various X-rays, including the one above, and examination, show some kind of abnormality- I don't know exactly what because I am not an expert, so I have to go on what I am told.

However, what I do know is this is a standard standing X-ray, so if it shows an abnormality standing it would sure as **** show an abnormality sitting. I don't need it done to tell me- the pain I have tells me. Would it alter the various treatments I have had- I am not sure, but I doubt it. Sadly there seems to be a bog standard attitude that 'one size fits all'. Whether this is true or not, who knows? I don't, and specialists don't seem to either.

I also don't really see how MUA helps a hypermobile coccyx? I have been told (by a surgeon and a pain management consultant) that the MUA is to massage the steroid injection and anaesthetic into and around the joint, rather than to just reposition the coccyx. This makes sense as surely a hypermobile or unstable coccyx would just pop back as soon as one sits again. Maybe this is why the success of this treatment is variable. I guess for a lucky few maybe the coccyx does stay repositioned and the steroid and anaesthesia are an added bonus while it settles down in its correct position, where it stays. It worked for me once- the first time, then the pain came back and subsequent MUA's and steroid injections have failed.

Like so many others with coccyx pain, I tend to sit on one side, to relieve the pain and pressure on my coccyx. This creates constant pressure on my buttock muscles, and results in myofascial/muscle knots (as discussed before). I am trying so hard not to do this, and persevering with massage and trigger point work. I know this poor posture can go onto cause even more problems, such as muscle spasm, nerve entrapment, numbness and altered sensation around the whole pelvic area, lower back and legs. I already have additional lower back pain from over compensatory positioning.

Coccydynia really is a debilitating condition. I just wish it was taken more seriously and when someone goes to see a healthcare provider it got correctly diagnosed. Only then will the real statistics show. Only then will everyone realise it is not 'rare', but sadly very common.

As I have already said- I am not an expert in this field, sadly. These are just my opinions. Please seek medical advice, and make sure you get the correct treatment and diagnosis. Make sure any X-Rays and MRI's include your tailbone, and if possible get a sit/stand X-Ray, and make sure if they do this, they do it correctly!

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