Mazzoleni MG. et al., 2025: Management of coccygodynia: talking points from a systematic review of recent clinical trials.

Monday, 02 June 2025

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Manuel Giovanni Mazzoleni 1, Nicola Maffulli 2 3 4, Tommaso Bardazzi 1, Michael Memminger 1, Francesca Alzira Bertini 1, Filippo Migliorini 1 5
1Department of Orthopaedic and Trauma Surgery, Academic Hospital of Bolzano (SABES-ASDAA), Bolzano, Italy.
2Department of Trauma and Orthopaedic Surgery, Faculty of Medicine and Psychology, University La Sapienza, Roma, Italy.
3School of Pharmacy and Bioengineering, Keele University Faculty of Medicine, Stoke on Trent, Staffordshire, UK.
4Centre for Sports and Exercise Medicine, Barts and the London School of Medicine and Dentistry, Mile End Hospital, Queen Mary University of London, London, UK.
5Department of Life Sciences, Health, and Health Professions, Link Campus University, Rome, Italy.

Abstract

Background: Coccygodynia, characterised by localised pain in the coccyx and surrounding tissues, presents challenges in diagnosis and management given its low prevalence and varied aetiology. Traumatic injury, particularly backward falls, is commonly implicated, while non-traumatic causes include degenerative joint disease, overloading stress forces from obesity and morphological variations of the coccyx. Diagnostic evaluation involves medical history, physical examination, and radiographic imaging. While conservative management is often successful, refractory cases necessitate intervention. However, optimal treatment strategies still need to be clarified. The present systematic review discusses the clinical evidence on the management of coccygodynia.

Methods: In December 2024, a systematic review followed PRISMA guidelines, accessing PubMed, Web of Science, and Embase databases. Eligible studies included solely clinical trials investigating coccygodynia management. The risk of bias was assessed using Cochrane risk of bias assessment tool (RoB2) for randomized controlled trials (RCTs) and the Risk of Bias in nonrandomized Studies of Interventions (ROBINS-I) for non-RCTs. Data extraction and statistical analyses followed the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions.

Results: Of 407 identified articles, 16 met inclusion criteria, comprising 858 patients, primarily women. Risk of bias assessment revealed varying methodological quality among included studies. Conservative treatments, including physiotherapy and shockwave therapy, showed promise in pain management. Interventional therapies, such as corticosteroid injections and ganglion-impair blockade, demonstrated efficacy in refractory cases. Surgical interventions, particularly coccygectomy, yielded moderate success rates but were associated with notable risks.

Conclusions: A multidisciplinary approach is advocated for managing coccygodynia, with conservative measures as initial strategies. Physical therapy-based interventions and interventional treatments, such as corticosteroid injections and ganglion impair blockade, offer viable options for refractory cases. Surgical intervention should be considered judiciously, weighing risks and benefits based on patient-specific factors and treatment response. Further research is needed to establish standardized guidelines for coccygodynia management based on high-quality evidence.

Ann Jt. 2025 Jan 21;10:9. doi: 10.21037/aoj-24-40. eCollection 2025. PMID: 39981432

Comments 1

Jens Rassweiler on Monday, 02 June 2025 11:00

Background
Coccygodynia is characterized by localized pain around the coccyx and is often linked to trauma (e.g., falls) or non-traumatic factors (e.g., degenerative changes, obesity).The low prevalence and diverse causes of coccygodynia make diagnosis and management challenging.

Methods
Systematic Review conducted according to PRISMA guidelines, with literature updated until December 2024. Databases searched included PubMed, Web of Science, and Embase.Study Selection included clinical trials on coccygodynia management, assessing risk of bias through established tools like RoB2 for RCTs and ROBINS-I for non-RCTs.
Results
Study Inclusion: Out of 407 articles screened, 16 fulfilled inclusion criteria, involving 858 primarily female patients. The Studies exhibited varying quality in design and execution.

Conservative Treatments: Physiotherapy and extracorporeal shockwave therapy (ESWT) showed efficacy in alleviating pain.
ESWT involves the application of high-energy sound waves to the affected area, which can stimulate tissue repair, reduce inflammation, and promote blood circulation. It may also affect pain receptors in the coccyx region, potentially providing analgesic effects. Recent clinical trials show that shock wave therapy can significantly reduce pain intensity in patients with coccygodynia when compared to baseline levels. Some studies report a reduction in pain scores and improved functional outcomes, indicating enhanced mobility and quality of life for patients. Typically involves multiple sessions (usually 3-5 sessions) over a few weeks. Many studies report optimal pain relief occurring at energy levels around 0.5 to 1.0 mJ/mm² applying 1500 to 3000 impulses. However, this can vary to accommodate individual patient tolerance and response.
Patients may experience mild discomfort during treatment, but it is generally well tolerated. While findings are encouraging, not all studies show uniform results. Some patients may not experience the desired pain relief. Thus, more rigorous and larger-scale studies are needed to establish long-term effectiveness, optimal treatment protocols, and patient selection.
Interventional Therapies: Corticosteroid injections and ganglion nerve blocks were effective for refractory cases.
Surgical Interventions: Coccygectomy presented moderate success rates but carried significant risks.
Conclusions
Multidisciplinary Approach: A comprehensive strategy is recommended for managing coccygodynia. Conservative measures (e.g., physical therapy, ESWT) should be prioritized. For patients not responding to conservative treatment, interventional options like corticosteroid injections are viable. Surgical options like coccygectomy must be approached cautiously, taking into account individual patient factors and the associated risks.

Jens Rassweiler

Methods
Systematic Review conducted according to PRISMA guidelines, with literature updated until December 2024. Databases searched included PubMed, Web of Science, and Embase.Study Selection included clinical trials on coccygodynia management, assessing risk of bias through established tools like RoB2 for RCTs and ROBINS-I for non-RCTs.
Results
Study Inclusion: Out of 407 articles screened, 16 fulfilled inclusion criteria, involving 858 primarily female patients. The Studies exhibited varying quality in design and execution.

Conservative Treatments: Physiotherapy and extracorporeal shockwave therapy (ESWT) showed efficacy in alleviating pain. 
ESWT involves the application of high-energy sound waves to the affected area, which can stimulate tissue repair, reduce inflammation, and promote blood circulation. It may also affect pain receptors in the coccyx region, potentially providing analgesic effects. Recent clinical trials show that shock wave therapy can significantly reduce pain intensity in patients with coccygodynia when compared to baseline levels. Some studies report a reduction in pain scores and improved functional outcomes, indicating enhanced mobility and quality of life for patients. Typically involves multiple sessions (usually 3-5 sessions) over a few weeks. Many studies report optimal pain relief occurring at energy levels around 0.5 to 1.0 mJ/mm² applying 1500 to 3000 impulses. However, this can vary to accommodate individual patient tolerance and response.
Patients may experience mild discomfort during treatment, but it is generally well tolerated. While findings are encouraging, not all studies show uniform results. Some patients may not experience the desired pain relief. Thus, more rigorous and larger-scale studies are needed to establish long-term effectiveness, optimal treatment protocols, and patient selection.
Interventional Therapies: Corticosteroid injections and ganglion nerve blocks were effective for refractory cases.
Surgical Interventions: Coccygectomy presented moderate success rates but carried significant risks.
Conclusions
Multidisciplinary Approach:  A comprehensive strategy is recommended for managing coccygodynia. Conservative measures (e.g., physical therapy, ESWT) should be prioritized. For patients not responding to conservative treatment, interventional options like corticosteroid injections are viable. Surgical options like coccygectomy must be approached cautiously, taking into account individual patient factors and the associated risks.

Jens Rassweiler

Background Coccygodynia is characterized by localized pain around the coccyx and is often linked to trauma (e.g., falls) or non-traumatic factors (e.g., degenerative changes, obesity).The low prevalence and diverse causes of coccygodynia make diagnosis and management challenging. Methods Systematic Review conducted according to PRISMA guidelines, with literature updated until December 2024. Databases searched included PubMed, Web of Science, and Embase.Study Selection included clinical trials on coccygodynia management, assessing risk of bias through established tools like RoB2 for RCTs and ROBINS-I for non-RCTs. Results Study Inclusion: Out of 407 articles screened, 16 fulfilled inclusion criteria, involving 858 primarily female patients. The Studies exhibited varying quality in design and execution. Conservative Treatments: Physiotherapy and extracorporeal shockwave therapy (ESWT) showed efficacy in alleviating pain. ESWT involves the application of high-energy sound waves to the affected area, which can stimulate tissue repair, reduce inflammation, and promote blood circulation. It may also affect pain receptors in the coccyx region, potentially providing analgesic effects. Recent clinical trials show that shock wave therapy can significantly reduce pain intensity in patients with coccygodynia when compared to baseline levels. Some studies report a reduction in pain scores and improved functional outcomes, indicating enhanced mobility and quality of life for patients. Typically involves multiple sessions (usually 3-5 sessions) over a few weeks. Many studies report optimal pain relief occurring at energy levels around 0.5 to 1.0 mJ/mm² applying 1500 to 3000 impulses. However, this can vary to accommodate individual patient tolerance and response. Patients may experience mild discomfort during treatment, but it is generally well tolerated. While findings are encouraging, not all studies show uniform results. Some patients may not experience the desired pain relief. Thus, more rigorous and larger-scale studies are needed to establish long-term effectiveness, optimal treatment protocols, and patient selection. Interventional Therapies: Corticosteroid injections and ganglion nerve blocks were effective for refractory cases. Surgical Interventions: Coccygectomy presented moderate success rates but carried significant risks. Conclusions Multidisciplinary Approach: A comprehensive strategy is recommended for managing coccygodynia. Conservative measures (e.g., physical therapy, ESWT) should be prioritized. For patients not responding to conservative treatment, interventional options like corticosteroid injections are viable. Surgical options like coccygectomy must be approached cautiously, taking into account individual patient factors and the associated risks. Jens Rassweiler

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