Recent Coccyx Case
I had a very interesting case. I saw a woman in late December and again in late January. She was away for several weeks. Her mechanism of injury was from a rowing machine, and she did have a prominent lower sacrum and an anterior tilt of the pelvis AKA Bilateral anterior Ilium, so she had a predisposition to injury. She brought a fluroscopy photo with a drawn outline of a subluxed coccyx. The pain Dr did an injection and explained that the subluxation was the cause of her pain and prior x-rays were negative given the fact that the coccyx is oftentimes obscured by bowel. It was distinctly subluxed dorsally by about 25% or greater. An Orthopedist has suggested surgery as a possibility with limited potential for improvement. She reasoned that it had a mechanical cause and therefore should have a mechanical treatment and found me online, as I post on www.coccyxpain.org web site. In retrospect I believe that she had a true fracture of the sacrococcygeal joint, meaning it had fused soome time ago. This is based on the fact that all passive motion tests at the sacroiliac, pelvis, lumbar and thoracic spine reveled lack of motion, yet costal joints had normal motion per passive accessory spring tests. I treated it with common sense. I distracted it inferiorly and then applied a dorsal to ventral force at the bases for several minutes then a superior force to "seat it". It did help, though she did need the second visit and I then taught her an easier method of self treatment which I spontaneously developed-much like the treatment. Common sense carries much weight. This is a less common mechanism of injury. All of my efforts at restoring motion through the pelvis failed me. given fairly normal x-rays and MRI, I suspect that she has a perhaps undocumented type of "soft tissue spinal fusion" that impacts the soft tissue elements of the spine and sacroiliac, perhaps the fibrous connective tissue, fibrocartilage; making it remarkably stiff in the absence of true bony fusion. I hope to work with her some more and measure spinal flexion and extension with a flexible ruler, and suspect that the outline will be unchanged. She compensates beautifully with full hip motion and no hx of prolonged back pain, no family history to suggest an inflammatrory spondylarthropathy such as Ankylosing Spondylitis. I will contact a university Rheumatologist to ask if there is such a thing in the annals.
Jerry Hesch
Jerry Hesch
Side Bent Coccyx & Lower Pelvic Sacroiliac & Symphysis Motion Dysfunction
I have noted a consistent pattern that can cause a side bent coccygeal fixation and at times, cause a mechanical pudendal neuralgia. It is a lower pelvic pattern which I discovered perhaps 15 years ago. To describe in simple terms, it must involve the symphysis pubis, the sacroiliac and the hips. One ischia is more lateral, th eother more medial. These also have an anterior and posterior component and also a subtle rotational element. The traditional palpation of the pelvis/sacroiliac will be misleading. It requires advanced palpation as taught in the Hesch method advanced work. It takes 5 seperate manuevers, performed sequentially prior to correcting the coccygeal side bent fixation. It is my belief that correction of the coccyx done firts, without correcting the lower pelvic fixation most likely will not be lasting. I so much dislike treating only "where it hurts", one needs a broader, more global context with which to view complex injuries.
Jerry Hesch
From an Online Forum Dear Group,
just a few thoughts re coccyx. All posts have been thought provoking to me.
At an appropriate juncture such as past 1st trimester, one could screen the
coccyx for a side bent fixation which would tend to cause pain to be
unilateral. These, when present, are easily corrected by pushing directly
onto the lateral coccyx towards midline while at the same time pushing on
the opposite side laterally to enhance tension on the sacrospinous and
sacrotuberous ligaments, holding for about 2 minutes. I understand the
client had a long road trip and I do think we tend to weight bear
asymmetrically in cars, due to gas and brake pedals and pre-existng pelvic
asymmetry.
If mid line, a pure inferior glide force could be applied externally, and
the distraction it induces might provoke a "self correction". I have also
compressed both ischial tuberosities medially to slacken the sacrotuberous
and sacrospinalis ligaments. This is difficult as a one person technique, easier
with one person on each side, again that magic creep thing of 2 minutes
seems ideal.
Shannon's post re treating other areas a helpful reminder, and sometimes a
midline disc bulge will be culpable. I agree that anything that can reduce
positional faults along the entire spine and rib cage is worthy of
intervention.
Just a few thoughts.
Best Reards
JH
Jerry Hesch
From an Online Forum Dear Group,
just a few thoughts re coccyx. All posts have been thought provoking to me.
At an appropriate juncture such as past 1st trimester, one could screen the
coccyx for a side bent fixation which would tend to cause pain to be
unilateral. These, when present, are easily corrected by pushing directly
onto the lateral coccyx towards midline while at the same time pushing on
the opposite side laterally to enhance tension on the sacrospinous and
sacrotuberous ligaments, holding for about 2 minutes. I understand the
client had a long road trip and I do think we tend to weight bear
asymmetrically in cars, due to gas and brake pedals and pre-existng pelvic
asymmetry.
If mid line, a pure inferior glide force could be applied externally, and
the distraction it induces might provoke a "self correction". I have also
compressed both ischial tuberosities medially to slacken the sacrotuberous
and sacrospinalis ligaments. This is difficult as a one person technique, easier
with one person on each side, again that magic creep thing of 2 minutes
seems ideal.
Shannon's post re treating other areas a helpful reminder, and sometimes a
midline disc bulge will be culpable. I agree that anything that can reduce
positional faults along the entire spine and rib cage is worthy of
intervention.
Just a few thoughts.
Best Reards
JH
Coccyx Screen
A mid line disc bulge at the thoraco-lumbar region and several segments below can cause coccygeal pain. Any post-op imaging to evaluate canal, discs - such as Ct or MRI?
Check the lateral allignment of the ischial tuberosity on both sides in relation to the midline gluteal crease. Check the ischia with respect to A-P, P-A relationships. Also test mobility with medial to lateral, lateral to medial at ischial tuberosity, P-A just above the ischial tuberosity on the ishium (bilaterally). If positive, contact me via my e-mail. There are 4 unilateral patterns that could be at work here, but invariably both sides require treatment. You will not find these described in the literature, someday I will publish.
The coccyx needs to be evaluated mechanically for forward/backward motion dysfunction and side-bending also.
It is relevant to palpate the Sacrotuberous ligament. Open your palms fully so that thumbs are nearly 90 degrees away from digits. Bring thumb tips and tips of index fingers together so that they form a triangle. Place the tip of index fingers on the coccyx and the thumbs should then be on the creases on top of the thighs. The index fingers then lie on top of the Sacrotuberous ligaments. Now with tip of thumbs push into the ligament, you will have to depress the gluteal fat ands muscle several centimeters. You can strum the ligament like guitar string or simply depress it - just like taking up the slack and performing a mobility test at a joint. Compare the tone side to side. Asymmetry of tone coupled with bony palpation and passive mobility testing should be informative, and can guide treatment.
It would be worthwhile to read up on Dr Maigne who has some excellent work on thoracolumbar junction mobility dysfunction. More often than not T12-L1 is in hyperextension and a foam roller placed below it with progressive flexion to isolate force at the junction is helpful, say for at least 5 minutes. Be creative, there are several ways to accomplish this. More details upon request.
Sitting on rolled towels in front of the ischial tuberosities will unweigh the coccyx, helpful if it is suffering from sitting compression. Mulligan has a sitting wedge, though I was making these in 1983 (Albuquerque, New Mexico, USA), just never did market properly. Best Regards Jerry Hesch, MHS, PT jerryhesch@cox.net
Check the lateral allignment of the ischial tuberosity on both sides in relation to the midline gluteal crease. Check the ischia with respect to A-P, P-A relationships. Also test mobility with medial to lateral, lateral to medial at ischial tuberosity, P-A just above the ischial tuberosity on the ishium (bilaterally). If positive, contact me via my e-mail. There are 4 unilateral patterns that could be at work here, but invariably both sides require treatment. You will not find these described in the literature, someday I will publish.
The coccyx needs to be evaluated mechanically for forward/backward motion dysfunction and side-bending also.
It is relevant to palpate the Sacrotuberous ligament. Open your palms fully so that thumbs are nearly 90 degrees away from digits. Bring thumb tips and tips of index fingers together so that they form a triangle. Place the tip of index fingers on the coccyx and the thumbs should then be on the creases on top of the thighs. The index fingers then lie on top of the Sacrotuberous ligaments. Now with tip of thumbs push into the ligament, you will have to depress the gluteal fat ands muscle several centimeters. You can strum the ligament like guitar string or simply depress it - just like taking up the slack and performing a mobility test at a joint. Compare the tone side to side. Asymmetry of tone coupled with bony palpation and passive mobility testing should be informative, and can guide treatment.
It would be worthwhile to read up on Dr Maigne who has some excellent work on thoracolumbar junction mobility dysfunction. More often than not T12-L1 is in hyperextension and a foam roller placed below it with progressive flexion to isolate force at the junction is helpful, say for at least 5 minutes. Be creative, there are several ways to accomplish this. More details upon request.
Sitting on rolled towels in front of the ischial tuberosities will unweigh the coccyx, helpful if it is suffering from sitting compression. Mulligan has a sitting wedge, though I was making these in 1983 (Albuquerque, New Mexico, USA), just never did market properly. Best Regards Jerry Hesch, MHS, PT jerryhesch@cox.net