Postpartum Coccydynia: Causes, Symptoms and Treatment

Title: Postpartum Coccydynia: Tailbone Pain After Childbirth and Rehabilitation

Postpartum coccydynia is a clinical condition characterized by acute or chronic pain localized at the level of the coccyx and the sacrococcygeal joint, which arises following vaginal delivery or, in rare cases, even after a cesarean section due to biomechanical changes during pregnancy. This painful syndrome represents a disabling problem for the new mother, significantly affecting her quality of life, her ability to care for the newborn, and the resumption of normal daily and work activities. The pain typically manifests during prolonged sitting, during postural transitions (particularly when moving from a sitting to an upright position) and, sometimes, during defecation or sexual intercourse. Despite its frequency, this condition is often underestimated or considered a normal consequence of childbirth destined to resolve spontaneously. However, timely diagnostic assessment and targeted rehabilitation intervention are essential to prevent the symptom from becoming chronic. It is always fundamental to consult your doctor or physical therapist to obtain an accurate diagnosis and a personalized treatment plan, excluding other pathologies affecting the pelvis or pelvic floor.

Anatomy and Biomechanics of the Sacrococcygeal Complex

The sacrococcygeal complex comprises the sacrum and coccyx bones at the base of the spine, connected by ligaments and cartilage, forming a weight-bearing structure that transmits forces during sitting and movement. To fully understand the pathogenesis of coccygeal pain, it is necessary to analyze the anatomy and biomechanics of the pelvic region. The coccyx represents the terminal segment of the vertebral column and is composed, in most individuals, of three to five rudimentary vertebrae fused together. It articulates superiorly with the apex of the sacrum via the sacrococcygeal joint, a symphysis equipped with a fibrocartilaginous disc that allows slight flexion and extension movements.

From a biomechanical point of view, the coccyx is not an inert structure, but serves as an important anchoring point for numerous ligaments and muscles of the pelvic floor. Among the most relevant ligaments are the anterior, posterior, and lateral sacrococcygeal ligaments, as well as the robust sacrospinous and sacrotuberous ligaments. Muscularly, the coccyx provides insertion for the gluteus maximus muscle, the ischiococcygeus muscle, and portions of the levator ani muscle (pubococcygeus and iliococcygeus). This complex myofascial network means that any alteration in muscle tension or any trauma to the coccyx affects the entire functionality of the pelvis (Maigne et al., 2012).

The Role of the Coccyx During Pregnancy and Childbirth

During gestation, the female body undergoes profound hormonal changes. The secretion of relaxin and progesterone induces greater laxity of the pelvic ligaments, necessary to allow for pelvic expansion and fetal passage. This physiological laxity, however, makes the sacrococcygeal joint more vulnerable to mechanical stress.

During the expulsive phase of vaginal delivery, the fetal head descends through the birth canal, exerting considerable pressure on the bony and soft structures of the pelvis. To widen the diameter of the pelvic outlet, the sacrum performs a movement of counternutation, while the coccyx is pushed into maximum extension (backward). Under normal conditions, the sacrococcygeal joint possesses sufficient mobility to accommodate this thrust (up to 30 degrees of extension). However, if the pressure is excessive, if the coccyx is rigid, or if fetal passage is abnormal, shear forces can exceed tissue resistance, causing joint, ligamentous, or bone injuries.

Causes and Risk Factors of Postpartum Coccydynia

The onset of **postpartum coccydynia** is multifactorial and depends on a combination of anatomical, obstetric, and biomechanical factors. Direct trauma during childbirth is the main cause, but there are different types of injuries that can occur to the sacrococcygeal complex.

Types of Coccygeal Injury

Structural alterations leading to the development of painful symptoms can be classified into different categories, depending on the severity of the mechanical impact sustained during childbirth (Lirette et al., 2014):

• Sacrococcygeal hypermobility: This is the most frequent cause. The sacrococcygeal ligaments undergo excessive stretching, making the joint unstable. During sitting, the coccyx flexes abnormally, causing chronic inflammation.
• Dislocation or subluxation: Fetal pressure causes anterior or posterior displacement of the coccyx relative to the sacrum, with loss of normal joint relationships. This condition is often associated with acute and disabling pain.
• Coccyx fracture: Although less common, a fracture of one of the coccygeal segments can occur in cases of particularly traumatic deliveries. It requires longer healing times and careful medical management.
• Reflex muscle spasm: Even in the absence of bone or joint injuries, birth trauma can trigger a defensive hypertonicity of the pelvic floor muscles (particularly the levator ani), which exert continuous traction on the coccyx, generating ischemic and tensive pain.

Obstetric and Maternal Risk Factors

Scientific literature has identified several factors that increase the likelihood of developing this pathology. Healthcare personnel should evaluate these elements during the postpartum anamnesis:

• Fetal macrosomia: A birth weight greater than 4 kg requires more space for passage through the birth canal, increasing mechanical stress on the coccyx.
• Operative delivery: The use of forceps or vacuum extractor alters the normal biomechanics of expulsion, applying traction forces that can traumatize the posterior structures of the pelvis.
• Maternal Body Mass Index (BMI): A high BMI (overweight or obesity) is correlated with a higher incidence of posterior coccyx dislocations, as gluteal adipose tissue modifies the sitting angle and load distribution (Maigne et al., 2000).
• Pelvic anatomy: A narrow pelvis or a coccyx positioned more anteriorly than normal (a “hooked” coccyx) are more exposed to direct trauma from the fetal head.
• Position during childbirth: Delivery in the lithotomy position (supine with legs raised) limits the mobility of the sacrum and coccyx compared to more physiological positions such as squatting or all fours.

Symptomatology and Clinical Picture

The clinical picture is dominated by pain, whose intensity can vary from a dull ache to sharp, stabbing pains that prevent normal activities. The localization is typically pinpoint, exactly at the apex of the coccyx or the sacrococcygeal joint, but the pain can radiate towards the buttocks, the lower lumbar region, or the perineum.

Symptoms are exacerbated in specific situations that involve mechanical load on the region:

• Prolonged sitting: Especially on hard or backward-sloping surfaces. The weight of the trunk is directly discharged onto the inflamed coccyx.
• Postural transition: Moving from a sitting to an upright position is often the most painful moment, due to the contraction of the gluteus maximus muscle and pelvic muscles that “pull” the unstable coccyx.
• Defecation: The passage of feces in the rectum, which is immediately in front of the coccyx, can cause pain, especially in cases of constipation (frequent postpartum).
• Dyspareunia: Pain during sexual intercourse can manifest due to pelvic floor muscle hypertonicity associated with the condition.

The psychological impact should not be overlooked. Chronic pain during a delicate phase such as the puerperium can interfere with breastfeeding (due to the inability to maintain a comfortable sitting position) and increase the risk of postpartum depression. For this reason, the importance of promptly consulting your doctor or physical therapist is reiterated.

Medical Diagnosis and Physiotherapeutic Evaluation

The diagnostic process must be rigorous to exclude other pathologies (differential diagnosis) such as pilonidal cysts, anal fissures, hemorrhoids, lumbar radiculopathies, or pelvic infections. The diagnosis is divided into a medical phase and a functional physiotherapeutic evaluation.

Medical Investigations and Imaging Diagnostics

The specialist doctor (orthopedist, gynecologist, or physiatrist) will collect a detailed anamnesis regarding the mode of delivery and the characteristics of the pain. The objective examination involves external palpation of the coccyx to elicit the symptom and evaluate the presence of swelling.

The gold standard for instrumental diagnosis is **dynamic coccyx radiography**. This examination involves taking two lateral projection radiographs: one in an upright position and one in a sitting position (at the moment the patient experiences pain). By comparing the two images, the doctor can measure the pelvic rotation angle and the coccyx flexion angle. Flexion greater than 25 degrees indicates hypermobility, while translation greater than 25% indicates dislocation (Maigne et al., 2000). In specific cases, the doctor may prescribe Magnetic Resonance Imaging (MRI) to evaluate the condition of soft tissues, bone edema, or exclude pelvic masses.

Functional Physiotherapeutic Evaluation

Once the medical diagnosis is obtained, the physical therapist specialized in pelvic floor rehabilitation performs a thorough functional evaluation. This phase is crucial for setting up the treatment plan and includes:

• Postural analysis: Evaluation of the alignment of the spine, pelvis, and lower limbs, to identify antalgic compensations.
• External muscle evaluation: Palpation of the gluteal muscles, piriformis, obturator internus, and lumbar paravertebral musculature to identify trigger points or areas of hypertonicity.
• Pelvic floor evaluation: With the patient’s informed consent, the specialized physical therapist can perform an intracavitary (vaginal or rectal) evaluation to test the tone, strength, and relaxation capacity of the levator ani and ischiococcygeus muscles, often involved in reflex spasm.

Conservative Treatment and Rehabilitation for Postpartum Coccydynia

The management of **postpartum coccydynia** is predominantly conservative. Surgical intervention (coccygectomy) is considered only as a last resort in cases of pain refractory to months of conservative therapies. The rehabilitation plan must be multimodal and personalized, under the strict supervision of your doctor or physical therapist.

Manual Therapy and Osteopathic Techniques

Manual therapy represents one of the pillars of treatment. The goal is to restore correct joint mobility and reduce myofascial tensions that perpetuate pain.

• External myofascial treatment: Release techniques applied to the gluteal muscles, sacrotuberous and sacrospinous ligaments. Deactivating trigger points in these areas significantly reduces referred coccygeal pain.
• Joint mobilization: Gentle mobilization techniques for the sacrum and sacroiliac joints to improve overall pelvic biomechanics.
• Thiele’s massage (Internal mobilization): A specific technique that involves massaging and stretching the pelvic floor muscles (levator ani and coccygeus) transrectally or transvaginally. This technique, performed exclusively by trained healthcare personnel, is highly effective in reducing muscle spasm that maintains the coccyx in abnormal traction (Patijn et al., 2010).

Therapeutic Exercise and Postural Re-education

Therapeutic exercise is not based on strengthening, but rather on relaxation and body awareness. In the presence of coccygeal pain, the pelvic floor tends to be hypertonic. Therefore, traditional Kegel exercises (based on contraction) are often contraindicated in the acute phase, as they could worsen the spasm.

The physical therapist will guide the patient through:

• “Down-training” exercises (Pelvic relaxation): Diaphragmatic breathing techniques associated with voluntary relaxation of the perineal musculature. The goal is to teach the patient to “let go” of tension in the pelvic area.
• Specific stretching: Stretching exercises for the piriformis, psoas, hamstrings, and gluteal muscles, to reduce traction forces on the pelvis.
• Core Stability: Gentle strengthening of the deep abdominal muscles (transversus abdominis) to stabilize the pelvis without overloading the pelvic floor.

Instrumental Physical Therapies

In conjunction with manual therapy and exercise, your doctor or physical therapist may suggest the use of physical therapies to accelerate the healing process, reduce inflammation, and control pain. It is essential to evaluate contraindications, especially during the breastfeeding period.

Ergonomics, Return to Work, and INAIL Data

Daily management of postures is an essential element for the resolution of the pathology. Returning to work after maternity leave, especially for professional categories that require prolonged sitting (administrative clerks, cashiers, VDU operators), represents a critical moment that can trigger relapses.

Ergonomic Adaptations

The fundamental principle of ergonomics in cases of coccygeal pain is the redistribution of body weight onto the ischial tuberosities (the bones on which one sits) and the thighs, completely offloading the coccyx.

• Orthopedic cushions: The use of “U”-shaped, “V”-shaped, or donut-shaped cushions (although the latter is sometimes discouraged because it can increase perineal venous pressure) is essential. The cushion must have a posterior cutout so that the coccyx remains suspended in the air during sitting.
• Sitting posture: It is recommended to sit with the spine well-aligned, avoiding sliding forward with the pelvis (retroversion), a position that exposes the coccyx to direct contact with the chair. Leaning the trunk slightly forward can help transfer the load to the thighs.
• Frequent breaks: It is imperative to interrupt sitting every 30-45 minutes, standing up and walking to promote circulation and reduce joint stiffness.

The Risk of Biomechanical Overload: The INAIL Context

According to the guidelines of the National Institute for Insurance Against Accidents at Work (INAIL), maintaining incongruous and prolonged fixed postures is among the risk factors for the development of musculoskeletal disorders. Legislative Decree 81/08 on health and safety in the workplace requires employers to assess risks (DVR), including ergonomic risk for workers using visual display units.

INAIL data highlights how biomechanical overload pathologies are constantly increasing, representing one of the main causes of occupational disease. Although postpartum coccygeal injury has an obstetric rather than strictly work-related origin, returning to a non-ergonomic work environment acts as an aggravating and chronicizing factor. Workers affected by this problem should request, through the company’s occupational physician, the adaptation of their workstation (e.g., provision of specific ergonomic seating, height-adjustable desks to alternate between sitting and standing positions, known as *standing desks*).

Prevention and Long-Term Management

Preventing relapses requires a long-term approach based on maintaining tissue elasticity and proper load management. It is essential to continue performing pelvic mobility and stretching exercises learned during physiotherapy sessions even after the resolution of acute symptoms.

Furthermore, body weight management and ensuring regular bowel movements (through adequate hydration and a fiber-rich diet) are crucial factors in avoiding additional mechanical stress on the pelvic floor and rectum. In the event of subsequent pregnancies, it is essential to inform the obstetric team about previous coccygeal trauma, so that protective birthing positions (e.g., lateral decubitus or asymmetrical positions) can be adopted to reduce pressure on the sacrococcygeal joint. The need to always rely on your doctor or physical therapist to monitor clinical evolution over time is reiterated.

Frequently Asked Questions (FAQ)

Frequently Asked Questions

What is postpartum coccydynia?

Postpartum coccydynia is a clinical condition characterized by acute or chronic pain localized at the coccyx and the sacrococcygeal joint. This painful syndrome arises following childbirth, significantly impacting a new mother’s quality of life and daily activities.

What are the common causes of postpartum coccydynia?

This condition typically develops after vaginal delivery, or in rare cases, even after a cesarean section. It is primarily attributed to biomechanical changes that occur during pregnancy and childbirth, leading to pain in the tailbone region.

How does postpartum coccydynia typically manifest?

The pain commonly manifests during prolonged sitting and during postural transitions, particularly when moving from a sitting to an upright position. It can also sometimes occur during defecation or sexual intercourse.

Why is timely intervention important for postpartum coccydynia?

Timely diagnostic assessment and targeted rehabilitation intervention are essential to prevent the symptom from becoming chronic. Despite its frequency, this condition is often underestimated, but early management can significantly improve outcomes and quality of life.

Sources and Scientific References

1. Maigne JY et al. Postpartum coccydynia: a case series study of 57 women. Eur J Phys Rehabil Med. 2012. PubMed
2. Abdoelmagd SR et al. Influence of Photobiomodulation Therapy Combined with Pelvic Floor Exercises on Postpartum Coccydynia: A Randomized Controlled Trial. Photobiomodul Photomed Laser Surg. 2025. PubMed
3. Esmaeeli S et al. Caudal epidural steroid injections with paracoccygeal injections for management of postpartum coccydynia: a case series. Int J Obstet Anesth. 2023. PubMed
4. Márquez-Carrasco ÁM et al. Coccyx pain in women after childbirth. Enferm Clin (Engl Ed). 2019. PubMed