Anterior tilted coccyx (Full Version)

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steve -> Anterior tilted coccyx (May 8, 2006 3:19:00 PM)

Hi

I just had a patient referred to me with a diagnosis of an anteriorly tilted coccyx after a fall on the buttock. In conjunction with her low back pain she also had a number of other issues from a psychosocial perspective (High FABQ score, return to work issues etc.).

My question is what is the significance of an anteriorly tilted coccyx? Does it occur in normal populations (Similar to disk bulges and spondylolithesis) and what is the prognosis for these patients? I did a pubmed search and there was surprisingly little in the way of research.

She has been treated with some internal mobilizations and stabilization exercises and has begun an independent exercise program that she states is making her feel better.
Thanks

Steve




bhenchodh -> Re: Anterior tilted coccyx (May 8, 2006 5:22:00 PM)

http://www.nmssolutions.com/tailbone_injury.htm

Maybe this link will help you. I can think of long term nerve damage and stenosis due to scaring.




FLAOrthoPT -> Re: Anterior tilted coccyx (May 8, 2006 5:55:00 PM)

Really though, how do you know she has an anterior coccyx? Static palpation, dynamic palpation, internal palpation? X=rays based off of current views with no supposed "normal" prior to pain and injury. Don't get me wrong, I strongly believe in biomechanical stresses being a source of pain, but do not rule out red flags of pelvic problems nor rule out pelvic floor musculature or peripheral nerve issues with obturator, etc. I just have a hard time believing anyone could show how a "malaligned" coccyx can be the source of significant pain. That being said, if I did MET to someone without pain and who was theoretically "aligned" then wouldn't they be in pain from then on? I'd wager that if you manipulated my low back right now, and I have no history of low back pain, that I would not all of a sudden be in chronic pain until you manipulated it "back into place." While I know manual spinal work helps, I use it frequently, I do not think it works for the reasons we were taught or the reasons the founders of the methods propose. Think logically here, look at nerve testing obturators, etc to see if they are bogged down and sensitive, look at mobs being a source of reducing dural and neural irritation/sensitivity, look at stabilizing the area with motor control exercises theorizing that the muscles may have become inhibited via pain mechanisms, but do not get bogged down on anterior vs posterior coccyx. PS, theoretically the coccyx moves in conjunction with L5 and opposite the sacrum. Have fun-

Ben Galin, MPT (4 weeks until DPT!!!), OCS




steve -> Re: Anterior tilted coccyx (May 8, 2006 6:02:00 PM)

Ben,

The x-ray diagnosis came from a radiologist and was supported by the two treating physiotherapists. I have the same concerns as you but was unsure of any of the research in the coccyx region.

Congrats on the DPT

Steve




FLAOrthoPT -> Re: Anterior tilted coccyx (May 8, 2006 11:12:00 PM)

thanks, but come on now, radiologists diagnosing an anterior rotated coccyx. I'd say that was a bit beyond their scope or ability, a good radiologist will only say what is objectively there, for example to throw out loss of lordosis is a bit fishy when unless they can say marked changes to the bony structure that causes a decreased in lordosis they know that they are not sure if a behavioral posturing or positioning is causing the view they are seeing. I just am shocked any radiologist, unless prompted by a clinical history would make that comment, then again this is the US and that is Canada. I am also just reitterating that treating positional faults is not only barking up a wrong tree, but it is pretty much disproven in literature. I think it is a helpful tool to help confirm your hypothesis, but should not be the only thing that gears your treatment. There is an advitiser here, no names mentioned, but the entire course is based on treating positional malalignments, I wasn't quite sure that I had not noticed I went to chiropractic school when I stepped into the CEU course, so I listened with a grain of salt. Ok, enough of my 2 cents-
Ben




dosrinc -> Re: Anterior tilted coccyx (May 9, 2006 8:19:00 AM)

I treat quite a few pts with coccygodynia and can tell you that you can base very little on xrays and treatment must be directed at what you find clinically, I have found that the stiff, hypomobile coccyx responds well to joint (sacrococcygeal) mobs with ossilation, the hypermobile coccyx responds better to soft tissue, trigger point/myofascial release of the pelvic floor muscles and the point tender coccyx (especially one that is aggravated by direct sitting and activities like bike riding) may be more periostial pain related and responds well to periostial injections. Remember that the coccyx is a point of muscle attachment for the pelvic sling musculature and if hypermobile can and will be pulled in any direction the muscles want to take it. Also remember that the coccyx is an extension of the sacrum, if the sacrum is nutated the pt. will sit on the coccyx tip and if the sacrum is counternutated the sacrum will appear more anterior on x-ray. See JV Maignes articles (spine) on seated vs standing xrays and on soft tissue and joint mob techniques (also spine). good luck
Rick




PHSPT -> Re: Anterior tilted coccyx (May 15, 2006 12:38:00 PM)

Ben ,
Take a look at this report and imaging pic at the bottom. It clearly points to a possibility of having a posteriorly aligned coccyx.

http://www.sofmmoo.com/english_section/7_coccyx/coccyx.htm

I agree on the fact that we cant rely on imaging alone to make a clinical decision, but in can certainly guide us in our thought process.

Unfortunately this is a topic w/ limited research. At the moment i have an obese female mid-aged pnt, w/ focal point tenderness to the coccyx region. Her onset of sx's is immediate w/ pressure. 7/10. Ill look into ordering imaging to r/o fx. maybe Ill find a "pretzeled coccyx"!!

Rick,
Whats your hand placement for these mobs. Ive heard of some brave souls out there, going "ALA Prostate style" for manipulations/mobilizations of the coccyx. Talk about major bonding!. :)




chiroortho -> Re: Anterior tilted coccyx (May 15, 2006 7:18:00 PM)

[QUOTE]Ben Galin, MPT (4 weeks until DPT!!!)[/QUOTE]Hey Ben that's terrific! Congratulations to you.

Greg




ginger -> Re: Anterior tilted coccyx (May 17, 2006 8:26:00 PM)

Steve , you mentioned "internal mobilisations" of the coccyx, tell me this is not what I think it means.




FLAOrthoPT -> Re: Anterior tilted coccyx (May 18, 2006 5:44:00 PM)

sure is...i think we have posted on this before, look itup in past.




steve -> Re: Anterior tilted coccyx (May 18, 2006 5:56:00 PM)

Ginger,

For the record, I never gave the gloved treatment - it was another therapist.

Steve




ginger -> Re: Anterior tilted coccyx (May 22, 2006 6:54:00 PM)

Aaaaaarrrrgh, Oh, sorry just clearing my throat, ok now.
For the record Steve, I personally can't let this moment go by without saying again , aaaaaarrrrrrgh. yup.
Most of the folks I've seen with a complaint of coccyx area pain ( increased pain with intra abdominal pressures) turn out to have referred pain from L1 and L2, along with those with sacral area pain . For the few who have real coccyx pain I've found very good success with mobs to coccygeal joints without resorting to intra anal adventures. Just a personal thing , seems to works quite well however. I wonder what caused you to go with the glove, presumably you had tried a PA in the standard way first?




nari -> Re: Anterior tilted coccyx (May 22, 2006 8:02:00 PM)

Ginger

Don't you remember in the Maitland days there was a description of internal mobilisation of the coccyx? I can recall a diagram.....but I don't think many performed the procedure - it seems silly if there are other noninvasive methods that work quite well.

Nari




ginger -> Re: Anterior tilted coccyx (May 22, 2006 10:17:00 PM)

Nari I usually put the idea away into the "who'd go there?" category approaching urban myth. Hats off to those game enough but clearly not for everybody. No disrespect Steve , just a personal thing.




steve -> Re: Anterior tilted coccyx (May 23, 2006 12:33:00 AM)

Ginger,

None taken, the patient had seen a physio specializing in women's health and internal mobilizations. Personally, I'm skeptical of how effective internal mobilizations are and how accurate we can assess things in that area. As for a quick update on the patient, she has very high DRAM scores and a 39/42 on the FABQ with significant discrepancies on what activities exacerbate her pain. From my perspective, I dont think that she would benefit from mobilizations anywhere.

Steve




nari -> Re: Anterior tilted coccyx (May 23, 2006 1:52:00 AM)

Steve

I think that is quite right, given her scores.
Also, there have been incidences of tilted coccyxes (?) with no related pain - eg XRs done for other reasons.
I'd forget about it and look for other methods, including a gentle discussion re her high scores.

Nari




james097 -> Re: Anterior tilted coccyx (May 23, 2006 12:32:00 PM)

Nari, I remember well the Maitland days and a few PTs who rendered this service. Anyone interested in going a bit deeper into this area should look up [URL=http://www.joeschwartz.net]www.joeschwartz.net[/URL] and seek "working where the sun don't shine" the colorectal surgeons song. It's a cheeky little ditty.
Jim McGregor




nari -> Re: Anterior tilted coccyx (May 23, 2006 3:51:00 PM)

Jim

Must be getting old, you and I, talking of the frenetic "Maitland" era....

Cute little ditty. :)

Nari




dosrinc -> Re: Anterior tilted coccyx (May 23, 2006 5:42:00 PM)

There are several texts and journal articles that referrence the internal mobilization of the coccyx and there are several practitioners including myself throughout the country who will utilize the technique very successfully when alternatives to the mobilization have been tried and have failed. I have been doing this for about 5 years now and cannot tell you the number of patients I have seen who have had numerous PT, chiro, pain management and other treatment techniques attempted and failed. Then vast majority of these patients have had pain for at least 2 years before I see them. Many have had PT's say "there is an internal mobilization for this but I dont go there" and the pt continues to suffer. Eventually they find there way to me or to another practitioner who is willing to utilize the tools of their training and perform the technique, often but of course not always, with dramatic results (or maybe they just tell me they are much better because they dont want me to do it again?). I have trained other PT's in the technique and they also report similar results. Once you do it a few times the mystique goes away and you wonder what the big deal was in the first place. It is also very rewarding to "fix" someone who has had pain for such a long time.

I am still trying to figure out just why the internal seems to work better for some vs. others and would like to see a CPR done to determine those that are best suited for one vs. the other. I am always sure to rule everything else out first so as not to mobilize a coccyx on someone with an L12 dysfunction as Ginger describes ( by the way Ginger, what from L12 comes down or refers down to the tailbone region?

With the advent and growth of the women's health PT section and the increased continuing education opportunities in this field you will all see more and more PT's and PT journal articles relating to PT performance of internal soft tissue and joint mobilization techniques, hopefully further eroding the "taboo" of the subject so that our patients dont continue to suffer needlessly or travel half way across the country to see me.

I wonder if the first person to put a glove on and mobilize the TMJ or perform soft tissue work on the lateral pterygoid was looked on with such puzzlement?

Or, we could just leave it all to the Chiro's

Rick




ginger -> Re: Anterior tilted coccyx (May 23, 2006 7:14:00 PM)

You are to be applauded for your stirling efforts to relieve the difficult coccyx Rick . No kidding it is a fine thing , just realise it sets you up now for a very fine nick name. I'll get back to you on that.




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