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Clinically Relevant Anatomy

The coccyx, also known as the tailbone, is a small triangular bone that is usually formed by fusion of the four rudimentary coccygeal vertebrae, although in some people there may be one less or one more. The coccygeal vertebra 1 (Co1) may remain separate from the fused group, but with increasing age Co1 often fuses with the sacrum and the remaining coccygeal vertebrae usually fuse to form a single bone. (level of evidence D)
The forward movement of coccyx is performed actively by the M. levator ani, and the backward movement of coccyx is passively caused by relaxation of these muscles. The coccyx also provides the site of attachment for the M. gluteus maximus as well as the M. levator ani, which is responsible for voluntary control of bladder and bowel. (level of evidence B) The coccyx does not participate with the other vertebrae in support of body weight when standing, however when sitting it may flex anteriorly, indicating that it’s receiving some weight. ( level of evidence D)i

The coccyx is part of the sacrococcygeal joint, an cartilaginous joint with an IV disc. Fibrocartilage and ligaments join the apex of the sacrum to the base of the coccyx. The anterior and posterior sacrococcygeal ligaments are long strands that reinforce the joint. (level of evidence D)
The coccyx is also attached with the margin of the anus by the anococcygeal ligament. (level of evidence D)iii

Epidemiology /Etiology

Fracture of the coccyx often arise after a fall on the buttock, most prevalent a fall of the stairs on the tailbone, or by an impact directly applied. (level of evidence D) An especially difficult childbirth occasionally injures the mother’s coccyx. ( level of evidence D)

Characteristics/Clinical Presentation

General symptoms that appear are (level of evidence D)iv,vii,viii :
• Pain that increases in severity when sitting or getting up from a chair
• Provoked pain over the tailbone
• Bruising or swelling in the tailbone area
• Bowel movements and straining are often painful
• There are no neurological signs

An important number of people suffer from long lasting pains over the coccyx following trauma (with or without fracture of the coccyx), better known as cocydynia.(level of evidence D)

Patients with SCI, suffering from painful symptoms in the low back, gluteal, hip and thigh region, have coccyx fracture with a frequency of 34,6%. Patients who had coccyx fracture have higher pain scores when compared with those who don’t have any fracture, however the difference is only statistical significant regarding Sensory Pain Index (SPI) and total McGill scores.( level of evidence C)

Differential Diagnosis

Diagnostic Procedures

A plain radiography or MRI is necessary to confirm the diagnose of a coccyx fracture. (level of evidence D)

The diagnose is made after rectal examination. (level of evidence D)iv By passing the finger up the rectum and then pressing the bone backwards and forward, the unnatural degree of motion will then be felt. Related to the age and sex of the patient must be remembered that in the female this bone naturally possesses more motion than in the male, and that in youth a degree of motion, that does not exist at a later period of life, is present, allowing the ossification being less complete. However the free motion of the bone is taken as a symptom. (level of evidence D)

Outcome Measures

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Medical Management

By applying the novel techniques that are used in vertebroplasty and sacroplasty, coccygeoplasty is introduced as a new percutaneous treatment modality for fractures of the coccyx. This procedure can be helpful for patients with refractory pain resulting from a fracture of the coccyx and can be performed quickly and safely with high-resolution c-arm fluoroscopy. The coccygeal fracture treated with an injection of polymethylmethacrylate cement can provide early symptom relief. Although the promising results, an experience with a larger patient population is warranted. ( level of evidence C)

Literature reports suggest that coccygectomy, partial or total removal of the coccyx, has been beneficial with success rates as high as 60-91%. However, coccygectomy is a more invasive procedure, with a common complication rate as high as 22%, and is usually associated with perineal contamination of the wound. Other complications could include persistent bleeding from the hemorrhoidal venous complex of the rectum. (level of evidence C)ix

Physical Therapy Management

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see adding references tutorial.

MOORE K.L., DALLEY A.F., AGUR A.M.R., Clinically oriented anatomy: chapter 3: Pelvis and perineum, Wolters Kluwer health, sixth edition, 2010, pag. 451-452, level of evidence D
YU-TSAI T., LI-WEN T., CHENG-HSIU L., SHIH-WEI C., The influence of human coccyx in body weight shifting, medicine and science in sport and exercise, 2011, Volume 43, Number 5, pag. 494-496, level of evidence B
MOORE K.L., DALLEY A.F., AGUR A.M.R., Clinically oriented anatomy: chapter 3: Pelvis and perineum, Wolters Kluwer health, sixth edition, 2010, pag. 332, level of evidence D
HAARMAN H.J.Th.M., Klinische traumatologie, Elsevier gezondheidszorg, 2006, pag. 117, level of evidence D
MOORE K.L., DALLEY A.F., AGUR A.M.R., Clinically oriented anatomy: chapter 3: Pelvis and perineum, Wolters Kluwer health, sixth edition, 2010, pag. 461, level of evidence D
TEKIN L. et al., Coccyx fracture in patients with spinal cord injury, European journal of physical and rehabilitation medicine, March 2010, Volume 46, Number 1, pag. 43-46, level of evidence C
RAISSAKI M.T.,Fracture dislocation of the sacro-coccygeal joint: MRI evaluation, Pediatric radiology, March 1999, pag. 642-643, level of evidence D
LONSDALE E.F., A practical treatise on fractures, Walton and Mitchell printers, 1838, pag. 269-270, level of evidence D
MIYAMOTO K. et al., Exposure to pulsed low intensity ultrasound stimulates extracellular matrix metabolism of bovine intervertebral dosc cells cultured in alginate beads, Spine, November 2005, level of evidence B
EBNEZAR J., Essentials of orthopaedics for physiotherapist, Jaypee, 2003, pag. 174, level of evidence D
DEAN L.M. et al., Coccygeoplasty : treatment for fractures of the coccyx, J. Vasc. Interv. Radiol, 2006, pag. 909-912, level of evidence C
COOPER G., HERRERA J.E., Manual of musculoskeletal medicine, Wolters kluwer, Lippincott Williams & Wilkins, 2008, pag. 144, level of evidence D, 1.Search Strategy


3.Clinically Relevant Anatomy

4.Epidemiology /Etiology

5.Characteristics/Clinical Presentation

6.Differential Diagnosis

7.Diagnostic Procedures

8.Outcome Measures


10.Medical Management

11.Physical Therapy Management

12.Key Evidence


14.Clinical Bottom Line


1.Search Strategy
I used pedro, Pubmed, google scholar. In those database I systematically search with the keywords; Pulley A2, Pulley A4, Pulley ruptures, physiotherapy pulley rupture, climbing injury, ...

2.Definition/ Description
For a maximal efficiency of joint rotation in the hand, there are some pulleys; the transversal carpal ligament, the palmar aponeurosis and some pulleys along the digits. Those pulleys consist in five annular and 3 cruciform pulleys. [1]

3.Clinical Relevant Anatomy
The most important oneʼs are the A2 and the A4 pulleys [2], situated at the palmar side of the digits. The A2 pulley is continuous with the periosteum of the proximal phalanx and the A4 pulley is in the middle of the middle phalanx.
Bron 1
The annular pulleys are optimised for the purpose of flexor tendon positioning and gliding. In the A2 pulley there were identified 3 layers [3]. In the outmost layer is a loosely arranged areolar tissue contain fine capillary network. Itʼs also continue with the synovial membrane that provides nutrient vascular supplies to the pulley. The middle layer of the pulley is densely arranged with collagen bundles, those are oriented perpendicular to the long axis of the flexor tendon. This optimised the resistance of the pulley.
The innermost layer, correspond to the gliding surface of the pulley. It is composed of collagen bundles, oriented parallel with the flexor tendon. That optimised the gliding between the flexor tendon en the pulley. Within this layer, elongated elastin fibrils were regularly positioned within the collagen fiber array [4].

4.Epidemiology /Etiology

5.Characteristics/Clinical Presentation 6.Differential Diagnosis 7.Outcome Measures 8.Diagnostic Procedures
A fresh pulley injury results in a local swelling, tenderness and pain over the affected area. The main indicator to identifyif a total rupture of a pulley has occurred is the appearance of the clinical bowstringing (In this case; when the finger is in flexion, the flexor tendon is taking the shortest line between the top and the base of the finger. Instead of following the phalang).
Bron 2 This method is very conclusive, but you can only use it with a total rupture of the pulley [29]. The most recent study I found about the diagnostic procedure of the pulley, was a comparison between the effectiveness of ultrasonography and MRI (Magnetic Resonance Imaging) scanning. This study showed us that the ultrasonography is a better diagnostic tool than the MRI. Not only because itʼs an inexpensive method but also because you can have more precision and a better view with the ultrasonography [5].

There are 3 grades in the pulley injury: Grade III: "Complete rupture of the pulley causing bowstring of the tendon. Symptoms " are: " locally pain at the pulley, heard a PO or CRACK, swelling, pain when " squeezing or climbing, pain while finger extension GradeII:" Partialruptureofthepulley.Symptoms:locallypainatthepulley,painwhile " extending finger and while climbing GradeI:" Spraininthefingerligament.Symptoms:Locallypain,painwhensqueezing " or climbing

10.Medical Management
Tension of the grafts was evaluated to have an idea of the tension that is recommended in a new graft. The tension of an healthy pulley is between 0,49N and 1,69N. On the bases of those findings we recommend that reconstructed pulley be tensioned to approximately 1N [6].
Free extrasynovial tendon grafts are the most commune method currently in use for pulley reconstruction.
The A2 and A4 are recommended to be reconstructed using multiple loops of free extrasynovial tendon grafts on the same place were the original digital pulley was [7].
The strength of the repaired pulley is correlated with the number of loops in the tendon [8]. But recent studies suggest that intersynovial donor tendons may be more efficient as free extrasynovial tendon graft [9]. The intersynovial grafts had less frictions, what gives a better mobility in the digits.
An other method report on the use of the dorsal wrist retinaculum for the reconstruction of the annular digital pulleys [10]. About 8 cm. of the retinaculum is necessary for the reconstruction of each digital pulley. It is recommended that the under surface of the extensor retinaculum is orientated toward the tendon for a better gliding. An independent biomechanical assessment of this pulley reconstruction concluded that this method gives a limitation in the mechanical effectiveness.
The ever present Rim, is a tendon weave technique that is based on the remnant of the ruptured pulley. The advantage of this technique is that the long pulley structure retains the flexor tendon in close proximity to the bone. Itʼs a very efficient technique but itʼs also shown to be one of the weakest pulley reconstruction methods [11].

11.Physical Therapy Management
Rohrbough indicates that there remains some disagreement between researchers as to the treatment of pulley tears [15].
Stretching is recognized as an important promoter of formation of strong compacted scar tissue[16]. Stretching involves pulling the finger in the varus direction, effectively hyper
extending the metacarpophlangeal joint and PIP joint [17]. An alternative therapy such a squeezing a ball may be useful. Such therapy is useful in
promoting healing in the injury, it does not prevent atrophy of other healthy tissues [14].
Minor A2 pulley injuries or partial tears with no evidence of bowstringing can be treated with either firm circumferential taping for 2 to 3 months to permit healing [13]. The effectiveness of pulley taping was tested [18]. The effect was maximized (10% of bowstringing force) when the tape is positioned near the distal end of the proximal phalanx. The tape absorbed progressively less bowstringing force as the force produced at the fingertip increased [18]. Non stretch, zinc oxide tape of 1.3 cm width was used [13]. This result has two implications. Firstly, taping is likely to be most effective during the earlier stages of rehabilitation when the forces produced by the fingers are lower. Secondly, taping is unlikely to prevent pulley injuries, as these are likely to occur when forces on the pulley are maximal [19].

12.Key Research
Digital Flexor Sheath: Repair and Reconstruction of the Annular Pulleys and Membranous Sheath
Analysis of the gliding pattern of the canine flexor digitorum profundus tendon through the A2 pulley, Shigeharu Uchiyama1, Peter C. Amadio, Lawrence J. Berglund, Kai-Nan An!
Biomechanics Laboratory, Division of Orthopedic Research, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905, USA Accepted 15 January 2008
Zone II Combined Flexor Digitorum Superficialis and Flexor Digitorum Profundus Repair Distal to the A2 Pulley Jeffrey M. Pike, MD, Richard H. Gelberman, MD

Medscape Pubmed

14.Clinical Bottom Line


1. Kaplan EB: Functional andSurgical Anatomy of the Hand. Philadelphia, JB Lippincott Co, 2nd Ed, 1965
2. Lin GT, Amadic PC, An KN, et al: Functional anatomy of the human digital flexor pulley system. J Hand Surg Am 14:949-956, 1989
3. Cohen MJ, Kaplan L: Histology and ultrastructure of the human flexor tendon sheath. J Hand Surg Am 12:25-29, 1987 Level of evidence C
4. Katzman BM, Klein DM, Garven TC, et al: Anatomy and histology of the A5 pulley. J Hand Surg Am 23:653-657, 1998
5. Martinoli, C., Bianchi, S., Nebolio, M., Derchi, L. E., Garcia, J. F. (2000) Sonographic evaluation of digital annular pulley tears. Skeletal Radiol. 29: 387-391 Level of evidence: 2
6. Seiler JG, Uchiyama S, Ellis F, et al: Reconstruction of the flexor pulley. the effect of tension and source of the graft in an in vitro dog model. J Bone Joint Surg Am 80:699-703, 1998 Level of evidence: A2
7. Bunnell S: Repair of tendons in the fingers and descriptions of two new instruments. Surg Gynecol Obstet 26:103-110, 1918 Level of evidence: B
8. Widstrom CJ, Doyle JR, Johnson G: A mechanical study of the effectiveness of 6 digital pulley reconstruction techniques: Part 2. Strength of individual reconstructions. J Hand Surg Am 4:826-829,1989 Level of evidence: B
9. Nishida J, Amadio PC, Bettinger PC, et al: Excursion properties of tendon graft sources: interaction between tendon and A2 pulley. J Hand Surg Am 23:274-278, 1998 Level of evidence: C
10.Lister GD: Reconstruction of pulleys employing extensor retinaculum. J Hand Surg Am 4:461-464, 1979 Level of evidence: C
11.Kleinert HE, Bennett JB: Digital pulley reconstruction employing the always present rim of the other previous pulley. J Hand Surg Am 3:297-298, 1978 Level of evidence:C
12.Bowstring injury of the flexor tendon pulley system: MR imaging. Parellada JA, Balkissoon AR, Hayes CW, Conway WF. Source Department of Radiology, Medical College of Virginia, Virginia Commonwealth University, Richmond 23298, USA.31 Level of evidence: B
13.Hand Injuries in Rock Climbing: Reaching the Right Treatment Peter J. L. Jebson, MD; Curtis M. Steyers, MD THE PHYSICIAN AND SPORTSMEDICINE - VOL 25 - NO. 5 - MAY 97 Level of evidence B
14.A2 PULLEY INJURIES REVIEW RE-POSTED, TUESDAY, 4 MAY 2010 Dave macleod 15.Rohrbough, J. T., Mudge, M. K., Schilling, R. C. (2000) Overuse injuries in the elite rock
climber. Med. Sci Sports Exerc. 32(8): 1369-1372 Level of evidence B 16.Gailey, R. S., Raya, M. A. (2001) Manual Modalities. in: Gonzalez, E. G., Myers, S. J.,
Edelstein, J. E., Lieberman, J. S., Downey, J. A. Physiological basis of rehabilitation
medicine. 3rd ed. Butterworth Heinemann Level of evidence: 17.Gresham, N. (1996) High performance: warming up. High. 166: 14-15 Level of
evidence D
18.Schweizer, A. (2000) Biomechanical effectiveness of taping the A2 pulley in rock climbers. J. Hand Surg. 25B: 102-107 Level of evidence
19.Warme, W. J., Brooks, D. (2000) The Effect of circumferential taping on flexor tendon pulley failure in rock climbers. Am. J. Sports Med. 28(5): 674-678 Level of evidence:
Digital Flexor Sheath: Repair and Reconstruction of the Annular Pulleys and Membranous Sheath
Analysis of the gliding pattern of the canine flexor digitorum profundus tendon through the A2 pulley, Shigeharu Uchiyama1, Peter C. Amadio, Lawrence J. Berglund, Kai-Nan An!
Biomechanics Laboratory, Division of Orthopedic Research, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905, USA Accepted 15 January 2008
Zone II Combined Flexor Digitorum Superficialis and Flexor Digitorum Profundus Repair Distal to the A2 Pulley Jeffrey M. Pike, MD, Richard H. Gelberman, MD
Bron 1: http://www.orthobullets.com/hand/6004/flexor-pulley-system Bron 2: http://edgar.brand.edgar-online.com/EFX_dll/EDGARpro.dll?FetchFilingHTML1? ID=5479903&SessionID=cg7xWq-zAf69x47